Children with food allergies present with a variety of symptoms

AAP 2011 National Conference

BOSTON — Pediatricians should be aware of a cross-section of possible symptoms of food allergy, according to a presentation here at the American Academy of Pediatrics 2011 National Conference and Exhibition.

Terri Brown-Whitehorn, MD, assistant professor of Clinical Pediatrics at the Children’s Hospital of Philadelphia, outlined the main gastrointestinal symptoms pediatricians might encounter, including vomiting, dysphagia, abdominal pain, mucousy stools, bloody stools, bloating, diarrhea and growth concerns.

“Although food allergies may not be the etiology, it is helpful to keep it in mind when making diagnoses,” Brown-Whitehorn said. Other causes of adverse abdominal reactions include a poor reaction to a food or additive, or non-immune mediated reactions, such as food poisoning, pharmacologic effects (such as jitteriness from caffeine) or metabolic disorders (such as lactase deficiency).

Brown-Whitehorn had some advice for practicing pediatricians: “It is helpful to review the different types of reactions with your colleagues,” she said. “Pay particular attention to both the subtle and obvious presentations you may come across.”

She also noted that it may be necessary to send the patient to a gastroenterologist first, depending on the symptoms.

“I also recommend doing mock codes twice a year,” she said. “Figure out how you’re going to deal with anaphylaxis. Pediatric practices need to be cognizant and know how to treat anaphylaxis.”

Brown-Whitehorn reviewed several case reports that highlighted gastrointestinal complications that a pediatrician may encounter. She highlighted key characteristics and treatment strategies of each that may be unfamiliar to pediatricians.

“For children showing signs of lactose intolerance, a lactase breath test is available,” she said. “Celiac disease – an autoimmune disorder marked by an abnormal response to gluten – affects one out of 133 people in the US.”

Cramping, intestinal gas, distention, bloating, fatty stools and chronic diarrhea or constipation (or both) mark Celiac disease.

“The good news is that more gluten-free products are available in the US,” Brown-Whitehorn said. “It should be noted that gluten must be in the child’s diet in order to make a diagnosis.”

Allergic proctocolitis/colitis impacts healthy babies with no growth issues and frequently involves bloody, mucousy stools.

“Sixty-percent of breastfed infants may get this. The most common cause is cow's milk, and 30% may have concomitant issues with soy,” Brown-Whitehorn said. “Fortunately, most infants will outgrow this by one year of age.”

Severe vomiting and lethargy 2 hours after ingestion of food are key symptoms of enterocolitis, which can be associated with milk, soy, rice, oats, grains, peas, sweet potatoes or squash.

“This can be treated with IV fluid boluses and supportive care, but epinephrine will not work in these infants,” Brown-Whitehorn said. “Moms can also avoid milk and soy.”

Children will often outgrow this by age 3 years, but not all, according to Brown-Whitehorn. “The questions are when and where will we reintroduce the foods of concern? For the most severe, we give them a small amount of food and monitor them closely in a hospital setting. You can’t do skin testing or blood work to these kids. Sometimes we give them an ounce of milk in the hospital and follow them for four or five hours to see.”

If a skin test or a blood test is negative, Brown-Whitehorn suggested “patch testing” as a possible strategy for identifying what foods will cause a reaction.

“We put patches of food on the child’s back,” she said. “Sometimes the reaction on the back will correlate with the allergy. This was accurate in 23/27 instances in a recent study. I use patch testing as a guide, but I don’t think it is a perfect test. Typically we listen to the family as well.”

If a child has difficulty swallowing and reports drinking a lot of water with meals, it may be dysphagia. Children with dysphagia may have allergy cells (eosinophils) in the esophagus, which is known as eosinophilic esophagitis. "Treatment options for eosinophilic esophagitis include dietary restrictions or off-label use of swallowed steroids," she said. "Medications against chemokines or cytokines are in study."

Eosinophilic esophagitis is a chronic condition thought to be linked to an underlying food allergy, according to Brown-Whitehorn. “We are seeing more patients with this every year,” she said. “It frequently comes with concomitant atopy.”

Patients may present with symptoms of gastroesophageal reflux disease (GERD), reflux or food refusal are usually placed on a proton pump inhibitor. “Biopsy is key to diagnosis,” Brown-Whitehorn said. “And we usually restrict the diet.”

“Very few patients have outgrown all foods, so we are starting to think that this is a chronic condition,” Brown-Whitehorn said.

About 20% to 25% of children with eosinophilic gastroenteritis will respond to food elimination and elemental formula.

“However, it is hard to go from eating to not eating,” Brown-Whitehorn said.

She noted that pediatricians should be aware that growth may not indicate food allergy. “The interesting thing about growth is that some of these babies grow really well, and others don’t,” Brown-Whitehorn noted. “When they are growing well, it’s hard to think that they can have an underlying condition.”

Disclosures: Dr. Brown-Whitehorn reports no relevant financial disclosures.

For more information:

• Brown-Whitehorn T. #X2003. Are Food Allergies Causing My Child’s Abdominal Symptoms? Presented at: AAP 2011 National Conference and Exhibition; Oct. 15-18, 2011; Boston.

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