Cow’s-milk-free diet as a therapeutic option in childhood chronic constipation PDF
Preview Cow’s-milk-free diet as a therapeutic option in childhood chronic constipation
O A : G RIGINAL RTICLE ASTROENTEROLOGY Cow’s-Milk–free Diet as a Therapeutic Option in Childhood Chronic Constipation (cid:1)Inaki Irastorza, yBerta Iban˜ez, (cid:1)Lissette Delgado-Sanzonetti, zNatalia Maruri, and §Juan Carlos Vitoria ABSTRACT thirdofconstipatedchildrenwillcontinuetohavetheprobleminto Objectives:Ithasbeenreportedthatanumberofchildrenwithconstipation adulthood(2),whichcontradictstheextendedopinionthatconsti- respondtoadietfreeofcow’s-milk(CM)proteins,althoughevidenceis pationdisappearsbeforeorduringpuberty(3).Reducedingestion lackingtosupportanimmunoglobulinE–mediatedmechanism. ofresidue-richfood(fruitandvegetables)togetherwithexcessive Patients and Methods: We performed an open-label crossover study consumption of milk and dairy desserts have been proposed as a comparing CM and rice milk in 69 children who fulfilled Rome III possiblelinkbetweenmilkandconstipation(4).Morerecently,it criteria for chronic constipation. Clinical, physical, and immunologic has been suggested that cow’s-milk (CM) proteins could play a parametersofpatientswhoresponded(R)andwhodidnotrespond(NR) direct role in the genesis of constipation through an immune- toaCM-freedietwerecompared. mediated mechanism (5–8). The resolution of histologic and Results:Thirty-fiveofthe69children(51%)improvedduringthefirstCM- manometric abnormalities in patients on a CM-free diet further free diet phase, 8 of these did not develop constipation when CM was supports CM etiology (9–11). Despite these published data, few reintroduced,and27children(39%)developedconstipationduringtheCM articles evaluate the influence ofCMonpediatric chronicconsti- challengeandimprovedduringthesecondCM-freedietphase(Rgroup). pation,andthewithdrawalofCMasatherapeuticoptionhashad Thirty-fourchildren(49%)didnotimproveduringthefirstCM-freediet littleimpactinthemedicalcommunityandinpublishedguidelines phase (NR group). Bowel movements per week among R children forthemanagement of thesepatients (12,13). significantly increased compared with NR children (R: 2.8–7.7 vs NR: The aim of the present study was to describe the medical 2.6–2.7) (P<0.001). Seventy-eight percent of the children with history and analytical parameters ofchildren withchronic consti- developmental delay responded to the CM-free diet (P¼0.007). No pation and evaluate the utility of a CM-free diet as a treatment significant statistical difference was found between the R and NR option. children in terms of fiber and milk consumption; atopic or allergic history; full-blood eosinophil count and percentage, and lymphocyte populations; immunoglobulins, immunoglobulin (Ig)G subclasses, total PATIENTS AND METHODS IgE;andserum-specificimmunoglobulinEforCMproteins. Children between 6 months and 14 years of agewhowere Conclusions: A clear association between CM consumption and referred to our tertiary pediatric gastroenterology clinic between constipation has been found in more than one third of children. October2006andDecember2007andfulfilledtheRomeIIIcriteria However, analytical parameters do not demonstrate an immunoglobulin for the diagnosis of pediatric chronic constipation (14,15) were E-mediatedimmunologicmechanism. evaluated for study entry. Children taking medications that can KeyWords:allergy,constipation,cow’smilk causeconstipation,thosewithpreviousabdominalsurgery,piloni- dal sinus, or anatomic abnormalities, or with sensation of pelvic (JPGN2010;51: 