Pediatric Nutrition in Practice

198 Heine^

Breat h hydrogen testing may be used to conf irm
the diagnosis of lactose malabsorption; however,
its correlation with diet response varies [5]. Di-
etary avoidance of fresh cow’s milk and dairy
products is usually sufficient to control gastro-
intestinal symptoms in lactose-intolerant indi-
viduals, and small amounts of lactose are gener-
ally tolerated. In formula-fed infants, a lactose-
reduced formula or soy formula can be used if
symptoms are significant. In breastfed infants,
low-grade lactose malabsorption is physiologi-
cal. In cases of postenteritic lactose malabsorp-

tion, breastfeeding should be continued. Incu-

bation of expressed breast milk with lactase

drops may be effective if symptoms are severe

[5].

Diagnostic Evaluation

The diagnosis of IgE-mediated food allergy re-

quires a typical immediate-type clinical reaction

to a food, in conjunction with demonstration of

IgE antibodies by either SPT or measurement of

Ta b l e 1. Gastrointestinal food allergy

Diagnosis Clinical features Investigations Complications Treatment

Food
protein-
induced
enteropathy

Mainly affects formula-

fed infants (cow’s milk

or soy formula)

Persistent diarrhea

Occasional vomiting

Failure to thrive

SPT/serum-specific IgE

(ImmunoCAP®) negative

Intestinal biopsy: evidence

of small intestinal villus

shortening and crypt

hyperplasia

Duodenal disaccharidases:

secondary lactase

deficiency

Growth failure

Secondary lactose

malabsorption

Protein-losing enteropathy

Hypoproteinemia and

edema

Iron deficiency anemia

Hypogammaglobulinemia

in severe cases

Strict cow’s milk- and

soy-free diet

Extensively hydrolyzed

formula as first-line

treatment

If not tolerated, change

to amino acid-based

formula

FPIES Profuse vomiting about
2 h after ingestion of
food allergen
Does not occur in
breastfed infants
Common allergens are
cow’s milk, soy, grains
(rice, oats) and poultry
meat (chicken, turkey)
Low-grade rectal
bleeding may occur
after reaction

SPT/serum-specific IgE

(ImmunoCAP) negative

Negative atopy patch test

may predict tolerance on

subsequent food challenge,

but its clinical usefulness is

controversial

FPIES food challenge

generally not performed

before 2 years of age

Acute dehydration and

hypovolemic shock occur in

about 20% of first

presentations

May be mistaken for sepsis,

gastroenteritis or intestinal

obstruction

Strict avoidance of

offending food item

Requires hypoallergenic

formula if previous

reaction to cow’s milk or

soy (extensively

hydrolyzed formula

considered first-line

treatment)

Food
protein-
induced
proctocolitis

May occur in breast-

or formula-fed infants

within the first weeks

of life

Low-grade rectal

bleeding, often mixed in

with mucus

Infants otherwise well

and thriving

SPT/serum-specific IgE

(ImmunoCAP) negative

Sigmoidoscopy and biopsy

not always required,

particularly if responding to

cow’s milk protein

elimination

Rectal biopsy: increased

lymphocytes and

eosinophils, with focal

epithelial erosion

Iron deficiency anemia

uncommon

Breastfed infants often

respond to maternal

elimination diet

In formula-fed infants,

use extensively

hydrolyzed formula

If ongoing rectal

bleeding, change to

amino acid-based

formula (rare)

FPIES = Food protein-induced enterocolitis syndrome.

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 195–202

DOI: 10.1159/000360340