Monica Greco

Ondansetron for Food Protein-Induced Enterocolitis Syndrome

Recently, a study on 5 patients [Holbrook et al.: J Allergy Clin Immunol 2013;132:1219-1220] documented the efficacy of the intravenous administration of ondansetron in children with acute symptoms due to food protein-induced enterocolitis syndrome (FPIES). We report on the experience at our institution using ondansetron during oral food challenge (OFC) in 5 children affected by FPIES. In all 5 cases, the use of intramuscular ondansetron led to a complete and rapid resolution of symptoms within 15 min. Intramuscular administration, without the need for intravenous access for an infusion or steroid administration, enables this therapy to be easily performed, even at home (i.e. out of a hospital setting). A home treatment with ondansetron cannot be considered as an alternative to a medical examination with eventual treatment in hospital, which is advised after any acute episode of FPIES. We consider ondansetron to be very useful in the management of acute FPIES. Further study is required to confirm its efficacy.

Food protein-induced enterocolitis syndrome, from practice to theory.

Food protein-induced enterocolitis syndrome (FPIES) is an allergic disease, probably non-IgE-mediated, with expression predominantly in the GI tract. The most characteristic symptom is repeated, debilitating vomiting. It occurs 2−6 h after ingestion of culprit food and is usually accompanied by pallor and lethargy. There may be diarrhea, and in 10−20% of cases, severe hypotension. These symptoms resolve completely within a few hours. The food most frequently involved is cow’s milk, followed by rice, but many other foods may be involved. The prognosis is generally good in a few years. In this review the authors try to cope, with the help of some case histories, with the practical clinical aspects of FPIES. The authors also try to provide a management approach based on current knowledge, and finally, to point out the aspects of FPIES that are still controversial.

Clinical management of food protein-induced enterocolitis syndrome.

Purpose of reviewThe article discusses the clinical management of patients affected by food protein-induced enterocolitis syndrome (FPIES), focusing on established therapeutic choices and future options. Recent findingsAfter FPIES has been diagnosed and avoidance of the culprit food prescribed, the most important management needs are as follows. First, recurrence of acute FPIES episodes due to accidental ingestion of culprit food. It may be useful to give patients’ families an action plan. The principal suggested treatments are intravenous fluids and steroids, whereas the use of epinephrine and ondansetron requires further study. In mild-to-moderate cases, oral rehydration should be sufficient. Second, dietary introduction of at-risk foods. In children with FPIES, in addition to that/those identified as culprit(s), some foods may not be tolerated (typically cows milk, legumes, cereals, poultry). It has been suggested to avoid introducing these foods during the babys first year. Otherwise, they may be given for the first time in hospital, performing an oral food challenge. Third, acquisition of tolerance. Children affected by cows milk-FPIES have a good chance of acquiring tolerance by the time they reach age 18–24 months. For other culprit foods, insufficient data are available to indicate the appropriate time, so that it is suggested that an oral food challenge be performed about 1  year after the last acute episode. SummaryFuture clinical management of FPIES must take into account, among other factors, improved understanding of pathogenesis, possible detection of different phenotypes, and the introduction of more effective therapies for acute episodes. These factors will undoubtedly influence management decisions, which will become more diversified and effective.

Chronic Food Protein-Induced Enterocolitis Syndrome Caused by Cow's Milk Proteins Passed through Breast Milk

We describe 2 cases of food protein-induced enterocolitis syndrome (FPIES) caused by cows milk (CM) passed through breast milk. The onset in both cases was characterized by chronic symptoms (regurgitation, colic, diarrhea, failure to thrive); in one patient, two acute episodes due to the direct consumption of CM formula by the infant were also reported. The diagnosis of FPIES through breast milk can be easily overlooked, especially in milder cases. We also discuss some important issues concerning the general management of the disease. In conclusion, (1) the diagnosis of chronic FPIES should be taken into account even in exclusively breast-fed infants who present suggestive symptoms such as persistent regurgitation, small amounts of vomiting, lethargy, failure to thrive, dehydration, diarrhea (sometimes bloody) and abdominal distention. A 2-week maternal elimination diet should be considered even in apparently mild cases. (2) CM seems to be the most frequently reported culprit food. (3) In those cases in which acute FPIES is elicited by the direct consumption of the culprit food in breast-fed infants, maternal diet may be unrestricted.