171–176) floor were excluded. Informed consent was obtained from the parents of all of the patients involved in the study, which was approvedbytheethicscommittee of thehospital. T he frequency of chronic idiopathic constipation in the Sixty-nine consecutive children who fulfilled the inclusion pediatric population ranges from 3% to 16%, and it is 1 of criteria were included in the study. The parents of 2 patients themostcommonreasonsforseekingmedicaladvice(1).Recently, remembered that their child had passed meconium after the first therehavebeennosignificantadvancesintheunderstandingofthe day oflife, but inboth,constipationhad begun after 6months of mechanismsthatleadtotheonsetofconstipationorinproposing age. Hypothyroidism was ruled out in 7 children with cold intol- effectivetherapeuticapproaches.Itisstillthecasethataroundone erance.Abnormalitiesofthemedullaryconusandthepelvicfloor wereexcludedin2childrenwithahistoryofrecurrenturinarytract ReceivedMarch11,2009;acceptedNovember18,2009. infections and in 2 boys with urinary incontinence who had Fromthe(cid:1)PediatricGastroenterologyUnit,HospitaldeCruces,theyBasque previouslybeencontinent.Ninechildrenhaddevelopmentaldelay: ndationforHealthInnovationandResearch,thezImmunologyLabora- 1 girl with Down syndrome and 8 children with nonsyndromic tory, Hospital de Cruces, and the §University of the Basque Country developmentaldelay,3ofwhomhadassociatedreducedaxialtone. SchoolofMedicine,Bilbao,Spain. Noneof themexperiencedautism or hypothyroidism. Address correspondence and reprint requests to Dr Inaki Irastorza, MD, Patient history items were collected and physical examin- PediatricGastroenterologyUnit,HospitaldeCruces,BarakaldoE48903 ations performed following the recommendations of the 2006 Bizkaia,Spain(e-mail:[email protected]). ConstipationGuidelineCommitteeoftheNorthAmericanSociety Theauthorsreportnoconflictsofinterest. Copyright # 2010 by European Society for Pediatric Gastroenterology, forPediatricGastroenterology,HepatologyandNutrition(Tables1 Hepatology, and Nutrition and North American Society for Pediatric and 2). Gastroenterology,Hepatology,andNutrition Theconsistencyofstoolswasevaluatedusingasemiquanti- DOI:10.1097/MPG.0b013e3181cd2653 tativescaleof5points,basedonasimplifiedversionoftheBristol JPGN (cid:2)Volume 51, Number2,August 2010 171 Copyright 2010 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. Irastorza etal JPGN (cid:2)Volume 51, Number2,August 2010 TABLE1. History in pediatricpatients with constipation TABLE2. Physicalexamination of childrenwith constipation Age General appearance Sex Vital signs Chiefsymptom Temperature Constipation history Pulse Frequency andconsistency ofstools Respiratory rate Pain orbleeding withpassingstools Blood pressure Abdominal pain Growthparameters Waxingand waning ofsymptoms Head, ears,eyes, nose,throat Ageof onset Neck Toilettraining Cardiovascular Fecal soiling Lungsand chest Withholding behavior Abdomen Change inappetite Distension Nausea orvomiting Palpable liverand spleen Weight loss Fecal mass Perianal fissures, dermatitis, abscess, orfistula Anal inspection Current treatment Position Current diet (24-hourrecall history) Stoolpresent aroundanus oronclothes Current medications (forall medical problems) Perianal erythema Oral, enema, suppository,herbal Skin tags Previoustreatment Anal fissures Diet Rectal examination Medications Anal wink Oral, enema, suppository,herbal Anal tone Previoussuccessful treatments Fecal mass Behavioral treatment Presence of stool Results of previous tests Consistency of stool Estimate ofparent/patient