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Up to 20% of parents report a problem with infant crying or irritability in the first 3 months of life. Crying usually peaks at 6 weeks and abates by 12-16 weeks. For most irritable infants, there is no underlying medical cause. In a minority, the cause is cow's milk and other food allergy. Only if frequent vomiting (about five times a day) occurs is gastro-oesophageal reflux a likely cause. It is important to assess the mother-infant relationship and maternal fatigue, anxiety and depression. Management of excessive crying includes: explaining babies' normal crying and sleeping patterns; helping parents help their baby deal with discomfort and distress through a baby-centred approach; helping parents recognise when their baby is tired and apply a consistent approach to settling their baby; encouraging parents to accept help from friends and family, and to simplify household tasks. If they are unable to manage their baby's crying, admission to a parenting centre (day stay or overnight stay) or local hospital should be arranged.
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PMID:1. Problem crying in infancy. 1551 99

In children with medically refractory gastroesophageal reflux disease (GERD), fundoplication is effective and safe. However, in a subset of patients, gastrointestinal dysfunction occurs postoperatively. Symptoms include chest pain, persistent dysphagia in 5%, gas bloat in 2% to 4%, diarrhea in up to 20%, and dumping syndrome in up to 30%. Symptoms are often nonspecific, arising from recurrent or persistent GERD, anatomic complications such as disrupted or herniated wrap, functional disturbances such as rapid gastric emptying or altered gastric accommodation, or alternative diagnoses such as cyclic vomiting syndrome or food allergy. Detailed investigation, including various combinations of pHmetry, videofluoroscopy, endoscopy, motility studies, and dumping provocation testing, may be required to clarify pathophysiology and guide management.
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PMID:Gastrointestinal complications of fundoplication. 1591 82

Heiner syndrome (HS) is a food hypersensitivity pulmonary disease that affects primarily infants, and is mostly caused by cow's milk (CM). Only a few reports have been published, which may be due to its misdiagnosis. We review here a series of eight cases. When first diagnosed they were 4-29 months of age. They were fed CM from birth and their chronic respiratory symptoms began at age 1-9 months. The symptoms were in the form of cough in seven, wheezing in three, hemoptysis in two, nasal congestion in three, dyspnea in one, recurrent otitis media (OM) in three, recurrent fever in four, anorexia, vomiting, colic or diarrhea in five, hematochezia in one, and failure to thrive (FTT) in two. All had radiologic evidence of pulmonary infiltrates. High titers of precipitating antibodies to CM proteins were demonstrated in six of six and milk-specific immunoglobulin E (IgE) was positive in one of two. Pulmonary hemosiderosis (PH) was confirmed in one patient who showed iron-laden macrophages (ILM) in the bronchoalveolar lavage (BAL), gastric washing, and open lung biopsy. Additional findings, in a descending frequency, were eosinophilia, anemia, and elevated level of total IgM, IgE or IgA. Milk elimination resulted in remarkable improvement in symptoms within days and clearing of the pulmonary infiltrate within weeks. Parents consented to milk challenge in only three cases, all of whom developed recurrence of symptoms. After 2 yr of milk avoidance in one patient, milk challenge was tolerated for 2 months, and then the patient developed symptoms, serum milk precipitins, pulmonary infiltrate, and ILM. The HS should be suspected in young children with chronic pulmonary disease of obscure cause. The diagnosis is supported with a positive milk precipitin test and improvement on a trial of milk elimination. Severe cases may be complicated with PH, which should be suspected in the presence of anemia or hemoptysis and be confirmed with the demonstration of ILM.
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PMID:Milk-induced pulmonary disease in infants (Heiner syndrome). 1617 5

