Diagnosis and management of Non‐IgE gastrointestinal allergies in breastfed infants—An EAACI Position Paper

Abstract

It is well-established that food proteins, such as egg, soya, cow's milk and wheat, are detectable in breastmilk for many hours or days after ingestion. Exposure to these proteins is important to the process of developing tolerance but can also sometimes elicit IgE-mediated and non-IgE-mediated allergic symptoms in breastfed infants. Non-IgEmediated allergy, outside of food protein-induced allergic proctocolitis and eosinophilic oesophagitis, is not well understood, leading to variations in the diagnosis and management thereof. A primary objective of the European Academy for Allergy and Clinical Immunology is to support breastfeeding in all infants, including those with food allergies. A Task Force was established, to explore the clinical spectrum of non-IgE-mediated allergies, and part of its objectives was to establish diagnosis and management of non-IgE-mediated allergies in breastfed infants. Eight questions were formulated using the Patient, Intervention, Comparison, Outcome (PICO) system and Scottish Intercollegiate | 15 MEYER Et al. Highlights MEYER Et al. consultancy in the past for AbbVie. CV gives academic lectures for Mead Johnson, Abbot, Danone/Nutricia and Nestle; and received research support from Thermo Fisher. AUTH O R CO NTR I B UTI O N S RM involved in the literature review, writing of sections in article, Delphi consensus, merging of article sections and final submission. ACL involved in the literature review, writing of sections in article, Delphi consensus and critical review of publication. CD, RK, ANW, GdT, DF, YV, MCV, OC, PU and NS involved in writing of sections in article, Delphi consensus and critical review of publication. CV involved in the literature review, writing of sections in article, Delphi consensus and critical review of publication.

The Role of Diet Diversity and Diet Indices on Allergy Outcomes

“…In addition to this study, Venter et al (38) recently reported an association between increased diet diversity in the first year of life and reduced odds of food allergy over the first decade of life. In particular, they showed that the introduction of each additional food at 6 months of age reduced by 10.8% the odds of developing food allergy over the first 10 years of life.…”

Non-IgE-Mediated Gastrointestinal Food Allergies in Children: An Update

“…In contrast to FPIAP, symptomatic FPIES is very rare in the breastfed infant. Therefore, the mother should not avoid trigger foods unless symptoms are clearly documented [68,106]. Although no threshold dose has reliably been established in FPIES, only 0.15 g of protein/kg was sufficient to trigger 13/13 acute FPIES reactions to OFC in one study [119].…”

“…In addition, a biopsy suggestive of FPE helps to confirm the diagnosis [81]. In FPIAP, the causative association between the rectal bleeding and antigenic food must be established with a resolution of symptoms upon the elimination of the offending foods, and, preferably, with the documented recurrence of symptoms when foods are re-introduced [106]. Furthermore, other causes of hematochezia, such as anal fissures, must be excluded.…”

“…Occasionally, the elimination of multiple foods may be required, usually soy and/or egg [84]. Recent European guidelines recommend a 2-4 weeks maternal elimination diet, followed by an attempt to re-introduce foods in order to confirm the diagnosis [106]. In those in whom the maternal restriction diet is unsuccessful or too cumbersome, infants can be placed on an EHF instead.…”

“…In FPIAP, cow's milk can be progressively re-introduced in a stepwise manner by 12 months of age in most patients [84,106,174,175]. If the diagnosis is unclear, re-introduction can be attempted earlier, because some infants with mild rectal bleeding may have a self-limiting course [11,13].…”