Page 1072 - TNFlipTest

P38 Pediatrics
Gastroenterology Toronto Notes 2019 Milk Allergy (MA) & Cow’s Milk Protein Allergy
Pathophysiology
• milkallergy(MA)isIgEmediatedwhereascow’smilkproteinallergy(i.e.foodproteininduced proctocolitis of infancy (FPIPI) is non-IgE mediated and more common
Clinical Presentation
• MAreactionsoccurwithinhoursofexposureandarepresentontheskin(urticarial,pruritus),upper and lower resp tract symptoms (wheeze, cough)
• FPIPIoccursbetween2-8ofinfancy,presentswith:
■ proctocolitis: mild diarrhea, small amounts of bloody stools (common presentation in young infant) ■ enterocolitis: vomiting, diarrhea, anemia, hematochezia, constipation
■ enteropathy: chronic diarrhea, hypoalbuminemia
• upto50%ofchildrenintoleranttocow’smilkmaybeintoleranttosoyproteinaswell
Investigation
• foodchallenge(goldstandard),skinpricktest,serummeasurementofallergen-specificIgE,patch testing
Management
• MA:stopexposure
• FPIPI:stop,reintroducemilkat6-8mo,vastmajority(>90%)willoutgrowintoleranceby1yr
• caseinhydrolysateformula(dairy-freee.g.Nutramigen®,Pregestimil®)ormothermaysequentially
remove cow’s milk protein, all bovine protein, soy protein, legumes (7 d washout), and continue breastfeeding (with adequate calcium and vit D intake)
Inflammatory Bowel Disease
• seeGastroenterology,G19 Cystic Fibrosis
• seeRespirology,P80
Constipation
• decreasedstoolfrequency(<3stools/wk)and/orstoolfluidity(hard,pellet-like)
FUNCTIONAL CONSTIPATION
• 99%ofcasesofconstipation • RomeIIIcriteria
■ ≥2 of the following for at least one month: ◆ ≤2 defecations/wk
◆ history of excessive stool retention
◆ history of large-diameter stools
◆ history of painful or hard bowel movements
◆ history of large diameter stools
■ in toilet trained children, the following additional criteria may be used:
◆ at least one episode/wk of incontinence after the acquisition of toileting skills ◆ history of large diameter stools that may obstruct toilet
Pathophysiology
• lackoffibreindietorchangeindiet,poorfluidintake,behavioural
■ infants: often occurs when introducing cow’s milk after breast milk due to high fat and solute
content, lower water content
■ toddlers/older children: can occur during toilet training, or due to pain on defecation, leading to
withholding of stool
■ two crucial time periods: toilet training and starting school
Management
• education:explanationofmechanismoffunctionalconstipationforparents/olderchildren
• cleanout:PEG3350flakes(1-1.5g/kg/d,max100g/d),picosalax,PEGlyte®
• maintenance:adequatefluidintake(if<6mo,150mL/kg/d),adequatedietaryfibre(fruit,vegetables,
whole grains), stool softening (PEG 3350, mineral oil), appropriate toilet training technique (dedicated
time for defecation: 3-10 min, 1-2 x/d)
• childrenshouldbetreatedforatleast6mo,andshouldnotbeweanedfrommaintenancetherapyuntil
they are having regular bowel movements without difficulty
• regularfollow-upwithongoingsupportandencouragementisessential
Complications
• painretentioncycle:analfissures+painfromwithholdingpassingstool,chronicdilatation±overflow incontinence