Foods that account for 90% of allergic reactions in children are cow's milk protein, eggs, peanut, soy, tree nuts, fish, and wheat. Food allergy can manifest as urticaria/angioedema, anaphylaxis, atopic dermatitis, respiratory symptoms, or a gastrointestinal (GI) disorder. GI allergic manifestations can be classified as immunoglobulin E (IgE) mediated (immediate GI hypersensitivity and oral allergy syndrome); "mixed" GI allergy syndromes (involving some IgE components and some non-IgE or T-cell-mediated components) include eosinophilic esophagitis and eosinophilic gastroenteritis. Non-IgE-mediated or T-cell-mediated allergic GI disorders include dietary protein enteropathy, protein-induced enterocolitis, and proctitis. All these conditions share a common denominator: the response of the immune system to a specific protein leading to pathologic inflammatory changes in the GI tract. This immunological response can elicit symptoms such as diarrhea, vomiting, dysphagia, constipation, or GI blood loss, symptoms consistent with a GI disorder. The detection of food allergies can be accomplished by the use of radioallergosorbent (RAST) testing and skin prick tests in helping to assess the IgE-mediated disorders. Patch tests may help evaluate delayed hypersensitivity reactions. Treatment of GI allergic disorders ranges from strict dietary elimination of offending food(s), use of protein hydrolysates, and use of L-amino acid-based formula when protein hydrolysates fail. Treatment with topical (for eosinophilic esophagitis) or systemic steroids is used if all dietary measures are unsuccessful. Maternal breast feeding or the use from birth of hydrolysate formulas (extensive or partial hydrolysates) may be efficacious in the prevention of atopic disease in "high-risk" families (with at least 1 parent or sibling with a history of atopic disease).
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PMID:Gastrointestinal manifestations of food allergies in pediatric patients. 1620 93

While 6% of children under three years of age suffer from a food allergy, the figure for adults varies between 1.5 and 3%. Leading allergens in foodstuffs are glycoproteins having a molecular weight of between 10,000 and 60,000. The symptoms of an immediate type nutrient allergy mediated by IgE usually manifest within a matter of a few minutes to two hours after ingestion of the offending nutrient and take the form, for example, of tingling and itching, tissue swelling in the mouth, hoarseness, asthma, gastrointestinal complaints or acute urticaria; in severe cases anaphylactic shock may even occur. In contrast, no IgE antibodies are to be found in nutrient-induced enterocolitis, which is associated with diarrhea and vomiting occurring after a delay of one to six hours. Differential diagnostic considerations must include intolerance for certain foodstuffs, such as lactose intolerance, or pseudoallergic reactions.
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PMID:[Food allergies are often an unrecognized cause of clinical complaints]. 1630 89

Adverse reactions to foods are frequent in everyday life. They are divided into toxic and immunologic food reactions. The awareness of toxic food reactions among adverse reactions to food is essential for correct diagnosis. Enzymatic food intolerance, adverse reactions to food or food additives, pharmacologic food intolerance, psychosomatic factors, food allergy with classic symptoms (anaphylaxis, urticaria-angioedema), atopic dermatitis, contact dermatitis (protein), upper and lower respiratory symptoms like rhinitis or asthma, and gastrointestinal disorders (oral allergy syndrome, colic, nausea, vomiting, diarrhea, abdominal pain) are discussed. Target organs throughout the body-ear, eye, pharynx, skin, lung, joints, and muscles-can be involved. The gold standard in diagnosis is a double-blind, placebo-controlled food challenge test. The diagnostic tools available for most food-related disorders are the skin-prick test and radioallergosorbent test. The treatment of food-induced urticaria consists of elimination of the offending food or substance from the diet, use of antihistamines, and immunotherapy.
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PMID:Adverse reactions to food and clinical expressions of food allergy. 1668 80

Food allergies in children present with a wide spectrum of clinical manifestations, including anaphylaxis, urticaria, angioedema, atopic dermatitis and gastrointestinal symptoms (such as vomiting, diarrhoea and failure to thrive). Symptoms usually begin in the first 2 years of life, often after the first known exposure to the food. Immediate reactions (occurring between several minutes and 2 hours after ingestion) are likely to be IgE-mediated and can usually be detected by skin prick testing (SPT) or measuring food-specific serum IgE antibody levels. Over 90% of IgE-mediated food allergies in childhood are caused by eight foods: cows milk, hens egg, soy, peanuts, tree nuts (and seeds), wheat, fish and shellfish. Anaphylaxis is a severe and potentially life-threatening form of IgE-mediated food allergy that requires prescription of self-injectable adrenaline. Delayed-onset reactions (occurring within several hours to days after ingestion) are often difficult to diagnose. They are usually SPT negative, and elimination or challenge protocols are required to make a definitive diagnosis. These forms of food allergy are not usually associated with anaphylaxis. The mainstay of diagnosis and management of food allergies is correct identification and avoidance of the offending antigen. Children often develop tolerance to cows milk, egg, soy and wheat by school age, whereas allergies to nuts and shellfish are more likely to be lifelong.
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PMID:4. Food allergy in childhood. 1701 10

