ALLERGIC PROCTOCOLITIS IN INFANTS: analysis of the evolution of the nutritional status

Ludmilla S CAMARGO, Jonas AC SILVEIRA, José AAC TADDEI _and Ulysses FAGUNDES-NETO

RESUMO

Objetivo: Avaliar a evolução antropométrica de lactentes com proctocolite alérgica (PA) no momento do diagnóstico e 1 a 6 meses da intervenção nutricional. Métodos: Coorte retrospectiva de lactentes com diagnóstico de PA acompanhados no Instituto de Gastroenterologia Pediátrica de São Paulo (IGASTROPED), Brasil. Os dados foram obtidos a partir dos prontuários de lactentes atendidos ambulatorialmente, coletando-se informações acerca do diagnóstico clínico, conduta terapêutica e dados antropométricos. A intervenção terapêutica foi caracterizada pela manutenção do aleitamento materno exclusivo com dieta de exclusão materna de seis alérgenos (AME-DEM) ou uso de fórmulas hipoalergênicas (FHA). Resultados: Dos 44 lactentes diagnosticados com PA, 23 eram do sexo feminino. A mediana de idade dos lactentes foi de 3,5 meses no momento da admissão e de 6 meses após a intervenção. A queixa clinica principal foi hematoquezia associada ou não a outros sintomas da PA. A análise da evolução antropométrica quando relacionada às dietas nos dois momentos da investigação não demonstrou diferença estatisticamente significante. Conclusão: A vigência da PA não provocou agravo do estado nutricional dos lactentes e apesar de diferentes intervenções nutricionais, os lactentes se mantiveram dentro do canal de crescimento e ocasionou o desaparecimento total dos sintomas clínicos. Além disso, destaca-se o papel benéfico do AME-DEM no processo de manutenção do estado nutricional do lactente.

Palavras chave: Colite, aleitamento materno, hipersensibilidade a leite, nutrição do lactente.

Introduction

Food allergy (FA) is an adverse reaction to food mediated immune mechanisms and may be the type IgE mediated, not IgE mediated and even the mixed form ^(1,5). The actual prevalence of FA is still unknown and any kind of protein food can trigger an allergic reaction. However, most of the food allergies cases is generated for a food group, and about 90% of the following food allergens are recognized: cow milk, egg, wheat, soy, corn, peanut, fish, seafood ​​and almonds ⁽¹³⁾.

Allergy to cow's milk protein (CMPA) occurs on a larger scale, which affects about 2% to 7% of infants in the first months of life, in this group age, the immune system is not fully yet developed to inflammatory response ⁽¹¹⁾. Whereas food usually included in the diet of infants, replacing breastfeeding is cow's milk, this food is the main allergen directly connected to FA ^(6,2).

Allergic proctocolitis (AP) is a type of food allergy in a group of food hypersensitivities not IgE mediated, also called eosinophilic proctocolitis. The AP pathophysiological mechanism has not fully identified, but it is known that involves the presence of CD8 and TH-2 type cells and eosinophil infiltration in all mucosal layers. Moreover, the presence of current memory cells revealed by testing positive lymphocyte transformation suggests the involvement of T cells in the pathogenesis of AP, associated with the secretion of alpha tumor necrosis factor by activated lymphocytes. Everything suggests that genetic factors exert important role in the expression of FA, since a high incidence of atopy history in the families of children with allergy proctocolitis have been described ⁽⁸⁾.

AP commonly affects infants in the first months of life. It is a transitory disease, which in most cases disappears around the first year of life. The primary cause is the cow´s milk protein and / or soybean associated with breastfeeding, as we know that the diet of breastfeeding act directly in infant feeding.

The clinical manifestations are recurrent and the main complaints are diarrhea, blood in the stool (hematochezia), cramps, intense irritability and difficulty breastfeeding ⁽⁷⁾.

Considering that, the clinical manifestations can be a potential nutritional disorder factor and the limited information available in the literature ⁽¹²⁾, the present study aims to analyze the anthropometric evolution of infants with allergic proctocolitis (AP) at diagnosis and 1 to 6 months of nutritional intervention with monthly evaluation intervals.

Methods

During the period of January 2010 to December 2013 were attended consecutively and prospectively, 44 infants under nine months of age of both gender, with a confirmed diagnosis of allergic proctocolitis in Pediatric Gastroenterology Institute of São Paulo (IGASTROPED). In the first and for the role clinical followed all patients were attended by the same practitioner (UFN).

