Food protein-induced proctocolitis of infancy
- Alan M Lake, MD
Alan M Lake, MD
- Associate Professor of Pediatrics
- Johns Hopkins University School of Medicine
- Section Editors
- Scott H Sicherer, MD, FAAAAI
Scott H Sicherer, MD, FAAAAI
- Section Editor — Food Allergy
- Professor of Pediatrics
- Icahn School of Medicine at Mount Sinai
- B UK Li, MD
B UK Li, MD
- Section Editor — Gastroenterology
- Professor of Pediatrics
- Medical College of Wisconsin
Food protein-induced proctocolitis (formerly known as allergic or eosinophilic proctocolitis, or "protein intolerance") is a common cause of rectal bleeding in an otherwise healthy young infant, and in most cases resolves by late infancy. It is characterized by inflammation of the distal colon in response to one or more food proteins, through a mechanism that does not involve immunoglobulin E (IgE). Cow's milk and soy protein are common triggers. An association of symptoms to food protein antigens requires demonstration of objective improvement following withdrawal of the suspected food antigen, and in some cases, recurrence following a subsequent oral challenge. This disorder will be discussed in this topic review.
Other disorders of infancy characterized by non-IgE-mediated gastrointestinal inflammatory responses to food are food protein-induced enterocolitis syndrome (FPIES), in which the entire gastrointestinal tract is affected and the clinical manifestations are severe , and food protein-induced enteropathy in which the small bowel is affected. These disorders are discussed separately. (See "Food protein-induced enterocolitis syndrome (FPIES)".)
CLASSIFICATION AND TERMINOLOGY
Immunologic reactions to dietary proteins may be classified as immunoglobulin E (IgE)-mediated, non-IgE-mediated, or mixed (table 1). Guidelines from a panel of experts in allergy and immunology published in 2010 clarified the clinical distinctions and pathophysiologic processes implicated in each of these disorders, and established the classification and terminology used in this topic review .
●IgE-mediated – The classical food allergy (food-induced anaphylaxis) is mediated by Ig-E antibodies to food proteins with mast cell activation, and is also termed immediate hypersensitivity. These reactions are rapid in onset, typically beginning within minutes to two hours from the time of ingestion. Signs and symptoms can involve the skin, respiratory and gastrointestinal tracts, and cardiovascular system, in isolation or combination. This type of reaction is discussed in separate topic reviews. (See "Clinical manifestations of food allergy: An overview" and "Food allergy in children: Prevalence, natural history, and monitoring for resolution".)
●Mixed – Some food allergy disorders can have both IgE- and non-IgE-mediated components. These disorders are typically isolated to the gastrointestinal tract and/or skin. They include:
- Nowak-Węgrzyn A, Katz Y, Mehr SS, Koletzko S. Non-IgE-mediated gastrointestinal food allergy. J Allergy Clin Immunol 2015; 135:1114.
- NIAID-Sponsored Expert Panel, Boyce JA, Assa'ad A, et al. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. J Allergy Clin Immunol 2010; 126:S1.
- Willetts IE, Dalzell M, Puntis JW, Stringer MD. Cow's milk enteropathy: surgical pitfalls. J Pediatr Surg 1999; 34:1486.
- Moon A, Kleinman RE. Allergic gastroenteropathy in children. Ann Allergy Asthma Immunol 1995; 74:5.
- Odze RD, Wershil BK, Leichtner AM, Antonioli DA. Allergic colitis in infants. J Pediatr 1995; 126:163.
- Xanthakos SA, Schwimmer JB, Melin-Aldana H, et al. Prevalence and outcome of allergic colitis in healthy infants with rectal bleeding: a prospective cohort study. J Pediatr Gastroenterol Nutr 2005; 41:16.
- Arvola T, Ruuska T, Keränen J, et al. Rectal bleeding in infancy: clinical, allergological, and microbiological examination. Pediatrics 2006; 117:e760.
- Elizur A, Cohen M, Goldberg MR, et al. Cow's milk associated rectal bleeding: a population based prospective study. Pediatr Allergy Immunol 2012; 23:766.
- Lake AM. Food-induced eosinophilic proctocolitis. J Pediatr Gastroenterol Nutr 2000; 30 Suppl:S58.
