• Pediatric Gastroenterology, Hepatology & Nutrition
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• v.7 no.1
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• pp.40-47
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• 2004

Purpose: A new classification of gastrointestinal food allergy was published, but the changes of terminology between previously reported terms and the new ones were in a state of disorder. This has resulted in confusion between medical communication and diagnostic and therapeutic approaches. The clinical observations of infants presenting with gastrointestinal cow milk allergy (GI-CMA) were performed, and the changes in the terminology reviewed through the published Korean literature. Methods: Between March 2003 and July 2003, data from 37 consecutive infants with GI-CMA, aged 2 weeks to 15 months, were reviewed. The challenge and elimination test of cow milk, and the endoscopic and histologic findings, were used for the seven subdivisions of GI-CMA according to a new classification on the basis of patients' ages, clinical manifestations and location of gastrointestinal lesions. Results: The 37 patients had a mean age of $5.4{\pm}4.8$ months, with those observed in 26 (70.3%) of patients being below 6 months of age. The seven final diagnoses were; cow milk protein-induced enterocolitis (CMPIE) in 12 (32.4%), cow milk protein proctitis (PROC) in 12 (32.4%), IgE-mediated (IGE) in 6 (16.2%), gastroesophageal reflux-associated cow milk allergy (GERA) in 5 (13.5%) and eosinophilic gastroenterocolitis in 2 (5.4%). CMPIE was revealed as the typical type in 7 (18.9%) and the atypical type in 5 (13.5%), and all of typical CMPIE revealed cow milk protein-induced enteropathy. The mean age at symptom onset was $4.3{\pm}0.8$ months, and for those with typical and atypical CMPIE, and PROC and GERA were $3.8{\pm}4.6$, $10.4{\pm}3.8$, $3.4{\pm}3.9$ and $7.8{\pm}5.7$ months, respectively (p<0.05). The period from onset of symptom to diagnosis was $2.4{\pm}3.3$ (0.5~12) months, with those observed in atypical CMPIE and GERA being over 3months. Although the birth weights in all patients were within the 10~90 percentile range, the body weights on diagnoses were below the 3 percentile in 48.6%; IGE 16.7%, EOS 0%, typical CMPIE 85.7%, atypical CMPIE 60.0%, PROC 25.0% and GERA 100% (p<0.05). Through the review of the Korean literature, 8 case reports and 14 original articles for GI-CMA were found. Conclusion: GI-CMA is not a rare clinical disorder and is subdivided into seven categories on the basis of the patient's age, clinical manifestations and location of the gastrointestinal lesions. The terms for GI-CMA are changing with new classifications, and careful approaches are necessary for medical communications.

• Pediatric Gastroenterology, Hepatology & Nutrition
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• v.24 no.4
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• pp.384-391
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• 2021

Purpose: The Cow's Milk-related Symptom Score (CoMiSS^TM) was developed as an awareness tool for evaluating cow's milk-related symptoms in otherwise healthy children. Using a convenience sample of participants, this cross-sectional study aimed to determine CoMiSS^TM values of symptomatic infants based on retrospectively or prospectively obtained information. Methods: CoMiSS^TM values were determined in infants aged <12 months with symptoms suggestive of cow's milk protein allergy or functional gastrointestinal disorders. The exclusion criteria were previous diagnosis with acute or chronic disease, treatment with a therapeutic formula, and in case of breastfeeding, an elimination diet followed by the mother. Two CoMiSS^TM values were assessed. A retrospective collection was defined as the collection of data after initial contact with the medical center but before the first medical consultation. A prospective collection was defined as the collection of data within 24 hours from the time of medical consultation but before starting any therapeutic intervention. The CoMiSS^TM total and individual component scores obtained retrospectively or prospectively were compared between groups using the Wilcoxon signed-rank test. Results: This study was performed between August and November 2019. Data of 110 children (62 males and 48 females), with a mean±standard deviation age of 18.2±11.7 weeks, were obtained. The total CoMiSS^TM value (p<0.001) and some individual component scores (crying, regurgitation, and stool) were significantly lower when collected prospectively than when collected retrospectively. Conclusion: CoMiSS^TM values were retrospectively and prospectively determined. Lower CoMiSS^TM values were obtained during prospective evaluation. Possible differences should be considered when using CoMiSS^TM in clinical practice.

• Pediatric Gastroenterology, Hepatology & Nutrition
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• v.17 no.2
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• pp.74-79
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• 2014

Food protein-induced enterocolitis syndrome (FPIES) is an under-recognized non-IgE-mediated gastrointestinal food allergy. The diagnosis of FPIES is based on clinical history, sequential symptoms and the timing, after excluding other possible causes. It is definitively diagnosed by an oral food challenge test. Unfortunately, the diagnosis of FPIES is frequently delayed because of non-specific symptoms and insufficient definitive diagnostic biomarkers. FPIES is not well recognized by clinicians; the affected infants are often mismanaged as having viral gastroenteritis, food poisoning, sepsis, or a surgical disease. Familiarity with the clinical features of FPIES and awareness of the indexes of suspicion for FPIES are important to diagnose FPIES. Understanding the recently defined clinical terms and types of FPIES is mandatory to suspect and correctly diagnose FPIES. The aim of this review is to provide a case-driven presentation as a guide of how to recognize the clinical features of FPIES to improve diagnosis and management of patients with FPIES.

