Pediatric Gastroenterology ______________________ Dr Yasser Negm

1. Dr Yasser Negm

2. 13 May 2017
Yassin – The screaming baby

3. Case scenario (1): Yassin – The screaming baby
• 2 weeks old baby presented to the pediatric clinic with a complaint of inconsolable
crying for few hours on daily basis.
• On exclusive breast feeding.
• Breastfeeding all day and night.
• Regular bowel opening.
• No vomiting.
• Above expected weight gain.
• Normal examination apart from an umbilical hernia. 13 May 2017

4. What would you advise at this stage ?
A. Refer to surgeon for immediate repair of umbilical hernia?
B. Request abdominal ultrasound and urinalysis?
C. Add a comfort formula and probiotics?
D. Reassure the parents, prescribe anti-colic drops and provide general
feeding advice?
E. Do nothing?
13 May 2017

5. Case scenario (1): Yassin – The screaming baby
Whatever you advised didn’t work;
 The parents came back 2 weeks after, claiming that the screaming is worse, especially
on passing stools, but the stools are soft not hard.
 Now, there is vomiting as well.
 Blocked nose and noisy breathing for 10 days.
 Normal weight gain.
 No new examination findings.
13 May 2017

6. What would you advise at this stage ?
A. Start symptomatic treatment for blocked nose and vomiting?
B. Start anti-reflux medication?
C. Trial of anti-reflux formula?
D. Prescribe lactulose for constipation?
E. Trial of exclusion of dairy food from the mother’s diet?
13 May 2017

7. Case scenario (1): Yassin – The screaming baby
The mother excluded dairy from her diet and an anti-reflux medication was given to the
baby with partial improvement over 2 weeks;
 More settled with normal bowel opening.
 Yet, vomiting is still the same.
 Blocked nose and noisy breathing are better but still there.
 Normal weight gain.
 Sarted to have eczematous rash and dry skin.
13 May 2017

8. What is your diagnosis ?
A. Gastro-esophageal reflux?
B. Infantile colic?
C. Lactose intolerance?
D. Multiple food intolerance of infancy?
E. Cow’s milk protein allergy?
13 May 2017

9. Multiple food protein intolerance of infancy
• Intolerance to a wide range of food proteins. Most infants develop
symptoms while they are on only breast milk. Symptoms remit after
multiple exclusions from the diet of a breastfeeding mother or using
an amino acid–based or hydrolysed formula.
• Usually manifests in early childhood and is caused mainly by 7
foods: cow’s milk, eggs, soy, peanuts, tree nuts, wheat and fish.
• Cow's milk proteins are most frequently implicated during infancy.
Soybean protein is the second.
13 May 2017

10. Multiple food protein intolerance of infancy
• Can be immunoglobulin E (IgE) mediated, but most are non-IgE
mediated.
• Non-IgE-mediated reactions are caused by T-cells. The reactions are
generally delayed (manifest up to 48 hours or even 1 week after
ingestion).
• Allergic rash (apart from eczema) is not a predominant symptom in
non-IgE mediated reactions.
13 May 2017

11. 13 May 2017

12. Cow's milk protein allergy
• 45–50% outgrow their allergy at 1 year of age, 60–75% at 2 years and
75–90% at 3 years. It is most likely to persist with a family history of atopy.
• It costs the NHS £ 23.6 million per year to manage CMPA in children.
Treating 1 infant with an extensively hydrolysed formula for 1 year is
estimated to cost £1,000. Using an amino acid-based formula costs £2,500.
• Partially hydrolyzed formulas are absolutely not indicated in children with
cow's milk protein intolerance; only extensively hydrolysed or amino-acid
based.
13 May 2017