Cow's milk protein allergy is the most common food allergy in infants and young children. It is estimated that up to 50% of pediatric cow's milk allergy is non-IgE-mediated. Allergic proctocolitis is a benign disorder manifesting with blood-streaked stools in otherwise healthy-appearing infants who are breast- or formula-fed. Symptoms resolve within 48-72 h following elimination of dietary cow's milk protein. Most infants tolerate cow's milk by their first birthday. Food protein-induced enterocolitis syndrome presents in young formula-fed infants with chronic emesis, diarrhea, and failure to thrive. Reintroduction of cow's milk protein following a period of avoidance results in profuse, repetitive emesis within 2-3 h following ingestion; 20% of acute exposures may be associated with hypovolemic shock. Treatment of acute reactions is with vigorous hydration. Most children become tolerant with age; attempts of re-introduction of milk must be done under physician supervision and with secure i.v. access. Allergic eosinophilic gastroenteritis affects infants as well as older children and adolescents. Abdominal pain, emesis, diarrhea, failure to thrive, or weight loss are the most common symptoms. A subset of patients may develop protein-losing enteropathy. Fifty percent of affected children are atopic and have evidence of food-specific IgE antibody but skin prick tests and serum food-IgE levels correlate with response to elimination diet poorly. Elemental diet based on the amino-acid formula leads to resolutions of gastrointestinal eosinophilic inflammation typically within 6 wk.
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PMID:Educational clinical case series for pediatric allergy and immunology: allergic proctocolitis, food protein-induced enterocolitis syndrome and allergic eosinophilic gastroenteritis with protein-losing gastroenteropathy as manifestations of non-IgE-mediated cow's milk allergy. 1758 15

Duodenal web most commonly presents with a history of vomiting and failure to thrive in the early infancy period. This study reports on a child who had an initial presentation of feeding intolerance and rare nonbilious emesis. The unusual presentation of food refusal directed the investigation to an upper endoscopy to look for evidence of gastrointestinal mucosal disease such as gastroesophageal reflux disease, peptic ulcer disease, Helicobacter pylori infection, and food allergy including celiac disease. The finding of duodenal web with a central aperture was unexpected but explains the mild degree of her gastrointestinal symptoms.
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PMID:Food refusal as an unusual presentation in a toddler with duodenal web. 1859 77

Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food allergy characterized by severe vomiting, diarrhea, and often failure to thrive in infants. Symptoms typically resolve after the triggering food-derived protein is removed from the diet and recur within few hours after the re-exposure to the causal protein. The diagnosis is based on clinical symptoms and a positive food challenge. In this study, we report a case of FPIES to rice in an 8-month-old boy. We performed a double-blind placebo-controlled food challenge (DBPCFC) to rice and we measured the intracellular T cell expression of interleukin-4 (IL-4); IL-10, and interferon gamma (IFN-gamma) pre-and post-challenge during an acute FPIES reaction and when tolerance to rice had been achieved. For the first time we describe an increase in T cell IL-4 and decrease in IFN-gamma expression after a positive challenge with rice (i.e. rice triggered a FPIES attack) and an increase in T cell IL-10 expression after rice challenge 6 months later after a negative challenge (i.e., the child had acquired tolerance to rice) in an 8 month old with documented FPIES to rice. A Th2 activation associated with high IL-4 levels may contribute to the pathophysiology of the disease. On the other hand, T cell-derived IL-10 may play a role in the acquisition of immunotolerance by regulating the Th1 and Th2 responses.
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PMID:Cytokine expression in CD3+ cells in an infant with food protein-induced enterocolitis syndrome (FPIES): case report. 2001 55


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