Managing Childhood Diseases

Evaluating inflammation to aid disease management
A wide range of etiologies can trigger the inflammation causing GI distress symptoms like diarrhea, colic, acid reflux, vomiting, and constipation. To unlock the true nature of this inflammatory process it is important to determine if young patients with these symptoms have allergic sensitizations. Such a determination will not only aid treatment but will also help to determine if the patient is embarking on the Allergy March. If the results of specific IgE testing help to rule out an allergic etiology, the clinician can explore possible non-allergic symptom causes. He or she can then select treatments appropriate to the confirmed non-allergic etiology or consider referral if necessary.

If atopy is confirmed, once specific allergens are identified, the main course of action for food allergy is a targeted rotational elimination diet, which may include avoidance of foods in which the allergen is an ingredient. Thorough counseling and patient/parent education is therefore required. To avoid malnourishment, patients may require dietary supplementation. In addition, a wide range of symptom treatments is available for gastrointestinal symptoms and illnesses, with which practitioners are all well versed.

Targeted rotational food elimination diets
In the case of food-borne allergy, removal of the offending allergens from the diet can go a long way toward relieving symptoms. According to the Joint Task Force on Practice Parameters of the American College of Allergy, Asthma & Immunology, the American Academy of Allergy, Asthma and Immunology, and the Joint Council of Allergy, Asthma & Immunology, “elimination of suspected causal foods may be undertaken to determine whether symptoms are diet responsive.”¹ Care should be exercised to maintain adequate nutritional levels, and referral to or consultation with an allergist is generally recommended for a food challenge or elimination diet.²

If the patient’s test report shows multiple food sensitivities and the clinician feels comfortable following through on managing them, it is reasonable to assume that he or she could formulate a rotational food elimination diet based on the patient’s in vitro allergy test results. Such a diet would follow this approach:

• Focus first on the food with the highest reported specific IgE level and counsel the patient’s parents to eliminate that one food from the child’s diet
• Follow up in 2 to 3 weeks to see if symptoms have resolved or improved
• If symptoms have not improved, rotate the diet by counseling elimination of the food that registers the next highest level of specific IgE and adding the previous food back to the patient’s diet
• Patients showing even low-level reactivity to anaphylaxis-prone allergens (eg, peanut, tree nuts, and shellfish) should be referred directly to an allergist for further evaluation
• Elimination may involve avoidance of foods in which an allergen is an ingredient. Thorough counseling and patient/parent education is therefore required.³ To avoid malnourishment, dietary supplementation may be required²
• If the clinician has any doubts or concerns regarding a patient’s diet or the management of food allergy sensitivities, specialist referral is strongly recommended²

Formula switching
In young infants who drink formula, the offending allergen may be one or more ingredients in the formula. Avoidance may be achieved by switching the infant to a different formula, so it is important to know formula ingredients, not only to aid avoidance therapy, but also to ensure proper nutrition. The main source of potential allergy is derived from a formula’s key protein. As a result, formula products are generally categorized as cow’s milk-based, soy-based, or hypoallergenic. In the last category, formulas are either hydrolyzed (in which the cow’s milk protein [casein] is broken down either partially or extensively into amino acids) or amino acid-based (considered the most hypoallergenic).⁴ In order to be labeled hypoallergenic, formulas are required to undergo extensive preclinical studies to ensure that at least 90% of infants with documented cow’s milk allergy will not react with defined symptoms under double-blind, placebo-controlled conditions.⁵ The following chart lists top infant formula brands according to their protein source.

*The formulas listed above are the products or registered trademarks
  of their respective manufacturers.

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