ABSTRACT
Many guidelines have been published to help diagnose food allergies, which have included feeding difficulties as a presenting symptom (particularly for non-IgE-mediated gastrointestinal allergies). This study aimed to investigate the prevalence of feeding difficulties in children with non-IgE-mediated gastrointestinal allergies and the association of such difficulties with symptoms and food elimination. An observational study was performed at Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK. Children aged 4 weeks to 16 years without non-allergic co-morbidities who improved on an elimination diet using a previously published Likert scale symptom score were included. This study recruited 131 children, and 114 (87%) parents completed the questionnaire on feeding difficulties. Feeding difficulties were present in 61 (53.5%) of the 114 children. The most common feeding difficulties were regular meal refusals (26.9%), extended mealtimes (26.7%), and problems with gagging on textured foods (26.5%). Most children (40/61) had ≥2 reported feeding difficulties, and eight had ≥4. Children with feeding difficulties had higher rates of constipation and vomiting: 60.7% (37/61) vs. 35.8% (19/53), p = 0.008 and 63.9% (39/61) vs. 41.5% (22/53), p = 0.017, respectively. Logistic regression analysis demonstrated an association between having feeding difficulties, the age of the child, and the initial symptom score. Gender and the number of foods excluded in the elimination diet were not significantly associated with feeding difficulties. This study found that feeding difficulties are common in children with non-IgE-mediated gastrointestinal allergies, but there is a paucity of food allergy specific tools for establishing feeding difficulties, which requires further research in the long-term and consensus in the short term amongst healthcare professions as to which tool is the best for food allergic children.
Subject(s)
Food Hypersensitivity , Humans , Child, Preschool , Child , Food Hypersensitivity/complications , Food Hypersensitivity/epidemiology , Male , Female , Adolescent , Infant , Surveys and Questionnaires , Prevalence , Constipation/epidemiology , Constipation/etiology , Vomiting/epidemiology , Gastrointestinal Diseases/epidemiologyABSTRACT
Background: Oral food challenges remain the most reliable method for allergy confirmation. Although consensus guidelines have been published to unify Immunoglobulin E (IgE)-mediated challenges, this does not exist for non-IgE mediated gastrointestinal allergies outside of Food Protein Induced Enterocolitis Syndrome. We therefore set out to establish the use of home introduction protocols (HIP) for confirmation of food allergy for milk, soya, egg and wheat using a ladder approach in children with non-IgE mediated allergy. Materials and Methods: Patients with suspected non-IgE mediated gastrointestinal allergies (0-16 years) were recruited following symptom improvement on an elimination diet. All children had skin prick or specific IgE tests to rule out IgE-mediated allergies prior to suggestion the HIP. Number of trials and outcome was documented. HIPs were developed using a published ladder approach for cow's milk as baseline and final dose was calculated based on guidelines for food protein induced enterocolitis syndrome and portions for age from the National Diet and Nutrition Survey. First foods were baked/highly processed and every 4th day patients moved to a more unprocessed/unheated food. Results: From 131 recruited patients, 117 (89.3%) followed the HIP for food allergens. No adverse events were documented. In more than 50% of cases one attempt at the HIP was sufficient to establish allergy status, but many required 2-5 attempts before the outcome was clear. About half of the children were fully tolerant to foods they initially eliminated: 36, 26 and 30% were partially tolerant to milk, soya, and egg and only 15% achieved partial tolerance to wheat. Wheat was the allergen introduced earliest, followed by soya, cow's milk and egg. Conclusions: This study indicates that home HIPs are safe in non-IgE mediated gastrointestinal food allergy and that the ladder approach may be useful in re-introducing allergens in children at home with non-IgE mediated gastrointestinal allergies. From this study we can also conclude that tolerance to processed/baked allergens was observed in many children. Further studies should be performed on the HIP and ideally reintroduction should occur pre-defined time intervals.