adherence Other masses Familyhistory Explosive stool onwithdrawal offinger Significant illnesses Occult blood instool Gastrointestinal (constipation,Hirschsprung disease) Back and spineexamination Other Dimple Thyroid, parathyroid, cysticfibrosis, celiac disease Tuftof hair Medical history Neurological examination Gestational age Tone Time ofpassage ofmeconium Strength Condition atbirth Cremasteric reflex Acute injuryor disease Deep tendon reflexes Hospital admissions Immunizations Allergies Surgeries Delayed growthand development StoolScale(16)(1:veryhardlumpystools;2:hardorverylarge Sensitivity tocold stools;3:normal stools;4:soft-mushystools; 5:liquidstools). Coarse hair Dryskin Study Design and Protocol Recurrent urinarytract infections Daytime urinaryincontinence At the time of the first visit, all of the children were Other consuming CM and/or dairy products. No dietetic or behavioral Developmental history recommendationsweregivenduringthelengthofthestudy.Parents Normal, delayed whosechildrenweretakinglaxativetreatmentsbeforeenteringthe School performance studywereinstructedtocontinueorstopthetreatment,accordingto Psychosocial history theparents’owncriteriaandtheevolutionorresolutionofconsti- Psychosocial disruptionofchild orfamily pation.Thestudywasorganizedin4phases(Fig.1).Dietwasnot Interaction with peers modified during the first week of the study (phase I). After this, Temperament parentswereinstructedtowithdrawCMfromthedietfor3weeks Toilethabits atschool (phaseII).Inchildrenyoungerthan2yearsofage,CMwasreplaced byahydrolyzedCM-proteinformula.Childrenolderthan2years 172 www.jpgn.org Copyright 2010 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. JPGN (cid:2)Volume 51, Number2,August 2010 CM-freeDietas aTherapeutic Option inChronicConstipation Pre-study Phase Phase Phase Phase I II III IV Diet with CM CM-free diet Diet with CM CM-free diet E E E E v v v v a a a a lu lu lu lu a a a a tio tio tio tio n n n n Number of Number of Number of Number of motions motions motions motions Consistency Consistency Consistency Consistency Dairy intake Fiber intake Laxative/enema Laxative/enema FIGURE 1. Study design.CM¼cow’s milk. wereofferedricemilktoreplaceCM.Parentswereinstructednotto and casein) (Phadebas IgE paper radioimmunosorbent test kit, usesoymilkandsoy-containingproductstoreplaceCManddairy PharmaciaDiagnostics,Uppsala,Sweden)andIgAclassautoanti- productsbecauseoftheincreasedprevalenceofsoyallergyamong bodies against tissue transglutaminase were also determined. CM-allergic children(17). Serum-specific IgE antibodies to CM proteins >0.35 KU was ChildrenwhofailedtorespondduringphaseIIfinishedthe regarded as positive. study.Thosechildrenwhoseconstipationresolvedafter3weekson Immunologic studies included flow cytometry analysis of aCM-freedietcontinuedontophaseIII,andCMwasreintroduced peripheral blood lymphocytes to determine total leukocytes forthenext3weeks.Parentswereadvisedtoprovidetheirchildren (CD45), T lymphocytes (CD3), T helper lymphocytes (CD4), T with500mLofmilkperdayduringphaseIII.Childrenwhodidnot cytotoxic lymphocytes (CD8), B cells (CD19), and natural killer becomeconstipatedduringphaseIIIfinishedthestudy,andinthose cells(CD16)usingcommerciallyavailablefluorescentmonoclonal inwhomconstipationrelapsedduringphaseIII,CMwaswithdrawn antibodies(allfromBDBiosciences,Erembodegen,Belgium)ona forthenext3weeks(phaseIV).Accordingtotheirprogressduring FACScan flowcytometer (BDBiosciences). thestudy,childrenwhoseconstipationdidnotresolveduringphase IIwereclassifiedasnonresponders(NR);thosewhoseconstipation Statistical Methods