Pediatric emergency medicine trisk 2062 2062
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Current Evidence
Food allergy affects nearly 8% of children. Dietary proteins may induce
significant bowel injury via both IgE and non–IgE-based immunologic
mechanisms. Children may present with GER, dysphagia, colic, abdominal
pain, and/or constipation. The symptoms correlate with the portion of GI tract
affected (e.g., dysphagia is seen in EE). These allergic diseases begin at
different ages with FPIES and allergic proctitis affecting primarily infants
while EE more typically is seen in early childhood and later. The symptoms
resolve after the offending protein(s) are eliminated from the diet.
Clinical Considerations
Clinical Recognition
The typical presentation of milk-protein sensitivity (allergic) colitis is that of
acute onset of blood-streaked, mucoid stool in an otherwise well-appearing
infant often younger than 3 months. Blood loss is typically limited, so infants
do not appear acutely ill or dehydrated. They are afebrile, and weight gain has
typically been normal since birth. In contrast, children with FPIES may
present with significant vomiting, diarrhea, and dehydration resulting in
shock. Children with EE often have other chronic symptoms which mimic
GER but are more likely to present to the ED acutely in the case of food
impaction.
Initial Assessment/H&P
Dietary history including any recent changes in the child’s diet or, in the case
of breast-feeding infants the mother’s diet, should be noted. A medical history
of asthma, eczema, or rhinitis may be helpful in older children. A strong
family history of atopy or food allergy may be found. Identification of eczema
may support the diagnosis.
Management/Diagnostic Testing
Infants with allergic proctocolitis are rarely hemodynamically unstable or
seriously ill; therefore, initial ED management is focused on making a
presumptive diagnosis based on history and physical examination, initiating
appropriate dietary therapy (e.g., partially hydrolyzed formula), and/or
arranging adequate follow-up with the patient’s primary care provider or a
pediatric gastroenterologist. One might consider obtaining CBC count with