- Based on Lake J Pediatr Gastroenterol Nutr 2000, updated by the author with additional unpublished data in 2015.
- Patenaude Y, Bernard C, Schreiber R, Sinsky AB. Cow's-milk-induced allergic colitis in an exclusively breast-fed infant: diagnosed with ultrasound. Pediatr Radiol 2000; 30:379.
- Anveden-Hertzberg L, Finkel Y, Sandstedt B, Karpe B. Proctocolitis in exclusively breast-fed infants. Eur J Pediatr 1996; 155:464.
- Pittschieler K. Cow's milk protein-induced colitis in the breast-fed infant. J Pediatr Gastroenterol Nutr 1990; 10:548.
- Lake AM, Whitington PF, Hamilton SR. Dietary protein-induced colitis in breast-fed infants. J Pediatr 1982; 101:906.
- Sekerkova A, Fuchs M, Cecrdlova E, et al. High Prevalence of Neutrophil Cytoplasmic Autoantibodies in Infants with Food Protein-Induced Proctitis/Proctocolitis: Autoimmunity Involvement? J Immunol Res 2015; 2015:902863.
- Odze RD, Bines J, Leichtner AM, et al. Allergic proctocolitis in infants: a prospective clinicopathologic biopsy study. Hum Pathol 1993; 24:668.
- Wilson NW, Self TW, Hamburger RN. Severe cow's milk induced colitis in an exclusively breast-fed neonate. Case report and clinical review of cow's milk allergy. Clin Pediatr (Phila) 1990; 29:77.
- Ravelli A, Villanacci V, Chiappa S, et al. Dietary protein-induced proctocolitis in childhood. Am J Gastroenterol 2008; 103:2605.
- Winter HS, Antonioli DA, Fukagawa N, et al. Allergy-related proctocolitis in infants: diagnostic usefulness of rectal biopsy. Mod Pathol 1990; 3:5.
- Goldman H, Proujansky R. Allergic proctitis and gastroenteritis in children. Clinical and mucosal biopsy features in 53 cases. Am J Surg Pathol 1986; 10:75.
- Baldassarre ME, Laforgia N, Fanelli M, et al. Lactobacillus GG improves recovery in infants with blood in the stools and presumptive allergic colitis compared with extensively hydrolyzed formula alone. J Pediatr 2010; 156:397.
- Sinha CK, Fishman J, Clarke SA. Neonatal Meckel's diverticulum: spectrum of presentation. Pediatr Emerg Care 2009; 25:348.
- United States Food Allergen Labeling and Consumer Protection Act of 2004.
- Fiocchi A, Restani P, Leo G, et al. Clinical tolerance to lactose in children with cow's milk allergy. Pediatrics 2003; 112:359.
- Sicherer SH. Food allergy: when and how to perform oral food challenges. Pediatr Allergy Immunol 1999; 10:226.
- American Academy of Pediatrics. Committee on Nutrition. Hypoallergenic infant formulas. Pediatrics 2000; 106:346.
- Lucarelli S, Di Nardo G, Lastrucci G, et al. Allergic proctocolitis refractory to maternal hypoallergenic diet in exclusively breast-fed infants: a clinical observation. BMC Gastroenterol 2011; 11:82.
- Vanderhoof JA, Murray ND, Kaufman SS, et al. Intolerance to protein hydrolysate infant formulas: an underrecognized cause of gastrointestinal symptoms in infants. J Pediatr 1997; 131:741.
- Lake A. Infantile proctocolitis: are we empirically too casual? J Pediatr Gastroenterol Nutr 2005; 41:14.
- Lazare FB, Brand DA, Marciano TA, Daum F. Rapid resolution of milk protein intolerance in infancy. J Pediatr Gastroenterol Nutr 2014; 59:215.
- CLASSIFICATION AND TERMINOLOGY
- DIETARY TRIGGERS
- CLINICAL PRESENTATION
- DIFFERENTIAL DIAGNOSIS
- Exclusively breastfed infants
- Formula-supplemented or -fed infants
- Evaluating response
- Management of younger siblings
- SUMMARY AND RECOMMENDATIONS