13. • Levels of avoidance
Based on:
1. The type of food hypersensitivity:
● Most people with IgE-mediated allergy need to avoid the food completely, including trace
amounts. However, some are able to tolerate well cooked eggs. Some are able to tolerate
heated milk products.
● Some people with non-IgE-mediated allergy can tolerate small amounts of the food to
which they are allergic.
2. The characteristics of the particular protein and its degree of allergenicity:
e.g. Children with nut allergy need to avoid them completely, whereas some with egg
allergy can tolerate small amounts of cooked eggs.
3. The natural history of the hypersensitivity:
Most children will outgrow their milk allergy, but only a few will outgrow their peanut
allergy.
13 May 2017

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17. 13 May 2017

18. Lactose intolerance
• Primary Lactose intolerance in infancy is a rare disorder. This condition is most
common in Finland, where it affects an estimated 1 in 60,000 newborns.
• A review paper by the World Allergy Organization estimated that 1.9% to 4.9%
of children suffer from cow's milk protein allergy (CMA), yet perceived food
allergy could be up to 10 times higher than that confirmed by appropriate tests.
• Symptoms of primary lactose intolerance rarely occur before the age of 6
years.
• Babies with CMPI may temporarily improve on lactose free formula due to
resolution of secondary effects of GIT inflammation, causing secondary lactose
intolerance.
13 May 2017

19. Infantile colic
• A benign, self-limited process in which a healthy infant has
paroxysms of inconsolable crying.
• The standard diagnostic criteria-known as the “rule of 3”—is crying
more than 3 hours/day, more than 3 days/week, for longer than 3
weeks.
• It affects 10% to 40% of infants worldwide and peaks at around 6
weeks of age. Symptoms typically resolve by 3 to 6 months of age.
• Proposed causes include: alterations in fecal microflora, intolerance
to cow's milk, GIT immaturity, increased serotonin secretion, and
poor feeding technique.
13 May 2017

20. 13 May 2017
Infantile colic

21. 13 May 2017
Sara – The reaaally reaaally screaming baby

22. Case scenario (2): Sara – The reaaally reaaally screaming baby
• 3 weeks old baby presented to the pediatric clinic with a complaint of feeding
refusal.
• On breastfeeding + a couple of formula feeds daily.
• No vomiting.
• Slightly constipated.
• Stops breastfeeding after 3 minutes and refuses to take any more. With formula,
takes a bit more (finishes half the bottle in 5 minutes then slows down).
• Suboptimal weight gain.
13 May 2017

23. What would you advise at this stage ?
A. Start Duphalac for constipation?
B. Take more detailed history about symptoms?
C. Observe the baby while feeding?
D. Prescribe anti-colic drops + probiotics?
E. Advice to switch to a comfort formula and discontinue breastfeeding?
F. Ask the mother to modify her diet, reassure her, and book for follow-up
in 2 weeks ?
13 May 2017

24. Case scenario (2): Sara – The reaaally reaaally screaming baby
 Anti-colic drops, diet modification and probiotics didn’t work.
 Came back after few days, with the complaints getting worse + noisy breathing.
Seems to be in bad pain
 On examination, the baby was suspected to have stridor/wheezy chest.
 Diagnosed to have respiratory viral infection.
 Started on nebulizers + steroids (for croup).
 Partially improved and discharged on home treatment.
13 May 2017

25. Case scenario (2): Sara – The reaaally reaaally screaming baby
o Next week, the baby’s screaming turned really really loud, inconsolable and
continuous.
o Now, the baby has torticollis.
o The Baby was noticed to have hiccups during the clinic visit. When queried, the
parents mentioned that the hiccup has been there since birth, but they were told
that it is normal.
o On observation during feeding, the baby was found to have back arching before
refusal to continue.
13 May 2017

26. What is your diagnosis ?
A. Laryngo-pharyngeal reflux?
B. Infantile colic?
C. Gastro-esophageal reflux?
D. Gastro-esophageal reflux disease?
E. Food allergy?
F. Upper respiratory infection
13 May 2017