ABSTRACT
BACKGROUND: The impact on health related quality of life (HRQL) has been well studied in children with Immunoglobulin E (IgE)-mediated food allergy. However limited data exists on related quality of life (QOL) of families who have a child suffering from food protein induced non-IgE mediated gastrointestinal allergies. We aimed to establish the QOL of families with children at the beginning of following an elimination diet for non-IgE mediated gastrointestinal food allergies. METHODS: A prospective, observational study was performed. Parents of children aged 4 weeks-16 years who improved after 4-8 weeks of following an elimination diet for suspected non-IgE mediated allergies were included. The Family Impact Module (FIM) of the Pediatric Quality of Life (PedsQL™) was used and we compared our data to two historical cohorts: one with sickle cell disease and another with intestinal failure. RESULTS: One hundred and twenty three children with a median age of 20 months were included (84 boys). The total FIM Score was 57.43 (SD 22.27) and particularly low for daily activities and worry. Factors that impacted significantly included age (p < 0.0001), number of foods excluded (p = 0.008), symptom severity (p = 0.041) and chronic nasal congestion (p = 0.012). Children with non-IgE mediated food allergies had worse scores in all domains (p < 0.0001) compared to sickle cell disease and worse physical (p = 0.04), emotional (p = 0.04) and worry (p = 0.01) domains compared to intestinal failure. CONCLUSIONS: This study found that parent QOL and family functioning was worse in those families who had a child on an elimination diet for non-IgE mediated allergies compared to those with sickle cell disease and intestinal failure, highlighting the impact this disease has on families.
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BACKGROUND: There is no data on the prevalence of vitamin D deficiency in children with non-immunoglobulin-E (IgE) mediated gastrointestinal food allergy. The aims of our study were to understand the prevalence of vitamin D insufficiency and deficiency in children with non-IgE mediated gastrointestinal food allergy and identify predisposing factors. METHODS: This was a retrospective study which looked at data from Great Ormond Street Hospital from January 2002 to September 2015. Children 0-18 years old with a confirmed diagnosis of non-IgE mediated gastrointestinal food allergy who had a vitamin D level measured during the course of their disease were included. Low vitamin D levels were defined as <50 nmol/L; insufficient levels were defined as 25-50 nmol/L and deficient levels as <25 nmol/L. Patient characteristics and clinical factors were also recorded. RESULTS: Ninety-two patients met the study criteria; 49% were female and median age was 10 years 2 months [IQR: 4 years 8 months to 13 years 7 months]. Of the cohort, 26% (24/92) had low vitamin D levels; 16% had insufficient vitamin D levels and 10% had vitamin D deficiency. Gender (p = 0.043) and age (p = 0.035) were significantly associated with low vitamin D levels. Twelve percent of children who were on an amino acid formula (AAF) had low vitamin D compared to 31% of children who were not (p = 0.06). No other clinical factors were found to be significantly associated with low vitamin D levels. CONCLUSIONS: Children with non-IgE mediated gastrointestinal food allergy are at risk of vitamin D insufficiency and deficiency. Further prospective studies need to be performed in all children with non-IgE mediated gastrointestinal food allergies. TRIAL REGISTRATION: The study was registered with the GOSH Research & Development department as a retrospective case note review. The Health Research Authority confirmed that NHS Research and Ethics Committee approval was not required; thus there is no trial registration number.
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OBJECTIVES: Inflammatory bowel disease [IBD] presenting in early childhood is extremely rare. More recently, progress has been made to identify children with monogenic forms of IBD predominantly presenting very early in life. In this study, we describe the heterogeneous phenotypes and genotypes of patients with IBD presenting before the age of 2 years and establish phenotypic features associated with underlying monogenicity. METHODS: Phenotype data of 62 children with disease onset before the age of 2 years presenting over the past 20 years were reviewed. Children without previously established genetic diagnosis were prospectively recruited for next-generation sequencing. RESULTS: In all, 62 patients [55% male] were identified. The median disease onset was 3 months of age (interquartile range [IQR]: 1 to 11). Conventional IBD classification only applied to 15 patients with Crohn's disease [CD]-like [24%] and three with ulcerative colitis [UC]-like [5%] phenotype; 44 patients [71%] were diagnosed with otherwise unclassifiable IBD. Patients frequently required parenteral nutrition [40%], extensive immunosuppression [31%], haematopoietic stem-cell transplantation [29%], and abdominal surgery [19%]. In 31% of patients, underlying monogenic diseases were established [EPCAM, IL10, IL10RA, IL10RB, FOXP3, LRBA, SKIV2L, TTC37, TTC7A]. Phenotypic features significantly more prevalent in monogenic IBD were: consanguinity, disease onset before the 6th month of life, stunting, extensive intestinal disease and histological evidence of epithelial abnormalities. CONCLUSIONS: IBD in children with disease onset before the age of 2 years is frequently unclassifiable into Crohn's disease and ulcerative colitis, particularly treatment resistant, and can be indistinguishable from monogenic diseases with IBD-like phenotype.