resolved during phase II, relapsed during phase III, and resolved during phase IV were regarded as responders (R); and children Frequencies and percentages were used to describe categ- whose constipation resolved during phase II but did not relapse orical variables, mean and standard deviations for normally dis- duringphase IIIIwere declared indeterminate responders(IR). tributedcontinuousvariablesandmediansandinterquartileranges Constipationwasconsideredresolvedifthechildfulfilledthe fortherest.Wilcoxontestforpairedsampleswasusedtoanalyze followingcriteria:theoccurrenceof3 ormorebowelmovements depositionalfrequencyandconsistencybeforeandafterwithdrawal per week without use of laxative treatment or enemas and no of dairy products for each group, whereas comparisons between discomfort, pain, orirritability duringdefecation. groups both before and after withdrawal of these products were After the end of the study, NR children resumed CM and carriedoutusingtheMann-Whitneytest.Theeffectontheimprove- weregivendieteticadviceandlaxativetreatmentwasprescribedif ment of patients after CM withdrawal of constipation history, constipationpersisted.ChildrenclassifiedasIRcontinuedonCM, anamnesis, physical examination, and immunologic results was whereaschildrenintheRgroupwereinitiallykeptonCM-freediet, evaluated using x2 or Fisher exact tests (categorical variables) or and were given soy milk. Increasing amounts of CM and dairy usingStudentttest,orMann-Whitneytest(continuousvariables). productswereprogressivelyintroducedintheirdiettodeterminethe Logistic regression models were fitted with those covariates that amount of CM or dairy products they were able to tolerate. If had P values <0.1 in the univariate analyses to model the prob- calcium intake was considered insufficient, then calcium supple- ability of improvement in both frequency and consistency as a mentation wasprescribed. functionof thosefactors. Parents were given a notebook and asked to record the following items during the final week of each phase: phase I, depositions and consistency of each deposition, use of laxatives RESULTS orenemas,andingestionofCM,dairyproducts,vegetables,fruits, Baselinecharacteristicsofthe69patientsareshowninTable andcereals;phaseII,depositions,consistencyofeachdeposition, 3.In35children(51%),constipationresolvedduringCM-freediet useoflaxativesorenemas,andingestionofvegetables,fruits,and inphaseII.Thirty-fourpatients(49%)didnotrespondtotheCM- cereals;phaseIII,depositionsandconsistencyofeachdeposition; freediet(NRgroup),andin27of35patientswhoseconstipation phaseIV,depositionsand consistencyofeachdeposition. resolved during phase II, relapse occurred when CMwas reintro- AbloodsamplewastakenfromeachchildduringphaseIto duced during phase III but subsequently resolved in all of them measureperipheraleosinophilcountandserumlevelsofimmuno- duringphaseIV(Rgroup)(Fig.2).Amongthechildrenclassified globulin (Ig) A, IgM, IgG (and IgG subclasses), and total IgE. as responders, constipation resolved within 1 to 5 days after SpecificIgEagainstCMproteins(b-lactoglobulin,a-lactoalbumin, initiating CM-free diet and reappeared again within 2 to 5 days www.jpgn.org 173 Copyright 2010 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. Irastorza etal JPGN (cid:2)Volume 51, Number2,August 2010 TABLE3. Baseline characteristics ofthe 69children Sex,M/F 25/44 Age, mo 60(cid:3)43.2 Ageattheonsetof constipation, mo 16.4(cid:3)27.3 Constipation from birth,no. 23 Duration of constipation, mo 16.3(cid:3)27.3 Discomfort duringdefecation, no. 63 Recurrent abdominalpain,no. 35 Historyof