27. Laryngo-pharyngeal reflux
(Silent Reflux)
 Defined by the reflux of gastric acid into the larynx, oropharynx, and/or nasopharynx.
 Although once believed to be an extension of GERD, the differences in symptoms, findings,
and treatments has led to the evolution of LPRD as a unique and distinct disease process.
 Classically diagnosed by symptomatology in the patient.
 Although confirmation requires objective findings on various tests, including endoscopy, pH
probes, and radiographs, a high index of suspicion must be maintained to diagnose the baby.
 Although LPRD is present in both infants and younger children, it usually presents with a
different set of symptoms depending on age.
13 May 2017

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30. 13 May 2017
Arwa – The leaking baby

31. Case scenario (3): Arwa – The leaking baby
• 11 months old baby presented to the ER with projectile vomiting for 1 day and
diarrhea for 3-4 hours.
• On breastfeeding + solids.
• 3rd episode with the same presentation in 6 weeks.
• No fever.
• Mucous in stools but no blood.
• Weight is 8 kgs. 4 months ago, at 7 months was also 8 kgs.
13 May 2017

32. Case scenario (3): Arwa – The leaking baby
• Dehydrated.
• Given IV fluids and anti-emetics in ER.
• Vomiting and diarrhea continued, so the baby was admitted.
• Stool tests were negative for bacterial infection, rota and adenoviruses. Blood tests
showed no evidence of infection.
• Mother on ward rounds insisted that those episodes happen only whenever the
father visits the family (Lives and works in another city).
• Baby recovered and discharged, but the mother wants to see a specialist for her
baby’s recurrent problem.
13 May 2017

33. What would you advise when you see the baby in the clinic ?
A. Reassure the mother that it was just bad luck to have 3 gastroenteritis episodes
within 6 weeks ?
B. Suscpect that Arwa is allergic to her father ?
C. Offer more investigations into the problem?
D. Offer monitoring and longer follow-up in the clinic with no more tests at this stage?
E. Start the baby on probiotics to improve the immunity of the gut ?
13 May 2017

34. Case scenario (3): Arwa – The leaking baby
• The pediatric gastroenterologist ordered some tests which have shown:
- High fecal eosinophils
- High fecal calprotectin
- Normal RAST, skin prick tests and atopy patch test.
• The family were told that Arwa is allergic to some food, but the doctors are unable to
identify without the help of their history.
• The mother insisted that it is sweet potatoes brought by the father whenever he visits.
The father denied that this could be the trigger.
• Oral challenge test done under medical supervision proving that Arwa is allergic to
sweet potatoes.
• The family stopped giving it, symptoms never recurred and the stool eosinophils
disappeared with normalization of fecal calprotectin.
13 May 2017

35. FPIES (Food protein-induced enterocolitis syndrome)
• A non-IgE-mediated gastrointestinal food hypersensitivity.
• Manifests as profuse vomiting, often with diarrhea, leading to dehydration and
lethargy in the acute setting, or failure to thrive in a chronic form.
• Primarily affects infants.
• Most commonly caused by cow's milk or soy protein, although other foods can be
triggers.
• The diagnosis is based upon the presence of consistent clinical features with
improvement following withdrawal of the suspected causal protein.
13 May 2017

36. FPIES (Food protein-induced enterocolitis syndrome)
• Affected children are often misdiagnosed as having acute viral gastrointestinal illness
or sepsis, delaying diagnosis of FPIES for many months.
• An oral food challenge (OFC) is sometimes performed to confirm the diagnosis or to
determine resolution of the food allergy.
• Treatment consists of elimination of the food trigger(s) from the diet.
• FPIES represents the severe end of the spectrum of food protein-induced
gastrointestinal diseases in infants.
• Cow's milk and soy FPIES resolve in a majority of patients by age three years. However,
patients with solid-food FPIES and/or those with concomitant detectable food-specific
IgE may have a more protracted course.
13 May 2017