Subject(s)
Inflammatory Bowel Diseases/pathology , Age of Onset , Colitis, Ulcerative/genetics , Colitis, Ulcerative/pathology , Crohn Disease/genetics , Crohn Disease/pathology , Endoscopy, Gastrointestinal , Female , Genetic Testing , Humans , Infant , Inflammatory Bowel Diseases/genetics , Intestines/pathology , Male , PhenotypeABSTRACT
BACKGROUND: Non immunoglobulin E (IgE) mediated allergies affecting the gastrointestinal tract require an elimination diet to aid diagnosis. The elimination diet may entail multiple food eliminations that contribute significantly to macro- and micro-nutrient intake which are essential for normal growth and development. Previous studies have indicated growth faltering in children with IgE-mediated allergy, but limited data is available on those with delayed type allergies. We therefore performed a study to establish the impact on growth before and after commencing an elimination diets in children with food protein induced non-IgE mediated gastrointestinal allergies. METHODS: A prospective, observational study was performed at the tertiary gastroenterology department. Children aged 4 weeks-16 years without non-allergic co-morbidities who were required to follow an elimination diet for suspected food protein induced gastrointestinal allergies were included. Growth parameters pre-elimination were taken from clinical notes and post-elimination measurements (weight and height) were taken a minimum of 4 weeks after the elimination diet. A 3-day estimated food diary was recorded a minimum of 4 weeks after initiating the elimination diet, including also any hypoallergenic formulas or over the counter milk alternatives that were consumed. RESULTS: We recruited 130 children: 89 (68.5 %) boys and a median age of 23.3 months [IQR 9.4-69.2]. Almost all children (94.8 %) in this study eliminated CM from their diet and average contribution of energy in the form of protein was 13.8 % (SD 3.9), 51.2 % (SD 7.5) from carbohydrates and 35 % (SD 7.5) from fat. In our cohort 9 and 2.8 % were stunted and wasted respectively. There was a statistically significant improvement in weight-for-age (Wtage) after the 4 week elimination diet. The elimination diet itself did not improve any of the growth parameters, but achieving energy and protein intake improved Wtage and WtHt respectively, vitamin and/or mineral supplements and hypoallergenic formulas were positively associated with WtHt and Wtage. CONCLUSION: With appropriate dietary advice, including optimal energy and protein intake, hypoallergenic formulas and vitamins and mineral supplementation, growth parameters increased from before to after dietary elimination. These factors were positively associated with growth, irrespective of the type of elimination diet and the numbers of foods eliminated.
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BACKGROUND: The prevalence of food allergy has increased in recent decades, and there is paucity of data on time to symptom improvement using elimination diets in non-Immunoglobulin E (IgE)-mediated food allergies. We therefore aimed to assess the time required to improvement of symptoms using a symptom questionnaire for children with non-IgE-mediated food allergies on an elimination diet. METHODS: A prospective observational study was performed on patients with non-IgE-mediated gastrointestinal food allergies on an elimination diet, who completed a questionnaire that includes nine evidence-based food allergic symptoms before and after the exclusion diet. The questionnaire measured symptoms individually from 0 (no symptom) to 5 (most severe) and collectively from 0 to 45. Children were only enrolled in the study if collectively symptoms improved with the dietary elimination within 4 or 8 weeks. RESULTS: Data from 131 patients were analysed including 90 boys with a median age of 21 months [IQR: 7 to 66]. Based on the symptom questionnaire, 129 patients (98.4%) improved after 4-week elimination diet and only two patients improved after 8 weeks. A statistically significant difference before and after commencing the elimination diet was seen in all nine recorded symptoms (all p < 0.001), and in the median of overall score (p < 0.001). CONCLUSION: This is the first study attempting to establish time to improve after commencing the diet elimination. Almost all children in this study improved within 4 weeks of following the elimination diet, under dietary supervision.