hematochezia,no. 37 Historyof analfissures, no. 38 Sphincter control,no. 59 Fecal incontinence atleast1 wk,no. 18of59 Fecal retention posturing,no. 43 Previoustreatment for 43 constipation, no. Premature birth,no. 3 FIGURE 3. Bowel movements per week. Historyof hospitaladmissions,no. 12 Onset ofbottlefeeding, mo 3.5(cid:3)2.9(13 frombirth) depositions of R and NR children in phase I and phase II of Historyof atopy,no. 15 thestudy. Historyof allergy,no. 5(CMP: 2;mites: 3) There were no significant differences between respondent Celiac diseaseongluten-freediet, no. 3 andnonrespondentchildrenduringstudyphaseI(dietwithCM)in Cold intolerance, no. 7 termsofbowelmovementsperweek(2.85(cid:3)1.85vs2.66(cid:3)1.21), Recurrent urinarytract infection,no. 2 stoolconsistency(1.4(cid:3)0.84vs1.4(cid:3)0.6),anduseoflaxativesand Developmental delay,no. 9 enemas(26%vs38%).Amongnonrespondentchildren,therewere Familyhistory ofchronic 38 nosignificantdifferencesbetweenstudyphaseI(dietwithCM)and phase II (CM-free diet) in terms of bowel movements per week constipation, no. (2.66(cid:3)1.21 vs 2.74(cid:3)1.28), stool consistency (1.4(cid:3)0.6 vs Fecal masses intheleftiliac fossa, no. 16 1.68(cid:3)0.78), and use of laxatives or enemas (38% vs 32%). Hard feces intherectum, no. 39 However, children from the respondent group had significantly Anal lesions, no. 13 (P<0.001)morebowelmovementsperweekandmoreconsistent Social dysfunctionor childabuse, no. 0 stool,anddidnotuselaxativesinCM-freediet(phaseII)compared Malnutrition,no. 0 with phase I (2.85(cid:3)1.85 vs 7.7(cid:3)2.85, 1.4(cid:3)0.84 vs 3(cid:3)0, and 26%vs0%,respectively).Thesedifferenceswerealsosignificant Plus/minusvaluesaremean(cid:3)SD. betweenrespondentandnonrespondentchildrenduringstudyphase CMP¼cow’s-milkprotein. II(P<0.001).MilkanddairyproductconsumptionduringphaseI (dietwithCM)washigherintherespondentgroup(4132(cid:3)945mL/ week)thaninthenonrespondentgroup(3671(cid:3)976mL/week),but of reintroducing CM-containing diet. There were 8 patients who the difference was not significant (P¼0.148). There were no improved with CM-free diet in phase II but did not develop constipation when CM was reintroduced in phase III (IR group). In this group, constipation had improved slowly in 1 to 3 weeks duringphaseII.Figures3and4showthenumberandconsistencyof 69 CM-free diet Improvement No improvement 35 (NR) 34 Diet with CM No relapse Relapse (IR) 8 27 CM-free diet Improvement No improvement (R) 27 0 FIGURE 4. Stool consistency (1: very hard lumpy stools; 2: hard or very large stools; 3: normal stools; 4: soft-mushy FIGURE2. Diagramoftheresponsetocow’s-milk–freediet. stools). 174 www.jpgn.org Copyright 2010 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. JPGN (cid:2)Volume 51, Number2,August 2010 CM-freeDietas aTherapeutic Option inChronicConstipation TABLE4. Clinical history and physicalexamination Rgroup NR group P Sex (male),% 38 33 0.791 Gestational ageatbirth,wk 39((cid:3)1.5) 39((cid:3)1.3) 0.981 Meconium eliminationdelay, % 4 0 0.443 Hospital admissionasneonate, % 19 9 0.447 Ageatwhich bottlefeeding started,mo 3.6((cid:3)2.4) 3.3 ((cid:3)2.3) 0.792 Sphincter control,mo 27((cid:3)7) 25((cid:3)7) 0.374 Atopyhistory,% 19 21 0.635 Allergic history,% 4 12 0.371 Celiac disease(on gluten-freediet) 2 1 0.595 Cold intolerance, % 11 12 1 Recurrent UTI,% 4 3 0.579 Urinaryincontinence, % 0 10 0.499 Recurrent abdominalpain,% 50 50 1 Developmental delay,% 26 6 0.007(cid:1) Familyhistory ofconstipation, % 63 38 0.055(cid:1) Ageat1stvisit, mo 52((cid:3)40) 60((cid:3)40) 0.74 Ageatconstipation onset,mo 15((cid:3)20) 