Pediatric emergency medicine trisk 2063 2063
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white blood cell (WBC) differential to assess the hemoglobin level and check
for eosinophilia in cases which are severe, refractory, or where there is
concern for anemia. Examination of stool for blood, fecal leukocytes, bacterial
culture should be performed on infants who have proven refractory to dietary
therapy or if there is a known infectious exposure. C. difficile may also be
considered though infants may be colonized with this organism. Infants who
have milk-protein sensitivity colitis will characteristically have leukocytes
seen on fecal smear and eosinophils may also be present. In cases of suspected
food impaction, a two-view CXR is often obtained but often does not identify
the nonradiopaque food item.
Treatment consists of identifying and eliminating the offending protein
from the diet. There is generally improvement in symptoms within 72 hours of
the dietary change, though complete resolution may take weeks. Guaiacpositive stools may also persist for several weeks.
Mothers of breast-feeding infants may be asked to eliminate milk protein or
other suspected culprit proteins from their diet, but breast-feeding can often be
continued. Infants receiving cows’ milk–based or soy protein formulas should
be changed to a formula containing casein hydrolysate as the protein source.
Nutramigen, Pregestimil, and Alimentum are currently available in the United
States. Occasionally, in patients with severe allergic colitis or FPIES, an
amino acid–based elemental formula, such as Neocate or Elecare, is
recommended.
Children with EE presenting with food impaction require removal of the
impaction by either gastroenterology, surgery, or ENT, depending on
institutional protocol.
Clinical Indications for Discharge or Admission
Most children can be safely discharged from the emergency department.
Parents should be counseled that infants who respond to dietary elimination
require follow-up and generally should not be challenged with a milk- or soybased formula until 1 year of age. Allergic symptoms may also change with
age, such as the development of vomiting and diarrhea in addition to GI
bleeding. Infants with evidence of persistent gross bleeding 2 weeks following
formula change require further evaluation and potential consideration for a
more intensive dietary change or workup for an alternative diagnosis.
Children with vital sign instability, significant failure to thrive, failure to
gain weight on amino acid–based formulas, or significant anemia should be
