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.