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AllergyIntolerance in Children

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Recurrent wheeze/ constant crying ... Respiratory or dermatology problems. Referral to Paediatrician in community, hospital or allergy clinic, or dermatology ... – PowerPoint PPT presentation

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Title: AllergyIntolerance 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 SPTs, RAST
  • Urticaria
  • Angioedema
  • Diarrhoea and vomiting
  • Anaphylaxis
  • Non IgE mediated delayed reaction
  • Eczema
  • Many GI symptoms

4
Cows milk protein most common in 1st year of
life 5infants
  • Main atopic symptoms
  • Dermatitis
  • GI diarrhoea, bloody stools, vomiting, abdominal
    distension, constipation
  • Recurrent wheeze/ constant crying
  • Estimated that16-42 of GOR in infants is cows
    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
  • SPTs 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 GI symptoms
  • Clinical history
  • Confirm with exclusion and reintroduction

7
Breast feeding Bottle feeding
  • Diarrhoea/colic and vomiting/GOR/urticaria/eczema
  • Consider CPM-free diet for mother ensure diet
    nutritionally adequate
  • Host et al, Arch Dis Child8180-84 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

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 aas-Prejomin, Pepdite
  • Partial Hydrolysates not suitable
  • Soya formula in theory suitable in IgE med.
  • Not with GI symptoms. Note directive.
  • Other mammalian milks, eg Goats, Sheeps

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 gt3 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 gt1 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
  • Goats milk later tried only on skin erythema
  • SPTs Strongly ve to milk, and to egg
  • Moved to Nutramigen 2 and to soya products
  • At 3 years soya milk and other dairy
    substitutes
  • SPTs redone and still ve to milk and egg and
    to peanut!
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