17((cid:3)34) 0.436 Defecation discomfort, % 100 91 0.248 Hematochezia oranal lesions, % 56 56 1 Fecal soilingor encopresis, % 35 33 0.903 Retentive posturing,% 69 70 1 Fecal masses inleftiliac fossa, % 35 20 0.46 Hard feces inrectum, % 41 45 0.815 Anal lesions, % 11 24 0.644 Plus/minusvaluesaremean(cid:3)SD. NR¼nonrespondentgroup;R¼respondentgroup;UTI¼urinarytractinfection. (cid:1) Pvalueaftermultivariateanalysis. differences regarding average fiber consumption between respon- constipation among children with developmental delay may be dent and nonrespondent groups during CM-free diet phase II secondary to their condition, our study shows that 78% of the (47(cid:3)32 vs46(cid:3)38g).Nostatisticallysignificantdifferenceswere childreninthissubgroupalsorespondedtoaCM-freediet.Despite found in constipation history, medical history, or physical exam- thisassociation,thedemonstrationofacausalrelationbetweenCM ination between respondent and nonrespondent groups (Table 4). andconstipationwouldrequireadouble-blindcrossoverplacebo- Forty-eight percent of the respondent children versus 25% of the controlledtrial.ApreviousstudytrialusingchocolateflavorinCM, nonrespondentchildrenhadfirst-degreerelativeswithconstipation soymilk,andricemilkwasunsuccessfulinmaskingthetasteofthe history (P¼0.081). Seventy-eight percent of the children with formulas, andtherefore theideal trialcouldnot beconducted. developmental delay responded to CM-free diet versus 33% of Ithasbeenproposedthatthelinkbetweenconstipationand thechildrenwithoutdevelopmentaldelayimprovedduringCM-free CMingestionistheresultofchildrenconsuminganexcessofdairy diet inphaseII(P¼0.065). products and having a low residue diet because they eat fewer After multivariate analysis of variables with statistical sig- vegetables and, especially, fewer fruits (18). However, in the nificance P<0.1, only developmental delay showed statistical presentstudy,dairyandfiberconsumptionwassimilarinchildren significance (P¼0.007), and although not significant, there was who improved and in those who did not respond after a CM-free atrendsuggestingtheimplicationoffamilialhistoryofconstipation diet, suggesting that dairy products and fiber intake are not pre- (P¼0.055). dictorsof response toCM-free diet. No differences were found between respondent and nonre- Iacono et al (7,8) and Daher et al (19) reported a high spondentgroupsintermsofeosinophilcount,humoralimmunity, prevalenceofpositiveserum-specificIgEantibodiesandskinprick cellularimmunity,CMprotein–specificIgE,andantitissuetrans- testforCMproteinamongconstipatedchildrenwhorespondedtoa glutaminase IgA(Table 5). CM-freediet.Shahetal(20)foundahighprevalenceofpersonal andfamilialhistoryofatopyandfoodallergy.Wehaveobserved thatasimilarpercentageofRandNRchildrendisplayedahistoryof DISCUSSION atopyorallergy,andnodifferenceswerefoundbetweenRandNR To determine whether children with chronic constipation children regarding eosinophil count, total IgE, or CMP-specific could benefit from a CM-free diet, we applied a 4-phase CM serum-specific IgEantibodies. withdrawal and reintroduction protocol to 69 children with the Moreover,ourstudyshowsthattotalimmunoglobulins,IgG conditionwhofulfilledourinclusioncriteria.Thirty-ninepercentof subclasses, and lymphocyte populations were similar in both the children studied responded to a CM-free diet, supporting the groups, in contrast to previous reports suggesting that children hypothesisthatCMplaysasignificantroleinmanychildrenwith experiencing non-IgE-mediated food allergies may present a pat- constipation. Interestingly, although