Morning Report
Catherine Suppan
3/20/2019
Background
Two previous hospitalizations
Severe dehydration, emesis, diarrhea; toxic appearance
Elevated lactic acid, very low bicarb, leukocytosis,
hypernatremia, hyperkalemia; PICU level care
W/U: sepsis, genetic/metabolic, GI infxn, CF, RTA, adrenal
insufficiency
Resolved with NPO, pedialyte, and eventually Alimentum,
abnormalities thought to be secondary to dehydration
On discharge second time, metabolics pending, working
diagnosis: FPIES
This Admission
Symptoms started 2PM, 2AM OSH, transferred from OSH
by lifeflight 8AM
Leukocytosis, hypernatremia, hyperkalemia->hypokalemia,
low Ca, elevated BUN and Cr
Thrush
What Else Do You Want To Know or Do?
Poisoning (ethylene glycol) or giving
Similac
Need a level when coming in acutely,
osmole gap
Osmoles measured – osmoles calculated What
[2(Na+K)+glucose/18+BUN/2.8]
We
Metabolic disorder
Thought
All the metabolic labs
FPIES
Food challenge!
What We Did
Hydrate, hydrate, hydrate, replacement, NPO
Food challenge (consult allergy!)
Similac – 0.06-0.6g/kg in three equivalent doses over 30
minutes (worked out to a 3 ounce feed)
Repeat in 4 hours if no response
Had a response (2 hrs)
Stool replacement, boluses
Electrolyte replacement (bicarb)
Lasted ~ 24 hours
Growth Chart
FPIES
Non-IgE mediated hypersensitivity response in the GI
tract
Protracted vomiting and diarrhea 1-4 hours after
exposure
Early vs late (9mos), mild-severe, acute (resolution within
~24hrs) or chronic (intermittent symptoms)
Most common triggers milk and soy
Dx by history and oral food challenge
Types of Hypersensitivity
Type I
Soluble allergen binds to IgE on mast cells, deregulates
Anaphylaxis
Type II
IgG or IgM binds to cellular antigen, activates complement
ABO incompatibility
Type III
IgG or IgM bind to soluble or cellular antigen, forms complexes
Post strep glomerulonephritis, serum sickness
Type IV
T-cells activated by allergens, activate macros, cytokines
Atopic dermatitis
Food Challenges
Used to diagnose or rule out true, IgE mediated food
allergy when allergy is in question (gold standard), skin,
blood test not conclusive or symptoms suspicious,
outgrowing allergies, FPIES, expanding diet, determine
associations with chronic conditions (EoE), cross reactive
foods, food process effects
Food in question eaten slowly, in increasing quantities
“Open”
Close observation!
“Pure” food
Benefits- Conclusive test, reassurance
Risks- Anaphylaxis (no deaths)
Food Specific Protocols
Amount
Time between doses
Observation time
Treatments
Epi, Benadryl, steroids
Most protocols have very little evidence behind them
What it Is NOT
Skin test (prick or patch)—Blood test—OIT
As a PCP
Guidance about food introduction
Modified food trial in office if family history, eczema, family
nervous
Referral to allergist
Current Food Exposure Guidelines
Introduce high risk allergens between 4-6 months of age
Fish, peanut, treenut, egg
Introduce at home, introduce in increasing amounts, one new
food every 3-5 days
High risk: bad eczema, family history
“Primary Prevention of Allergic Disease Through
Nutritional Interventions” 2013; “Learning Early About
Peanut” 2015; Addendum Guidelines for the Prevention of
Peanut Allergy in the US” 2017
INSTRUCTIONS FOR HOME FEEDING OF PEANUT
PROTEIN FOR INFANTS AT LOW RISK OF AN
ALLERGIC REACTION TO PEANUTS
https://www.niaid.nih.gov/sites/default/files/addendum_guidelines_peanut_appx_d.pdf
Resources
1. Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the Diagnosis and Management
of Food Allergy in the United States: Summary of the NIAID-Sponsored Expert
Panel Report. J Allergy Clin Immunol 2010;126:1105-18.
2. Sampson HA, Aceves S, Bock SA, et al. Food allergy: A practice parameter update-
2014. J Allergy Clin Immunol 2014.
3. Nowak-Wegrzyn A, Assa'ad AH, Bahna SL, et al. Work Group report: oral food
challenge testing. J Allergy Clin Immunol 2009;123:S365-83.
4. Nowak-Wegrzyn A 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 & Immunology. J Allergy Clim Immunol 2017.