37. Message to take home
1- Cow’s milk allergy occurs in exclusively breastfed babies.
2- If they visit twice, it is probably not just a simple colic.
3- Beware the overweight baby breastfeeding all the time (Not hunger
crying).
4- Blocked/runny nose/stridor/wheezes can be signs of food allergy
(link the symptoms).
5- It is not only cow’s milk.
13 May 2017

38. Message to take home
6- It is not lactose intolerance.
7- Allergic babies don’t necessarily have rash.
8- Don’t treat food allergy with an HA formula.
9- Babies with reflux don’t necessarily vomit.
10- Please, take detailed history and observe the feeding if necessary.
13 May 2017

39. References
• Venter C et al. Prevalence and cumulative incidence of food hypersensitivity in the first 3 years of life. Allergy
2008; 63(3): 354-359.
• 0. Guest JF. Resource Implications and Budget Impact of Managing Cow Milk Allergy in the UK. 2008.
Catalyst Health Economics Consultants UK and Guildford: Postgraduate Medical School, Surrey University.
• Carlo Caffarelliet al. Cow's milk protein allergy in children: a practical guide. Italian Journal of Pediatrics 2010
36:5.DOI: 10.1186/1824-7288-36-5.
• Host A, Halken S, Jacobsen HP, Christensen AE, Herskind AM, Plesner K. Clinical course of cow's milk
protein allergy/intolerance and atopic diseases in childhood. Pediatr Allergy Immunol. 2002. 13 Suppl 15:23-8.
• Fiocchi A et al: World Allergy organization diagnosis and rationale for action against Cow's milk allergy
guidelines. World Allergy Organ J. 2010, 3 (4): 57-161. 10.1097/WOX.0b013e3181defeb9.
• Rona RJ, Keil T, Summers C, Gislason D, Zuidmeer L, Sodergren E: The prevalence of food allergy: a meta-
analysis. J Allergy Clin Immunol. 2007, 120 (3): 638-646. 10.1016/j.jaci.2007.05.026.
• Johnson J et al. Infantile Colic: Recognition and Treatment. Am Fam Physician. 2015 Oct 1;92(7):577-582.
• Venkatesan N et al. Laryngopharyngeal Reflux Disease in Children. Pediatr Clin North Am. 2013 Aug; 60(4):
865–878.
• Stavroulaki P. Diagnostic and management problems of laryngopharyngeal reflux disease in children. Int J
Pediatr Otorhinolaryngol. 2006;70:579–90
13 May 2017

40. References
• Venter C et al. Prevalence and cumulative incidence of food hypersensitivity in the first 3 years of life. Allergy
2008; 63(3): 354-359.
• McGuirt WF., Jr Gastroesophageal reflux and the upper airway. Pediatr Clin North Am. 2003;50:487–502.
• May JG, Shah P, Lemonnier L, et al. Systematic review of endoscopic airway findings in children with
gastroesophageal reflux disease. Ann Otol Rhinol Laryngol. 2011;120(2):116–22.
• Moore, D. Food Protein-Induced Enterocolitis Syndrome. (2007, April 11). Retrieved on December 31, 2007
from http://allergies.about.com/od/foodallergies/a/fpies.htm.
• Caubet JC, Nowak-Węgrzyn A. Current understanding of the immune mechanisms of food protein-induced
enterocolitis syndrome. Expert Rev Clin Immunol 2011; 7:317.
• Caubet JC, Ford LS, Sickles L, et al. Clinical features and resolution of food protein-induced enterocolitis
syndrome: 10-year experience. J Allergy Clin Immunol 2014; 134:382.
• González-Delgado P, Caparrós E, Moreno MV, et al. Clinical and immunological characteristics of a pediatric
population with food protein-induced enterocolitis syndrome (FPIES) to fish. Pediatr Allergy Immunol 2016;
27:269.
• Lee E, Campbell DE, Barnes EH, Mehr SS. Resolution of acute food protein-induced enterocolitis syndrome
in children. J Allergy Clin Immunol Pract 2017; 5:486.
13 May 2017