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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 10  |  Issue : 4  |  Page : 239-241

Unusual presentation of cow's milk protein allergy in a neonate


1 Department of Pediatrics, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
2 Department of Gastroenterology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India

Date of Submission10-May-2021
Date of Acceptance13-Jul-2021
Date of Web Publication24-Sep-2021

Correspondence Address:
Ramesh Srinivasan
Department of Pediatrics, PSG Institute of Medical Sciences and Research, Avinashi Road, Peelamedu, Coimbatore - 641 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.jcn_55_21

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  Abstract 


Cow's milk protein allergy is the most common food protein allergy in children. We report a neonate on breast feeds and formula feeds presenting on day 9 of life with blood in stools, anemia, shock, respiratory failure with multiorgan dysfunction, and recovered with intensive care. Colonoscopy and biopsy confirmed the diagnosis as allergic colitis. Neonate improved with cow's milk protein-eliminated diet. Food protein allergy can present with protean signs and symptoms; high index of suspicion is needed for the prompt early diagnosis.

Keywords: Colonoscopic biopsy, cow's milk protein allergy, food protein-induced allergic proctocolitis, food protein-induced enterocolitis syndrome


How to cite this article:
Palanisamy S, Srinivasan R, Perumal T. Unusual presentation of cow's milk protein allergy in a neonate. J Clin Neonatol 2021;10:239-41

How to cite this URL:
Palanisamy S, Srinivasan R, Perumal T. Unusual presentation of cow's milk protein allergy in a neonate. J Clin Neonatol [serial online] 2021 [cited 2021 Dec 2];10:239-41. Available from: https://www.jcnonweb.com/text.asp?2021/10/4/239/326612




  Introduction Top


Cow's milk protein allergy (CMPA) is the most common food protein allergy in children.[1],[2],[3],[4] Cow's milk-based infant formula is the most common allergen triggering food protein allergy in infants. Although maternal cow's milk intake can lead to secretion of cow's milk protein in breast milk, it is rarely the sole trigger for CMPA.[5] The current case report is to discuss an unusually severe presentation of CMPA in a neonate.


  Case Report Top


A 9-day-old girl presented with blood in stools and marked pallor. She was born at term with birth weight of 2600 g. Vitamin K was given at birth. She was on breastfeeding with occasional formula feeds. She was passing small volume stools 4–5 times a day which was blood stained for the past few days. This was associated with progressive pallor in the baby. There was no significant vomiting. She had good weight gain and crossed her birth weight.

She was lethargic with poor respiratory efforts at admission and started on mechanical ventilation. She had shock requiring fluid boluses and inotrope. There was no hepatosplenomegaly or other bleeding manifestations. The perianal region was normal. Admission hemoglobin was 2.2 g/dl, and packed red blood cell (PRBC) transfusion was done. Hemolytic workup was negative. She had elevated liver enzymes, coagulopathy, thrombocytopenia, hypoglycemia, acute kidney injury, and seizures during the course of hospitalization and was managed appropriately. Her blood culture was negative. Echocardiography initially showed mild ventricular dysfunction which improved later. Ultrasound cranium and abdomen were normal. Barium study ruled out malrotation with intermittent volvulus. PRBC transfusions were repeated on days 2, 5, and 10 of hospitalization. Baby improved and was started on breast milk feeds on day 3. She was discharged on day 10 with provisional diagnosis of clinical sepsis with multiorgan dysfunction. Her discharge hemoglobin was 10.7 g/dl.

During the follow-up on day 37 of life, her weight gain was inadequate and hemoglobin was 7.6 g/dl. After 1 week, mother reported the frequent episodes of blood in stools and was continuing on formula feeds once or twice a day. She was admitted for poor weight gain with hemoglobin 5.9 g/dl and high reticulocyte count. There were no features suggestive of hemolysis. Radionucleotide scan for Meckel's diverticulum was normal. Ultrasound abdomen ruled out duplication cyst. Serum immunoglobulin E was 45 IU/ml (normal <1.5 IU/ml). Esophago-gastro-duodeno (OGD) scopy was normal. Colonoscopy showed the features suggestive of severe allergic colitis. Histopathology of colonoscopic biopsy showed lymphoid hyperplasia with focal tissue eosinophilia (50/high-power field) and occasional microgranulomas suggestive of allergic colitis.

Breastfeeds were continued for the baby with dairy products eliminated from mother's diet. Mother was supplemented with calcium and Vitamin D. Elemental aminoacid-based formula was used for top up feeds. Baby was transfused PRBC on day 2 of admission and was discharged on day 8 with hemoglobin of 9 g/dl. Subsequent follow-up showed improvement in hemoglobin with adequate weight gain. Complementary feeds were started at 5 months of age. Cow's milk-related products were eliminated from baby's diet and Vitamin D with calcium supplements was added. At 10 months' follow-up, she had good weight gain and normal development.


