Food allergies and – intolerances greatly impacts quality of life. There is hope. Enjoy reading the following case study on a three-year old female living with multiple food allergies – and intolerances.
Case study_Three-year-old female with multiple food allergies and intolerances
Idonette van Zyl, B Dietetics (UP); MSc Dietetics (NWU)
1. Literature review
Food allergy (FA) is an abnormal immune response to a food protein, mediated by immunoglobulin E (IgE), non-IgE or mixed IgE/non-IgE immunological mechanisms. Non-IgE mediated gastrointestinal food allergic disorders (non-IgEGI-FA) are typically characterised by subacute and/or chronic conditions including i.e. food protein-induced enteropathy (FPE), food protein-induced enterocolitis syndrome (FPIES), food protein-induced allergic proctocolitis (FPIAP), celiac disease, and cow’s milk (CM)-induced iron deficiency anaemia. 1, 2 In addition, non-IgEGI-FA has been implicated as a possible cause in a subset of patients with gastroesophageal reflux disease, chronic emesis and diarrhoea, constipation, and irritable bowel syndrome. 3 In a study conducted by Meyer et al, over 40% of children with non-IgE-mediated protein-induced gastrointestinal allergies also presented with atopic eczema. 4 It has also been reported that 30% to 40% of children with food protein-induced gastrointestinal allergies have feeding difficulties. 5
Food intolerance on the other hand, is a non-immunological response initiated by a food or food component, such as a food additive. 2, 6 Food additives can be classified as preservatives, antioxidants, emulsifiers, stabilisers, flavors, sweeteners and food colouring agents /food colourants (FC). 6 A small number of food additives have been implicated in IgE-mediated or other immunological response. 7 There is a shortage of reproducible well-designed double-blind, placebo-controlled studies, making the understanding of mechanisms, diagnosis and management of food intolerances challenging. 7, 8 In challenge studies, the prevalence of symptoms to food additives has been reported to be 2–7% in atopic children. 9 No studies have been published regarding the prevalence of intolerance or allergic reactions to FCs alone, even in the adult population. 6 Sulphites mostly affect asthmatics and children. Typical adverse effects of sulphites in sensitive individuals include i.e. dermatitis, urticaria, abdominal pain, diarrhea, asthmatic reactions and anaphylaxis. 8, 10
A detailed dietary history is of utmost importance when additives are suspected to be the cause of a reaction, as there are currently no widely accepted diagnostic tests available to assess food additive or chemical sensitivity. 6, 11
2. Patient assessment
2.1 Patient history
Patient H has been diagnosed with multiple non-IgE mediated FA, as well as food intolerances. She was born via caesarian section, at the gestational age of 37 weeks-and-five days. Born to an atopic family, the mother applied a few allergy prevention strategies during pregnancy, as well as after birth, including the use of an emollient as part of daily skincare, up to the age of two years and beyond. Patient H was exclusively breastfed since birth. During that time, she presented with colicky symptoms, explosive foul-smelling stools, frequent night-waking, and abdominal pain. Maternal exclusion of cow’s milk and onions resulted in partial resolution of symptoms. Cow’s milk was later safely reintroduced into the maternal diet at 3 months of age.
During the introduction of complementary feeding, from the age of four-and-a-half months, eczema on her face and dorsum of both hands, rhinorrhea, loss of appetite, allergic “shiners” and constipation associated with peanut consumption. Abdominal pain, mild constipation with painful defecation, behavioural changes, and eczema, associated with cow’s milk intake. Due to a family history of peanut and tree-nut allergies, tree nuts were introduced only later. Upon exposure, she could tolerate pecan nuts, but exerted an acute response including profuse vomiting, diarrhoea, abdominal pain and -distention with loss of appetite, to cashew nuts. Legumes, including soy, and egg forms a part of her usual intake, with no food-associated symptoms.
After a detailed food- and symptom diary was kept, it was also noticed the she experienced behavioural changes including aggression and emotional outbursts, abdominal pain with severe loss of appetite, diarrhoea, vaginal rash, and mild eczema when consuming food, supplements, or medication containing artificial colourants. This association of FC with the latter reactions was first made after consumption of a chocolate flavoured soy milk, containing 4 different artificial colourants, including E133 (brilliant blue), E110 (sunset yellow), E122 (carmoisine) and E104 (quinoline yellow). Patient H consumed the unflavoured version of the same soy milk brand on a daily basis, with no associated symptoms. Artificial colourant associated symptoms resolve within three to seven days after cessation of consumption of the food product. Similar symptoms, with the addition of rhinorrhea occur when she consumes food containing sulphites.
2.2 Anthropometrical assessment
Her birth weight was 2.57 kg (-2 SD), and birth length 48 cm (-1 SD). Her weight-for-length at birth was -1 SD. Her growth at times was slow, however, at the age of three years, her growth standards, including weight-for-age (-1 SD), height-for-age (0 SD), and weight-for-height (-1 SD) reflected adequate growth.