• Pediatric Gastroenterology, Hepatology & Nutrition
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• v.19 no.3
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• pp.153-161
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• 2016

This paper covers algorithms for the management of regurgitation, constipation and infantile colic in infants. Anti-regurgitation formula may be considered in infants with troublesome regurgitation, while diagnostic investigations or drug therapy are not indicated in the absence of warning signs. Although probiotics have shown some positive evidence for the management of functional gastrointestinal disorders (FGIDs), the evidence is not strong enough to make a recommendation. A partially hydrolyzed infant formula with prebiotics and ${\beta}$-palmitate may be considered as a dietary intervention for functional constipation in formula fed infants. Lactulose has been shown to be effective and safe in infants younger than 6 months that are constipated. Macrogol (polyethylene glycol, PEG) is not approved for use in infants less than 6 months of age. However, PEG is preferred over lactulose in infants >6 months of age. Limited data suggests that infant formula with a partial hydrolysate, galacto-oligosaccharides/fructo-oligosaccharides, added ${\beta}$-palmitate may be of benefit in reducing infantile colic in formula fed infants in cases where cow's milk protein allergy (CMPA) is not suspected. Evidence suggests that the use of extensively hydrolyzed infant formula for a formula-fed baby and a cow's milk free diet for a breastfeeding mother may be beneficial to decrease infantile colic if CMPA is suspected. None of the FGIDs is a reason to stop breastfeeding.

• Nutrition Research and Practice
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• v.16 no.3
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• pp.344-353
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• 2022

BACKGROUND/OBJECTIVES: Hydrolyzed formula is often fed to infants with gastrointestinal or immune issues, such as malabsorption or cow's milk allergy, because enzymatic treatment has rendered it more digestible and less allergenic than standard cow's milk formula (SF). Partially hydrolyzed formula (PHF) should be considered for those infants who are intolerant to extensively hydrolyzed formula. However, there are concerns about the nutritional insufficiencies of PHF. We aimed to evaluate the effects of PHF on the growth and health indicators in infants who were at high-risk of allergic disease and potential candidates for consuming PHF. SUBJECTS/METHODS: A total of 83 infants aged 0-2 mon with a family history of allergies were assigned to consume either PHF or SF until 24 weeks of age. Anthropometric measures were obtained at baseline, 12 weeks, and 24 weeks; blood samples were drawn and evaluated at the end of the study. RESULTS: No significant differences were observed in weight, height, and weight-for-height at any time point in each sex between the PHF and SF groups. At 24 weeks of age, the weight-for-age and height-for-age z-scores of the SF group were higher than those of the PHF group, but there was no significant difference in the weight-for-height z-score. There were no significant differences in levels of white blood cells, hemoglobin, ferritin, protein, albumin, aspartate aminotransferase, alanine aminotransferase, eosinophil cationic protein, and immunoglobulin E. CONCLUSIONS: In this study, there were no differences in growth and blood panels between the infants consuming PHF or SF. Therefore, infants who are unable to tolerate SF can be fed PHF without nutritional concerns about growth.

• Pediatric Gastroenterology, Hepatology & Nutrition
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• v.3 no.1
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• pp.30-40
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• 2000

