The debate about a possible link between food allergy (FA) and pediatric gastroesophageal reflux disease (GERD) continues, and more, better-designed research is needed, a position paper by the European Academy of Allergy and Clinical Immunology reports.
The report offers consensus-based recommendations and a graphical decision pathway to guide providers through assessing and treating food allergy-related GERD. And the authors call for further, better-designed related research.
Food allergy and GERD are common in babies under 1 year of age and can lead to bothersome GERD, the authors write.
"An extensive literature search has found that whilst food proteins, in particular cow milk protein, can be a contributing factor to FA-associated" GERD, distinguishing between FA and non–FA-associated GERD is difficult, lead author Rosan Meyer, RD, PhD, senior lecturer at Imperial College London, UK, and colleagues from the Academy task force on non-IgE mediated allergy, write in Pediatric Allergy and Immunology.
Consensus Despite Limited Data
Meyer and colleagues developed clinical questions that addressed various aspects of the relationship between food allergy and GERD — pathophysiology, symptoms, diagnosis, dietary and medical management, prevalence, and impact on quality of life.
To address these issues, they systematically searched the literature for randomized controlled, observational, case-control, and retrospective studies of infants and children diagnosed with non-IgE gastrointestinal food allergies and GERD, published in English until February 2021.
Because of limited data in many of these areas, they used a modified Delphi method to reach consensus and provide practical advice on food allergy-associated GERD management.
The task force concludes:
Food proteins, especially cow's milk protein, can contribute to food allergy-associated GERD. The confirmation of food allergy is based on the elimination diet, always followed by reintroducing the offending allergen, and the diagnosis and treatment pathway should consider effects on quality of life.
Breastfeeding should be supported in food allergy-associated GERD, and dietary advice should consider the potential nutritional impact on the breastfeeding mother. When breastmilk is not available or is insufficient, formula and dietary advice to counteract the child's nutrient deficiencies should be considered.
Although some clarity exists about when GERD medications may be considered, they are often used inappropriately and may harm patients, especially infants.
Rigorous Research Needed
"Clinicians can use this algorithm to help them identify patients who may be affected by food allergy-related GERD," Jonathan Tam, MD, medical director of the Gores Family Allergy Center at Children's Hospital Los Angeles, told Medscape Medical News by email.
"Clinicians who suspect their patients may have food allergy-related GERD now have clearer guidance on how to systemically evaluate their patients," added Tam, who was not involved in developing the report.
"Many allergists fear that patients may be labeled with a food allergy unnecessarily. Because no biomarkers or tests for food allergy-related GERD are available, elimination diets are a crucial part of the evaluation," he said.
Tam added that the authors point out two key parts of a trial elimination: First, the trial should last at least 2 weeks, but full resolution may not occur until 6 weeks. Second, targeted elimination must be followed by reintroduction to confirm that the food was causing the symptoms, not that time itself may have been responsible for the clinical change.
"The authors' note on allergy testing is important," he said. "Allergy testing is not necessary when a clinician is concerned about food allergy-related GERD unless there are other associated atopic comorbidities, like eczema or IgE-mediated immediate food allergies."
Jonathan M. Spergel, MD, PhD, chief of the Allergy Section at Children's Hospital of Philadelphia, said in an email that families often ask whether food allergy is causing their child's reflux.
"Both conditions are common and, in most cases, may not be related. As the report highlights, the risk of food allergy is increased if the patient has other atopic disease (atopic dermatitis), and standard allergy testing (skin testing, specific IgE) and IgG4 testing are not recommended," he explained. "Food allergy in a patient with reflux can be considered if standard therapy is failing."
Expert Opinion on Diagnosis and Management
Spergel, also not involved in the report, joined the authors in advocating further, stronger studies. "While the expert opinion is a major strength," he said, "with most available studies being neither randomized nor placebo-controlled, the true prevalence of food allergy reflux is unknown."
Jay M. Portnoy, MD, specialist in pediatric allergy and immunology and medical director of telemedicine at Children's Mercy Kansas City, said: "While most physicians believe that food allergy contributes to GERD, the evidence for the relationship is minimal. Reflux often occurs regardless of what food is eaten," said Portnoy, was not associated with the research.
Before removing a food from the diet, it's important to determine whether that food is causing the problem, he urged.
"Blaming a food is easy. Food allergy is often suspected to cause symptoms it does not cause," he said. "This unfounded blame can lead to unnecessary avoidance, reduce a family's quality of life, and cause malnutrition.
"How a child is evaluated and treated depends as much on which physician they see as on whether the food is the culprit," Portnoy said. "This report is an attempt to clarify the issues and to standardize an approach to the condition, so each provider evaluates and manages the condition in a consistent and evidence-based manner.
"It is important to see how well this report is incorporated into practice and whether following its guidance actually improves patient care," Portnoy noted.
Funding information was not provided. Meyer and two co-authors report financial relationships with the nutritional healthcare industry. The full list can be found with the original article. The remaining authors and Tam, Spergel, and Portnoy report no relevant financial relationships.
Pediatr Allergy Immunol. Published online October 17, 2022. Abstract
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Image 1: Children's Hospital Los Angeles
Image 2: Children’s Hospital of Philadelphia
Image 3: Children's Mercy Kansas City
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Cite this: How Can Clinicians Distinguish Food Allergy and GERD in Young Kids? - Medscape - Dec 01, 2022.