Subject(s)
Food Hypersensitivity/diet therapy , Gastrointestinal Diseases/diet therapy , Adolescent , Child , Child, Preschool , Female , Food Hypersensitivity/diagnosis , Food Hypersensitivity/immunology , Gastrointestinal Diseases/diagnosis , Gastrointestinal Diseases/immunology , Humans , Infant , Infant, Newborn , Male , Prospective Studies , Remission Induction , Risk Factors , Surveys and Questionnaires , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND: The management of food allergy in children requires elimination of the offending allergens, which significantly contribute to micronutrient intake. Vitamin and mineral supplementation are commonly suggested as part of dietary management. However a targeted supplementation regime requires a complete nutritional assessment, which includes food diaries. Ideally these should be analysed using a computerised program, but are very time consuming. We therefore set out to evaluate current practice of vitamin and mineral supplementation in a cohort of children with non-Immunoglobulin E (IgE) mediated food allergies. METHODS: This prospective, observational study recruited children aged 4 weeks - 16 years, who required to follow an elimination diet for non-IgE mediated allergies. Only children that improved according to a symptom score and were on a vitamin and/or mineral supplement were included. A 3-day food diary including vitamin and mineral supplementation was recorded and analysed using Dietplan computer program. We assessed dietary adequacy with/without the supplement using the Dietary Reference Values. RESULTS: One hundred-and-ten children had completed food diaries and of these 29% (32/110) were taking vitamin and/or mineral supplements. Children on hypoallergenic formulas were significantly (p = 0.007) less likely to be on supplements than those on alternative over-the-counter milks. Seventy-one percent had prescribable supplements, suggested by a dietitian/physician. Sixty percent of those without a vitamin supplement had a low vitamin D intake, but low zinc, calcium and selenium was also common. Of the supplemented cohort many continued to be either under or over-supplemented. CONCLUSION: This study has raised the question for the first time, whether clinicians dealing with paediatric food allergies should consider routine vitamin and/or mineral supplements in the light of deficient intake being so common in addition to being so difficult to predict.
ABSTRACT
Cow's milk protein allergy (CMPA) is the most common food allergy in infants and can affect a family's quality of life. The purpose of this paper is to evaluate the knowledge and experience of general practitioners (GPs) in terms of CMPA diagnosis and management and to explore the views of parents on the current diagnostic process. Two surveys were conducted in June 2014, which collected data from GPs and parents of infants diagnosed with CMPA in the United Kingdom. The questionnaires included quantitative and qualitative questions, which measured self-reported knowledge, management and perceived treatment progression, and the educational needs of GPs. We also explored parents' experiences of local healthcare support in relation to CMPA. A total of 403 GPs and 300 parents completed the surveys. The main symptoms of CMPA and diagnosis period differed between GPs and parents. Other key points include different perceptions on symptom presentation and improvement, lack of awareness from GPs about current guidelines, and the significant burden on both families and GPs. This is the first study attempting to establish GP and parental experience in diagnosing CMPA. It is notable that the difference can be improved through training, appropriate diagnostic tools and improved communication between physicians and parents.
Subject(s)
Education, Medical, Undergraduate/methods , Health Status Disparities , Play and Playthings , Problem-Based Learning/methods , Sociology, Medical/education , Students, Medical/psychology , Canada , Education, Medical, Undergraduate/standards , Gender Identity , Humans , Problem-Based Learning/standards , Racial Groups , Sexual Behavior , Socioeconomic FactorsABSTRACT
BACKGROUND: In response to a scarcity of teaching tools regarding the social determinants of health (SDOH), Kate Reeve and Kate Rossiter created The Last Straw! board game, an innovative participatory education tool to facilitate and engage critical thinking about the SDOH. OBJECTIVES: The Last Straw! is designed to encourage discussion about the SDOH, promote critical thinking, and build empathy with marginalized people. METHODS: The game begins as each player rolls the dice to create a character profile, including socioeconomic status (SES), race, and gender. Based on this profile, players then receive a certain number of "vitality chips." Moving across the board, players encounter scenarios that cause them to gain and lose chips based on their profile. The player who finishes the game with the most chips wins the game. The game can be facilitated for a variety of audiences, including both players with no prior knowledge of the SDOH and those experienced in the field. CONCLUSIONS: The game has been played with students, policymakers, and community workers, among others, and has been met with immense enthusiasm. Here, we detail the game's reception within the community, including benefits, limitations, and next steps.