IgE-Mediated Food Allergy Risk Higher in Kids With Food Protein-Induced Allergic Proctocolitis

By Will Boggs MD

August 31, 2020

NEW YORK (Reuters Health) - Children with food-protein-induced allergic proctocolitis (FPIAP) have a significantly increased risk of IgE-mediated food allergy (IgE-FA), according to a new study.

"The increased risk of IgE-FA in children with FPIAP raises the concern about our current recommendation in management of FPIAP (that is, diet restriction, most commonly dairy and soy)," Dr. Qian Yuan of MassGeneral Hospital for Children, in Boston, told Reuters Health by email. "But the increased IgE-FA is not limited to these foods, indicating that a more complex mechanism is likely involved."

FPIAP, which commonly develops in the first two weeks to two months of life, is treated with avoidance of the trigger antigen, most commonly milk, for the first year of life. IgE-FA, on the other hand, usually occurs later and can be prevented by early introduction of allergenic foods. The two conditions are not thought to be associated with each other.

Dr. Yuan and colleagues used data from the Gastrointestinal Microbiome and Allergic Proctocolitis on healthy infants to investigate whether children with FPIAP were at increased risk for IgE-FA.

Of the 903 infants between the ages of 24 and 59 months analyzed, 17% had FPIAP and 6% had IgE-FA.

Overall, 11% of children with FPIAP developed IgE-FA, compared with 5% of children without FPIAP, the researchers report in Pediatrics.

After adjustment for eczema, children with FPIAP had 1.9 times greater odds of developing IgE-FA, compared with children without FPIAP.

FPIAP was most strongly associated with milk IgE-FA, but the study was not powered to detect a relationship with individual foods.

Based on these findings, the authors recommend continued use of oral challenges to restrict prolonged milk elimination only to those infants with FPIAP who react to postelimination challenge. They also recommend earlier attempts at milk reintroduction and consideration of early peanut and egg introduction for infants with FPIAP.

"The results of our current study call for more in-depth clinical and basic research about non-IgE-mediated FA and IgE-mediated FA," Dr. Yuan said.

He advised physicians to "be aware of the potential development of IgE-FA in children with FPIAP (infants with bloody, mucusy stools and irritability and gastroesophageal reflux symptoms). Be mindful when recommending the diet restriction to infants with FPIAP (either formula changes or diet restriction to moms who are nursing)."

Dr. Scott H. Sicherer of Icahn School of Medicine at Mount Sinai, in New York, who studies food allergy, told Reuters Health by email, "The rate of proctocolitis (FPIAP) at 17% of healthy children is higher than one might have expected and is surprising. The rate of 'regular' IgE food allergy at 6% is in line with what is expected (rates are usually in the 6-10% range)."

"Since FPIAP is supposed to be an allergic disease, you might expect an association with the regular IgE type of allergy, but there is not much study on this," he said.

"The most interesting part is the relatively high rate of milk allergy in those with FPIAP," added Dr. Sicherer, who was not involved in the research. "Milk is the most common food attributed to FPIAP and eliminated from the diet, although it seems details about that (what percent with FPIAP eliminated milk and are they the ones with higher milk allergy) are not included in this report. The 'interesting' part then is that perhaps avoiding the food is causing more IgE-mediated allergy. For this study, it is only a theory with some possible evidence."

Dr. Betul Buyuktiryaki of Koc University Hospital, in Istanbul, who recently identified risk factors influencing features of FPIAP, told Reuters Health by email, "We observed IgE sensitization in 23% of (our) study group, and IgE sensitization was found to be as a risk factor for persistent course and late tolerance development. These findings emphasize that patients with FPIAP might have different phenotypes, as we commonly see in asthma."

"It would be interesting to investigate the children with FPIAP (to see) whether they also develop asthma and/or allergic rhinitis, which would lead to an increase in the burden of allergic diseases and a decrease in the quality of life of patients and parents," said Dr. Buyuktiryaki, who also was not part of the new work. "Although FPIAP is a benign condition that usually resolves by 12 months of age, this new phenotype of patients who develop IgE-FA needs to be followed up for a longer time."

SOURCE: https://bit.ly/2QvbBYw Pediatrics, online August 27, 2020.