2.3 Biochemical assessment
No allergy tests were done initially. FA was diagnosed based on a detailed and comprehensive history and physical examination by her Paediatrician. At the age of 35 months, corrected calcium, iron studies, and 25-OH Vitamin D tests were done. All the values were within normal range. At the age of three years-and-three months, the Fx5 food mix screen (consisting of cow’s milk, egg white, fish, wheat, peanut and soy) was conducted, with negative results.
2.4 Dietary assessment
Besides avoidance of the trigger foods and food ingredients, she consumes a well-balanced, varied diet, including mostly home-cooked meals. The mother reported a poor appetite, with challenging meal times during the first three years of life. Only after the age of three, eating became more enjoyable as a family. Some of the challenges the family face, include social gatherings and celebrations where a very limited number of shop-bought snacks are cow’s milk, peanut and cashew, artificial colourant, and preservative-free for her to enjoy. Soy milk is used as a cow’s milk substitute. Cow’s milk has approximately six times more calcium per 100 ml than the soy milk brand that she consumed. The dietary reference intakes (DRI) for calcium in children aged 1 – 3 years, is 700 mg per day. Her soy milk provided approximately 20% of her daily requirements. Therefore, additional calcium of 500 mg per day has been supplemented from the age of two-years-and-four months, after weaning off breastmilk. An alternative soy milk, containing higher calcium levels has been discussed with the mother.
2.5 Clinical signs and symptoms upon food challenges
A cow’s milk food challenge was done at home, according to the IMAP guidelines and MILK LADDER 12 at the age of 12 months, and again approximately every eight to ten months thereafter, during the first three years of life. At the age of three, she still reacted to cow’s milk, as well as products containing milk. Peanut was also challenged at home at the age of two, and again at the age of three. Her last peanut challenge resulted in facial eczema, allergic “shiners”, and abdominal discomfort with loss of appetite. Food challenges will continue every one to two years under the guidance of an Allergist.
During those times when patient H is relatively symptom-free, her appetite and food intake is good, with normal age-appropriate stool patterns.
2.6 Medical treatment plan
Patient H responds well to Loratadine, but not to cetirizine. Skin-prick testing for cashews and peanut will be conducted before planning the next food challenge. The milk-ladder will again be used as a guide for a home-based cow’s milk challenge, one year after her last reaction. Tolerance to FCs and sulphites will also be established in time.
Patient H suffers from multiple food allergies, as well as food intolerances. The management of non-IgE mediated allergies and food intolerances remain challenging secondary to few well designed clinical studies, limited availability of diagnostic tests, variable mechanisms of action and symptoms. A detailed patient history, including a thorough diet history with regular follow-up and growth monitoring remains essential. As health care professionals, we should strive to improve the quality of life of families affected by food allergies and intolerances.
- Caubet, J. C., Szajewska, H., Shamir, R., & Nowak‐Węgrzyn, A. (2017). Non‐IgE‐mediated gastrointestinal food allergies in children. Pediatric Allergy and Immunology, 28(1), 6-17.
- Turnbull, J. L., Adams, H. N., & Gorard, D. A. (2015). The diagnosis and management of food allergy and food intolerances. Alimentary pharmacology & therapeutics, 41(1), 3-25.
- Feuille, E., & Nowak-Węgrzyn, A. (2015). Food protein-induced enterocolitis syndrome, allergic proctocolitis, and enteropathy. Current allergy and asthma reports, 15(8), 50.
- Meyer R, Fleming C, Dominguez-Ortega G, Lindley K, Michaelis L, Thapar N, Elawad M, Chakravarti V, Fox AT, Shah N. (2013). Manifestations of food protein induced gastrointestinal allergies presenting to a single tertiary paediatric gastroenterology unit. World Allergy Organization Journal, 6:13.
- Meyer R, Rommel N, Van Oudenhove L, Fleming C, Dziubak R, Shah N. (2014). Feeding difficulties in children with food protein induced gastrointestinal allergies. Journal of Gastroenterology and Hepatology, 29:1764-9.
- Feketea, G., & Tsabouri, S. (2017). Common food colorants and allergic reactions in children: Myth or reality?. Food chemistry, 230, 578-588.
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- Young, E., Patel, S., Stoneham, M. D., Rona, R., & Wilkinson, J. D. (1987). The prevalence of reaction to food additives in a survey population. Journal of the Royal College of Physicians of London, 21(4), 241.
- Vally, H., Misso, N. L., & Madan, V. (2009). Clinical effects of sulphite additives. Clinical & Experimental Allergy, 39(11), 1643-1651.
- Barrett, J. S., & Gibson, P. R. (2012). Fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) and nonallergic food intolerance: FODMAPs or food chemicals? Therapeutic advances in gastroenterology, 5(4), 261-268.
- Fox, A., Brown, T., Walsh, J., Venter, C., Meyer, R., Nowak-Wegrzyn, A., & Vieira, M. C. (2019). An update to the Milk Allergy in Primary Care guideline. Clinical and Translational Allergy, 9(1), 40.