Allergy/Intolerance in Children

1. Allergy/Intolerance in Children An overview Myrtle Walsh Dietitian

2. Food Hypersensitivity↓ ↓ Food Allergy Non-allergic FHS↓ ↓ IgE mediated Non IgE mediatedWorld Allergy Organisation, 2003

3. Adverse reactions to foods IgE mediated [SPT’s, RAST] • Urticaria • Angioedema • Diarrhoea and vomiting • Anaphylaxis Non IgE mediated [delayed reaction] • Eczema • Many GI symptoms

4. Cow’s milk protein –most common in 1st year of life [~ 5%infants] Main atopic symptoms: • Dermatitis • GI [diarrhoea, bloody stools, vomiting, abdominal distension, constipation] • Recurrent wheeze/ constant crying Estimated that16-42% of GOR in infants is cow’s milk protein allergy [Sicherer,SH 2003] Most infants with CMPA develop symptoms in 1st month, often within a week of CMP based formula introduced

5. IgE mediated food allergy • Usually immediate • Diagnosis relatively simple • SPT’s and RAST – not always available • Exclusion – resolution of symptoms • Care with reintroduction – if respiratory distress/anaphylaxis

6. Non IgE mediated allergy • More difficult to diagnose • Delayed reaction, eg in eczema, some GIsymptoms • Clinical history • Confirm with exclusion and reintroduction

7. Diarrhoea/colic and vomiting/GOR/urticaria/eczema Consider CPM-free diet for mother – ensure diet nutritionally adequate Host et al, Arch Dis Child;81:80-84 European guidelines AAP –CMP, egg, fish, peanuts & treenuts Diarrhoea/colic and vomiting/GOR/urticaria/eczema EHIF prescribed [have to demonstrate 90% success] Graded introduction over 3-4 days Breast feeding Bottle feeding

8. Formulae • EHIF – those of choice, as extensively hydrolysed therefore most hypoallergenic. Are casein based: Nutramigen & Pregestimil • 2nd line – not so extensively hydrolysed. Whey based – Pepti and Peptijunior Soya and pork [some aa’s]-Prejomin, Pepdite • Partial Hydrolysates – not suitable • Soya formula – in theory suitable in IgE med. Not with GI symptoms. Note directive. • Other mammalian milks, eg Goat’s, Sheep’s

9. Severe symptoms or not resolving • Severe GI problems +/- faltering growth • Respiratory or dermatology problems Referral to Paediatrician in community, hospital or allergy clinic, or dermatology Trial of Elemental formula [ amino acid formula] for finite period with EHIF restarted if weight gain and symptoms resolved Zeiger RS, 2003 advocates in Severe GI disturbances AA formula for gut rest European guidelines: EHIF / AA formula.

10. Reflux • Deciding plan • ? Medication • ? Change of formula – anti-reflux • In papers reported 16-42% GOR – CPMA • Trial EHIF

11. After 6 months • Change to EHIF stage 2, eg. Nutramigen 11 • Soya formula average 25% with CPMA also become allergic to soya formula [IgE mediated 8-14%, Non IgE mediated up to 67%] • Weaning at 6 months, not before 17 weeks onto CMP- free solids, low allergenic foods

12. Challenging with CMP • Expected remission date in infants • 45-50% at 1 year • 60-75% at 2 years • 85-90% at 3 years Host A.,2002 Allergy Immunology

13. Tests • SPT – size of weal predicts if need to challenge, 7-8mm to milk [or egg, peanut] allergy remains [Sporik et al,2000. Clin Exp Allergy] • If symptoms include hives, angiodema, wheeze – challenge in hospital • If mainly GI symptoms, eg diarrhoea, challenge at home • Caution in food protein-induced enterocolitis syndrome as 20% can go into shock [Sicherer et al]

14. Lactose Intolerance • Do not confuse with CPM allergy or intolerance • Symptoms – diarrhoea and colic, typical infantile colic • Diagnosis – presence of reducing substances • Empirical introduction of low lactose infant formula, or lactase drops

15. Cause • True Lactose Intolerance rare in Caucasians • Secondary to gastroenteritis, coeliac disease • Degree of lactase deficiency, immature digestive system Usually resolves in 4-8 weeks if secondary to gastroenteritis, or after 4 months of age if infantile colic. If symptoms do not resolve, consider CMPA

16. Prevention of Food Allergy • Inadvisable to restrict maternal diet [COT] • Exclusive breast feeding for 3 months, to 6 months recommended for all infants by DoH. In atopic family use EHIF or PHIF • Advice on food avoidance to individual atopic risk in breastfeeding [European group and Zeiger, 2003] • Weaning delayed to 6 months, not before 17 weeks, Now not advised to use low allergenic weaning foods/exclude known allergenic foods • By 1 year all major foods introduced, except peanuts, nuts and seeds [>3 years] This was advised 9 years ago, DoH advise full review as no change in incidence. BDA website for fact sheets [FAISG]

17. Case study Child : L.O. d.o.b 12/7/05 Presented at 3½ months with back arching, persistent crying, pushing feeds away, colic, weight faltering Initially breast fed baby Mum tried Omneocomfort – for colicky babies ? Reflux oesophagitis started on Domperidone and Ranitidine Problem not resolved/child in pain Nutramigen hypoallergenic formula introduced – resolved symptoms At 6 months Soya formula tried – widespread rash over body, so Nutramigen 2 prescribed At >1 year was starting to introduce cheese and yogurt

18. Case study Child B.C. Dob 4/2/05 Fhx of hayfever and eczema Child developed eczema at 3 months At 5 months exposed to formula milk, previously breast fed, result → erythema round lips, was sick and developed hives Nutramigen prescribed – no symptoms, eczema controlled Goat’s milk later tried – only on skin – erythema SPT’s Strongly +ve to milk, and to egg Moved to Nutramigen 2 and to soya products At 3 years – soya milk and other dairy substitutes SPT’s redone and still +ve to milk and egg – and to peanut!