Matrix effect on baked milk tolerance in children with IgE cow milk allergy

BACKGROUND Children with IgE-mediated cows milk allergy (IgE-CMA) often tolerate baked milk within a wheat matrix. In our study we evaluated the impact of wheat matrix and of little standardised cooking procedures on tolerance of baked milk. We also tested tolerance versus parmigiano reggiano (PR) and whey-based partially hydrolysed formula (pHF). METHODS Forty-eight children with IgE-CMA were enrolled. They underwent prick-by-prick (PbP) and open oral food challenge (OFC) with baked cows milk (CM), both within a wheat matrix (an Italian cake named ciambellone) and without (in a liquid form), with PR and with pHF. After a passed OFC, children continued to eat the food tolerated. In particular, after passed OFC with ciambellone, children were allowed to eat any food containing CM within a wheat matrix, with the only condition that it was baked at 180°C for at least 30min. Three months after, parents were asked to answer a survey. RESULTS 81% of children tolerated ciambellone, 56% liquid baked CM, 78% PR and 82% pHF. Negative predictive value of PbP performed with tested foods was 100%. No IgE-mediated adverse reactions were detected at follow-up carried out by the survey. CONCLUSIONS Wheat matrix effect on tolerance of baked milk was relevant in slightly less than half of cases. If our results are confirmed by larger studies, a negative PbP will allow patients to eat processed CM without undergoing OFC. Moreover, in order to guarantee tolerance towards baked milk, strict standardised cooking procedures do not seem to be necessary.

Effect of multiple honey doses on non-specific acute cough in children. An open randomised study and literature review

BACKGROUND Honey is recommended for non-specific acute paediatric cough by the Australian guidelines. Current available randomised clinical trials evaluated the effects of a single evening dose of honey, but multiple doses outcomes have never been studied. OBJECTIVES To evaluate the effects of wildflower honey, given for three subsequent evenings, on non-specific acute paediatric cough, compared to dextromethorphan (DM) and levodropropizine (LDP), which are the most prescribed over-the-counter (OTC) antitussives in Italy. METHODS 134 children suffering from non-specific acute cough were randomised to receive for three subsequent evenings a mixture of milk (90ml) and wildflower honey (10ml) or a dose of DM or LDP adjusted for the specific age. The effectiveness was evaluated by a cough questionnaire answered by parents. Primary end-point efficacy was therapeutic success. The latter was defined as a decrease in cough questionnaire score greater than 50% after treatment compared with baseline values. RESULTS Three children were excluded from the study, as their parents did not complete the questionnaire. Therapeutic success was achieved by 80% in the honey and milk group and 87% in OTC medication group (p=0.25). CONCLUSIONS Milk and honey mixture seems to be at least as effective as DM or LDP in non-specific acute cough in children. These results are in line with previous studies, which reported the health effects of honey on paediatric cough, even if placebo effect cannot be totally excluded.

Constipation and Cow's Milk Allergy: A Review of the Literature

The causal association between cows milk allergy (CMA) and constipation is not well established. Some guidelines describe constipation as a possible symptom of CMA, while others do not mention it. We conducted a literature review and found 10 prospective clinical trials. In all of them, an oral food challenge was performed, and 2 of them were randomized. These studies reported that a cows milk (CM) protein-free diet has a beneficial effect on constipation, with a rate of successful outcomes ranging from 28 to 78%. The hypothetic pathogenic mechanism lies in increased anal pressure at rest, probably caused by allergic inflammation of the internal sphincter area due to mucosal eosinophil and mast cell infiltration. Eighty percent of patients reach tolerance within 1 year after the diagnosis of CMA-related constipation. We believe that a CM-free diet for 2-4 weeks should be proposed for children with chronic functional constipation, even if it is not severe or resistant to laxatives.

Matrix effect on baked egg tolerance in children with IgE-mediated hen's egg allergy.

Children with IgE‐mediated hens egg allergy (IgE‐HEA) often tolerate baked egg within a wheat matrix.