Medical Care

The definitive treatment of food protein intolerance is strict elimination of the offending food from the diet.

Breastfeeding is the first choice in infants without lactose intolerance. The mother should eliminate cow's milk (and eventually eggs and fish or other implicated foods) from her diet.

As many as 50% of children affected by cow's milk protein intolerance develop soy protein intolerance if they are fed with soy-based formulas. Therefore, soy-based formulas should not be used for the treatment of cow's milk protein intolerance. Use complete milk protein hydrolysates in infants who cannot be breastfed. Partially hydrolyzed formulas are absolutely not indicated in children with cow's milk protein intolerance. Occasionally, children may develop intolerance toward complete hydrolysated formulas. In these cases, use amino acid–based formulas, which are now widely available and are balanced in trace elements and vitamins.

Eosinophilic gastroenteritis can show clinical and histologic improvement after oral corticosteroid therapy. Topical steroids, administered as inhaled corticosteroids, have also shown beneficial effect.

Consensus recommendations for eosinophilic esophagitis in children and adults by a multidisciplinary group of experts^[43]and management guidelines by ESPGHAN^[40]agree that treatment involves dietary therapy of 3 possible regimens: strict use of amino acid-based formula, dietary restriction based on allergy testing, or dietary restriction based on eliminating the most likely food antigens.

The elemental diet (aminoacid-based formulas) and 6-food elimination diet (withdrawing cow´s milk, wheat, egg, soy, nuts and fish/seafood for 6 weeks) appear to be the more efficacious treatment. However, the high level of restriction (and the need for multiple endoscopies) discourage many patients. A new strategy, starting with a 2-food elimination diet (without animal milk and gluten-containing cereals), followed by a 4-food (animal milk, gluten-containing cereals, egg, legumes), and eventually by a 6-food elimination diet in case of failure, may be better tolerated.^[44]

Swallowed topical steroids (fluticasone propionate or oral viscous budesonide for a minimum of 4 wk and a maximum of 12 wk) should be considered as a treatment option either alone or in combination with an elimination diet.^[45] Treatment with cromolyn sodium, leukotriene receptor antagonists, anti-TNF agents, antibodies against immunoglobulin E (IgE), or interleukin (IL)-5 (reslizumab) and immunosuppressive agents cannot be recommended for treatment in children with eosinophilic esophagitis.^[46]

Administration of food allergens as immunotherapy carries a greater risk of adverse and potentially severe allergic reactions compared with the administration of inhalant allergens.^{[47, 48]}Based largely on the clinical experience published in European trials, the general impression is that food allergen exposure through the oral or sublingual routes is less risky than through the subcutaneous route, but this perception has yet to be deﬁnitively demonstrated.

Recombinant monoclonal humanized anti-immunoglobulin E (IgE) therapy has been approved for the treatment of asthma with associated environmental allergies, but the response can vary with food allergies.

A 9-herb formula based on traditional Chinese medicine is currently under investigation as a treatment for food allergy.^[49]

Although probiotics might have a role in the treatment of food allergy by promoting gut barrier integrity, suppressing intestinal inflammatory responses, and inducing IgA production and tolerogenic immune responses, no evidence suggests that such an approach is effective for induction of tolerance in the clinical setting.^[38]

Current evidence indicates that probiotic treatment does not modify the natural course of food allergy.^[42] However, 4 children treated with Lactobacillus rhamnosus without food restrictions showed a resolution of their symptoms within 7-28 days.^[50]

Medication

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Typical atopic dermatitis on the face of an infant.

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Author

Agostino Nocerino, MD, PhD Chief of Pediatric Oncology, Department of Pediatrics, University of Udine, Italy

Agostino Nocerino, MD, PhD is a member of the following medical societies: Italian Society of Pediatric Emergency and Urgent Care Medicine, Italian Society of Pediatric Hematology and Oncology, Italian Society of Pediatrics

Disclosure: Nothing to disclose.

Coauthor(s)

Stefano Guandalini, MD Founder and Director Emeritus, Celiac Disease Center, University of Chicago; Former Chief, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Chicago Medicine; Professor Emeritus, The University of Chicago Pritzker School of Medicine

Stefano Guandalini, MD is a member of the following medical societies: American Gastroenterological Association, European Society for Paediatric Gastroenterology, Hepatology and Nutrition, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, North American Society for the Study of Celiac Disease

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Imaware.health.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

David A Piccoli, MD Chief of Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia; Professor, University of Pennsylvania School of Medicine

David A Piccoli, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Chief Editor

Carmen Cuffari, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching. for: Abbott Nutritional, Abbvie, speakers' bureau.

Additional Contributors

Chris A Liacouras, MD Director of Pediatric Endoscopy, Division of Gastroenterology and Nutrition, Children's Hospital of Philadelphia; Associate Professor of Pediatrics, University of Pennsylvania School of Medicine

Chris A Liacouras, MD is a member of the following medical societies: American Gastroenterological Association

Disclosure: Nothing to disclose.

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