Purpose: During the first year of life, cow's milk protein is the major offender causing food allergy. Cow's milk allergy (CMA) affects 2~7% of infants, of which approximately one-half show predominantly gastrointestinal symptoms. We studied the clinical types of cow's milk allergy with predominantly gastrointestinal symptoms (CMA-GI) of childhood. Methods: The retrospective study was performed on 30 (male 22, female 8) patients who had diagnosed as CMA-GI during 2 years and 3 months from March 1995 to June 1997. Results: 1) Children with CMA-GI presented in the three types of clinical manifestation on the basis of time to reaction to milk ingestion: Quick (Q) onset (5 cases), Slow (S) onset (20 cases), Quick & Slow (Q&S) (5 cases). 2) Age on admission of the three groups was significantly different (p<0.05): (Q onset: $81.4{\pm}67.1$ days, S onset: $31.9{\pm}12.7$ days, Q&S: $366.0{\pm}65.0$ days). Although the body weight at birth was 10~95 percentile in all patients, body weight on admission was different: (Q onset: 10~50 percentile, S onset: below 10 percentile, Q&S: 10~25 percentile). S onset group was significantly different compared with other groups (p<0.05) and 90% of this one was failure to thrive below 3 percentile. 3) Peripheral leukocyte counts were as followings: (Q onset: $5,700{\sim}12,300/mm^3$, S onset: $10,000{\sim}33,400/mm^3$, Q&S: $5,200{\sim}14,900/mm^3$). Slow onset group was significantly different compared with other groups (p<0.05). Serum albumin levels on admission were as followings: (Q onset: $4.2{\pm}0.4\;g/dl$, S onset: $3.0{\pm}0.3\;g/dl$, Q&S: $4.0{\pm}0.3\;g/dl$). S onset group was significantly different compared with other groups (p<0.05) and 85% of this one was below 3.5 g/dl. 4) Although morphometrical analysis on small intestinal mucosa did not show enteropathy in Q onset and Q&S groups, all cases of S onset revealed enteropathy: 45% of this one showed subtotal villous atrophy, 55 % showed partial villous atrophy. 5) Allergic reaction test to other foods was not performed in S onset group because of ethical problem and high risk in general condition. In Q onset group, allergic reaction to one or two other foods: soy formula, weaning formula and eggs. Q&S goup revealed allergic reactions to several foods or to most of all foods except protein hydrolysate formula: eggs, potatos, some kinds of sea food, apples, carrots, beef and chicken. 6) Serum IgE level, peripheral eosinophil counts, milk RAST, soy RAST, skin test were not significantly different among groups. Conclusion: CMA-GI may present in three clinical ways on the basis of time to reaction to milk ingestion, typical clinical findings and morphologic changes in the small bowel mucosal biopsy specimens. This clinical subdivision might be helpful in diagnostic and therapeutic approaches in CMA-GI. Early suspicion is mandatory especially in S onset type because of high risks with malnutrition and enteropathy.

• Pediatric Gastroenterology, Hepatology & Nutrition
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• v.10 no.2
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• pp.117-128
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• 2007

Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE mediated hypersensitivity disorder, which is associated with mainly gastrointestinal symptoms and has a delayed onset. The vomiting and/or diarrheal symptoms of FPIES typically begin in the first month of life in association with a failure to thrive, metabolic acidosis, and shock. Therefore, the differential diagnosis of FPIES and neonatal or infantile sepsis-like illnesses or gastroenteritis is difficult. The early recognition of indexes of suspicion for FPIES may help in the diagnosis and treatment of this disorder. The diagnosis of FPIES is generally made through clinical practice and food-specific IgE test findings are typically negative in this condition. Therefore, oral cow's milk challenge (OCC) remains the valid diagnostic standard for FPIES. An investigation of positive OCC outcomes helps to find out a diagnostic algorithm of criteria of a positive challenge in FPIES. Moreover, it has not been clearly determined in infantile FPIES when $1^{st}$ follow up-oral food challenge (FU-OFC) should be performed, with what kind of food protein (e.g., cow's milk, soy), and how much protein should be administered. Hence, to prevent the risk of inappropriate FU-OFC or accidental exposure and achieve appropriate dietary management, it is necessary to identify tolerance rates to major foods under the careful follow up of infantile FPIES patients. On the other hand, small intestinal enteropathy with villous atrophy is observed in FPIES and this enteropathy seems to be in part induced by both of epithelial apoptosis and intercellular junctional complex breakdown. The purpose of this report is to introduce an update on diagnostic and therapeutic approaches in FPIES and suggest the possible histopathological evidences in this disorder.

• Pediatric Gastroenterology, Hepatology & Nutrition
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• v.21 no.2
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• pp.101-110
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• 2018

Purpose: Functional constipation (FC) is a common gastrointestinal (GI) problem affecting children's well-being and quality of life. Although polyethylene glycol (PEG) is recommended as the first line therapy, it is not always applicable in lower socioeconomic populations. Hence, this study aimed to compare clinical courses of FC in children treated with different medications in order to identify prognostic factors related to treatment outcomes. Methods: We reviewed the medical records of patients aged ${\leq}15$ years diagnosed with FC according to the Rome IV criteria from 2007 to 2015 at the GI clinic, Songklanagarind Hospital. Baseline characteristic, medical history, and treatment outcomes were collected at first and subsequent visits. Results: Exactly104 patients (median age at diagnosis, 2.8 years) were diagnosed with FC. The number of follow-up visits per patient ranged from 1 to 35. The median duration of follow-up was 18.0 months (range, 6.0-84.2 months). PEG was given to 21% of patients. During the follow up period, 76% of patients experienced first recovery with a median time to recovery of 9.8 months. There were no significant differences in time until first recovery and relapse between patients who received and those who did not receive PEG (p=0.99 and 0.06, respectively). Age >6 years, normal defecation frequency, no history of cow's milk protein allergy, and use of laxatives were associated with successful outcomes. Conclusion: Treatment outcomes between patients who had and never had PEG demonstrated no significant difference in our study. Hence, current practices in laxative prescriptive patterns may be effective.