  Discussion Top


Food protein allergies are classified broadly into food protein-induced enterocolitis syndrome (FPIES), food protein-induced allergic protocolitis (FPIAP), food protein-induced enteropathy, and eosinophilic gastroenteritis. FPIAP seems to be the most common type of food protein allergy.[1]

FPIAP is a clinical diagnosis with predominant manifestation being blood in stools. Among infants presenting with blood in stools, 18%–65% might be having FPIAP.[2] Most of the babies appear clinically well though failure to thrive and irritability can occur rarely. Usually, they present within a few months of age and sometimes even as early as 1 week of age. Vitamin K deficiency, malrotation with volvulus, intussusception, and Meckel's diverticulum can also present with blood in stools at this early age and must be ruled out before considering allergic colitis.[6] The case reported here presented with blood in stools but also had life-threatening anemia and shock which is unusual in FPIAP.

FPIES is known to present with hemodynamic instability and hypotension in severe cases. However, as per the international consensus guidelines, the major criteria for diagnosing FPIES are vomiting within 1–4 h of ingestion of cow's milk protein. Extreme lethargy, diarrhea, pallor, hypotension, hypothermia, and need for intravenous fluid support are considered as minor criteria. The diagnosis of FPIES requires the presence of one major criterion with at least three minor criteria.[4] It is also reported that infants <2 months of age with cow's milk-related FPIES are more likely to present with diarrhea and blood in stools, whereas infants older than 2 months of age are more likely to present with vomiting.[4],[7]

OGD scopy in FPIES is likely to show gastric erythema and erosion only in the presence of significant vomiting. Colonoscopy in FPIES with bloody diarrhea shows diffuse inflammation of colon. In FPIAP, colonoscopy shows focal or diffuse colitis with edema and erosion. Colonoscopic biopsy in both the conditions will show the features of inflammation with increased number of eosinophils.[8],[9] Since colonoscopy and colonic biopsy findings are similar in both the conditions, clinical presentation is the main clue to the diagnosis.[10] Based on the clinical features, this baby is more likely to have FPIES even in the absence of significant vomiting. However, the management of both these pathological entities remains the same with the prescription of cow's milk protein eliminated diet.[2],[4]

CMPA should be considered in the differential diagnosis of babies presenting with blood in stool, especially if they are receiving formula feeds. Response to elimination diet with recurrence of symptoms on challenge with cow's milk based diet helps in confirming the diagnosis. The prognosis is good with the early diagnosis and institution of therapeutic elimination diet.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ben-Shoshan M. Food protein-induced allergic proctocolitis: Over- or underdiagnosed? J Allergy Clin Immunol Pract 2020;8:1700-1.  Back to cited text no. 1
    
2.
Mennini M, Fiocchi AG, Cafarotti A, Montesano M, Mauro A, Villa MP, et al. Food protein-induced allergic proctocolitis in infants: Literature review and proposal of a management protocol. World Allergy Organ J 2020;13:100471.  Back to cited text no. 2
    
3.
Petrosino MI, Scaparrotta A, Di Filippo P, Attanasi M, Di Pillo S, Chiarelli F, et al. Food protein-induced enterocolitis syndrome in children: What's known? What's new? Eur Ann Allergy Clin Immunol 2018;50:99-107.  Back to cited text no. 3
    
4.
Nowak-Węgrzyn A, Chehade M, Groetch ME, Spergel JM, Wood RA, Allen K, et al. International consensus guidelines for the diagnosis and management of food protein-induced enterocolitis syndrome: Executive summary-Workgroup Report of the Adverse Reactions to Foods Committee, American Academy of Allergy, Asthma and Immunology. J Allergy Clin Immunol 2017;139:1111-26.e4.  Back to cited text no. 4
    
5.
Tan J, Campbell D, Mehr S. Food protein-induced enterocolitis syndrome in an exclusively breast-fed infant-an uncommon entity. J Allergy Clin Immunol 2012;129:873, author reply 873-4.  Back to cited text no. 5
    
6.
Dupont C. Food protein-induced enterocolitis syndrome and proctocolitis. Ann Nutr Metab 2018;73:8-16.  Back to cited text no. 6
    
7.
Nomura I, Morita H, Hosokawa S, Hoshina H, Fukuie T, Watanabe M, et al. Four distinct subtypes of non-IgE-mediated gastrointestinal food allergies in neonates and infants, distinguished by their initial symptoms. J Allergy Clin Immunol 2011;127:685-8.e1.  Back to cited text no. 7
    
8.
Mehr S, Brown-Whitehorn T. What do allergists in practice need to know about non-IgE-mediated food allergies. Ann Allergy Asthma Immunol 2019;122:589-97.  Back to cited text no. 8
    
9.
Nowak-Węgrzyn A. Food protein-induced enterocolitis syndrome and allergic proctocolitis. Allergy Asthma Proc 2015;36:172-84.  Back to cited text no. 9
    
10.
Sánchez-Salguero CA. Food protein-induced proctocolitis. The shadow of allergic disorders. Allergol Immunopathol (Madr) 2018;46:1-2.  Back to cited text no. 10
    




 

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