Within this context of patients, we had 21 boys and 23 girls.

Diagnostic criteria

All patients on the first inquiry presented complaining of hematochezia (bright red blood mixed with the stool) associated with other symptoms such as diarrhea, irritability, cramps and food refusal.

Laboratory examination

Were submitted all patients to the following tests: blood count, stool culture for research pathogens, retoscopia or colonoscopy and rectal biopsy.

Morphological assessment of the rectal mucosa was performed according to the standard of Diaz et al ⁽⁷⁾, namely: Alteration of the surface epithelium, abnormal glandular architecture, mucous content of glands infiltrate the lamina propria, lymphoid nodules, presence of granulomas, parasites, fungi, cytomegalovirus inclusion bodies and other viral inclusions.

The diagnosis of allergic proctocolitis was confirmed using standard of Fiocchi et al ⁽⁹⁾, namely: Presence of rectal bleeding in an infant; exclusion of infectious causes of colitis; symptoms disappear after exclusion milk and dairy products from the diet of the mother and/or child.

Anthropometric measurements

Was collected the weight and length data at the time of diagnosis and 6 months of nutritional intervention with monthly intervals for evaluation. Weight (kg) was determined by electronic scale and length measured by wooden stadiometer. For the assessment of nutritional status analysis was performed based on the z-score weight for age, height for age, weight for height and body mass index (BMI), with the aid of Anthro program version 3.2.2 (2011) ⁽¹⁵⁾, for children up to 5 years and classified according to the World Health Organization (WHO) ⁽³⁾ for each respective index.

Nutritional intervention

1) Patients in exclusive breastfeeding (EBF): the mother was submitted to exclusion diet (MED) of the six major internationally recognized allergens, namely: cow's milk and dairy products, soy, fish and seafood, egg, and wheat derivatives and dried fruits (peanuts, walnuts, almonds, cashews, cocoa and hazelnuts), throughout the intervention period.

2) Patients on artificial feeding: exclusive use of hypoallergenic formulas (HF), such as extensively hydrolysed proteins formulas (HF-EHP) or basic amino acid mixture (HF-BAA).

Statistical Analysis

In the descriptive analysis of the categorical variables were presented as absolute numbers and frequencies, while continuous variables as median and interquartile range (IQR). Inferential analyzes were conducted with as outcome variable the difference among the z-scores of the anthropometric indices between admission and after the intervention. However, since the data of these variables were not normally distributed by the Shapiro-Wilk adhesion test. 

Additionally, we tested the difference of these same variables in relation to the type of diet (AME-DEM vs. FHA) using the Mann-Whitney test, but was not found difference statistically significant, which was the basis for the analysis without this stratification.

All analyzes were conducted using Stata / IC 12.0 (Stata Corp LP, College Station, TX, USA) ⁽¹⁴⁾.

Ethical aspects

The study was approve by the Ethics and Research of the Federal University of São Paulo-UNIFESP / Hospital São Paulo, (n ° 749894).  In the study, copies of the Consent and Informed (IC) to their legal guardian were given for all patients included.

Results

Clinical characteristics

Table 1 shows the general characteristics of the studied group. Of the 44 patients, 23 (52%) were female.

The main clinical manifestation that led to the suspicion of allergic proctocolitis was hematochezia (present in all patients), been unique and exclusive in 13 (29.5%) infants and associated with other symptoms in 31 (70.5%) infants. The most common symptoms associated with hematochezia were severe cramping, irritability, diarrhea, regurgitation, eczematous dermatitis and hard stools.

When we look for the feeding in the admission period 32 (73%) infants were exclusively breastfeeding, 7 (16%) partially hydrolyzed formula (FPH) and 5 (11%) making use of formula milk (FL). After nutrition intervention, 39% of patients remained in EBF-MED feeding, 54% extensively hydrolyzed proteins formulas (HF-EHP), 7% use basis of amino acid mixture of formula (HF-BAA) (Table 1).

Table 2 presents analyzes comparing the nutritional status evaluated in two periods (at the time of diagnosis and after dietary intervention). When performed analysis of pre and post intervention type seeing the difference between the median, it was observed that after the intervention infants gained weight and height in a statistically significant, approaching more  to the normal reference parameters defined by WHO for healthy children ⁽³⁾.

It is important to say that using both forms of treatment (EBF-MED and HF)  the infants maintained satisfactory progress of the anthropometric indicators and disappearance of signs and symptoms in all patients.

Discussion

The present research demonstrated that to assess the anthropometric evolution of infants with allergic proctocolitis at both times (admission and after intervention), there were no significant differences towards gender, clinic complaining of rectal bleeding and weight loss. These observations are consistent with those described by Lozinsky and Morais ⁽¹⁰⁾, in a review article shows that patients often do not have weight loss or impairment of the general state or changes of palpation of the abdomen ⁽¹⁰⁾. These observations point out the importance of nutritional monitoring of these children, since it is know that some manifestations that affect the gastrointestinal tract may implicate in the development of nutritional status of infants ⁽⁴⁾. Aguiar et al. using similar methodology employed in the present study, evaluated 214 children diagnosed with CMPA, the mean age was 3 months and they found that 49.5% of patients with clinical manifestations presented impairment of the digestive system simultaneously with other systems, such as respiratory and the skin. In the same study, they found 34.6% of patients with allergic colitis and when analyzed the nutritional status by ZBMI was identified thinness at 12.9%, 67.8% in normal weight, overweight risk in 15.2% and overweight at 4.1% ⁽²⁾. In accordance to the presented by the review study, we did not find statistically significant differences in relation to nutritional status before and after nutritional intervention by analyzing the parameters only.

Pereira et al. shows similar findings in a study involving 20 infants diagnosed with allergic proctocolitis, as result of the CMPA. In this study 70% of patients were eutrophic, however, the nutritional parameters was measure using the Gomez criteria ⁽¹¹⁾.

It is important to say that studies which demonstrate the effects of nutritional therapy in the development of infants has emphasized the use of hydrolyzed formulas, soy-based formulas and exclusion diets as forms of treatment ^{(2, 16, 11)}. Yonamine et al. followed 168 infants with CMA to evaluating nutritional status, which were separate into two groups, namely: a received soy-based formula and other receive extensively hydrolysed formula. The authors concluded that both treatments promote good evolution of nutritional status according to the Finnish reference standards, and that the choice of formula depends on the patient's tolerance and how much its cost. The retrospective observational study of a Spanish group got the same result as the form of treatment, noting that other food allergies such as eczema and wheezing appear frequently and can be negative for nutritional status⁽¹⁶⁾.

According to the Academy of Breastfeeding Medicine ⁽¹⁾, allergic proctocolitis was one of the topics mentioned for creating the protocol for diseases that can compromise breastfeeding, suggesting not to only excluded cow's milk, but the other allergens (soy, peanut, egg, corn, wheat, strawberry) as well from the maternal diet, so that following the elimination diet the symptoms should disappear ⁽¹⁰⁾.

In our research compared the difference between the median of pre nutritional status parameters and post-intervention, we observed a statistically significant improvement compared to the z-score of H/A and W/A pointing the efficacies of both forms of treatment, exclusive breastfeeding with maternal exclusion diet and hypoallergenic formulas.

One limitation of this study that we can say is about sample size for more evidences and comparison. However, allergic proctocolitis is not a highly prevalent disease, and with no frequent diagnosis ⁽¹⁷⁾, so the sample of 44 infants with a diagnosis of allergic proctocolitis is enough for clinical analysis and obtaining high value information.

Conclusion

Finally, we can conclude that allergic proctocolitis did not induce damage of the nutritional status of infants who receive proper nutrition intervention, if the diagnosis performed early with effective forms of treatment, will provide the infant to maintain the growth channel and complete disappearance of symptoms. Furthermore, it highlights the beneficial role of breastfeeding with maternal diet exclusion in the nutritional maintenance process of infants, a practice that has proved highly effective in the treatment of allergic proctocolitis. Thus, the incentive for mothers to perform the elimination diet and continue breastfeeding should be increased, providing not only a good nutritional status, but also strengthen the "bond mother and child" in such a particular situation such as allergic proctocolitis ; in addition, the introduction of hypoallergenic formulas, may represent expensive or unaffordable for many families.

Acknowledgment

The Federal University of São Paulo and the Pediatric Gastroenterology Institute of São Paulo (IGASTROPED) by all documents necessary for research. CAPES (Higher Education Personnel Improvement Coordination) granted the scholarship.

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