it has been suggested that tern of minor immunodeficiency consisting of increased IgG1, www.jpgn.org 175 Copyright 2010 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. Irastorza etal JPGN (cid:2)Volume 51, Number2,August 2010 TABLE5. Immunologic results Rgroup NRgroup P Eosinophil,(cid:4)1012/L 210(cid:3)109 307(cid:3)254 0.103 CD3þ,% 68.2(cid:3)5.7 67(cid:3)5.7 0.640 CD4þ,% 36.8(cid:3)8.8 38.9(cid:3)4.2 0.456 CD8þ,% 23.4(cid:3)6 23.1(cid:3)5.7 0.930 CD19þ,% 15.2(cid:3)9.2 17.5(cid:3)4.2 0.672 NKcells, % 9.7(cid:3)5.5 9.9(cid:3)5.9 0.971 IgG, mg/dL 943(cid:3)160 940(cid:3)219 0.989 IgA, mg/dL 95(cid:3)60 81(cid:3)54 0.465 IgE,KU/L 13(cid:3)11 92(cid:3)190 0.055 IgM,mg/dL 119(cid:3)68 116(cid:3)43 0.850 IgG1, g/L 7.07(cid:3)1.02 7.21(cid:3)1.4 0.886 IgG2, g/L 1.41(cid:3)0.57 1.16(cid:3)0.72 0.338 IgG3, g/L 0.36(cid:3)0.1 0.4(cid:3)0.17 0.529 IgG4, g/L 0.25(cid:3)0.29 0.42(cid:3)0.63 0.359 CMP-specific IgE þ serum-specificIgE antibodies >0.35KU, % 25 22 1 Anti-tTGIgA þ 0 0 1 Plus/minusvaluesaremean(cid:3)SD. Anti-tTG¼antitissuetransglutaminase;CMP¼cow’smilkprotein;Ig¼immunoglobulin;NK¼naturalkiller;NR¼nonrespondentgroup;R¼respondent group. decreased IgG2/G4, and low-normal IgA levels, together with 9. CarroccioA,ScaliciC,MaresiE,etal.Chronicconstipationandfood increased percentages of CD4 and CD19 and decreased CD8 and intolerance:amodelofproctitiscausingconstipation.ScandJGastro- natural killer lymphocytes (21). In our study, we did not find a enterol2005;40:33–42. recognizable pattern of immune deviation in children with CM- 10. IaconoG,BonventreS,ScaliciC,etal.Foodintoleranceandchronic sensitive constipation. constipation: manometry and histology study. Eur J Gastroenterol However,aclearcauseandeffectlinkbetweenCMingestion Hepatol2006;18:143–50. 11. BorrelliO,BarbaraG,DiNardoG,etal.Neuroimmuneinteractionand andchronicconstipationhasbeenobservedinmorethanonethird anorectal motility in children with food allergy-related chronic con- of children participating in our study. The fact that constipation stipation.AmJGastroenterol2009;104:454–63. resolved and relapsed in 1 to 5 days of CM withdrawal and 12. CrowleyE,WilliamsL,RobertsT,etal.Evidenceforaroleofcow’s reintroduction in respondent children suggests the intervention of milkconsumptioninchronicfunctionalconstipationinchildren:sys- lateallergyreactors.Indeed,ifitwereproventhatconstipationisa tematic review of the literature from 1980 to 2006. Nutr Diet form of food allergy presentation, it should be classified as a 2008;65:29–35. delayed symptom. Most delayed allergic reactions are not IgE 13. ConstipationGuidelineCommitteeoftheNorthAmericanSocietyfor mediated, and therefore IgE-mediated immunologic parameters PediatricGastroenterology,HepatologyandNutrition.Evaluationand should not be expected (22). Our results seem to discard an IgE- treatmentofconstipationininfantsandchildren:recommendationsof mediated mechanism, but we have not obtained any conclusive theNorthAmericanSocietyforPediatricGastroenterology,Hepatology andNutrition.JPediatrGastroenterolNutr2006;43:e1–13. informationregardingotherpossibleimmunemechanismsofcon- 14. Hyman P, Milla PJ, Benninga MA, et al. Childhood functional stipation inourCM-sensitive children. gastrointestinal disorders: neonate/toddler. Gastroenterology 2006; 130:1519–26. REFERENCES 15. Rasquin A, di Lorenzo C, Forbes D, et al. Childhood functional 1. Loening-BauckeV.Constipationinearlychildhood:patientcharacter- gastrointestinal disorders: child/adolescent. Gastroenterology 2006; istics,treatmentandlong-termfollow-up.Gut1993;34:1400–4. 130:1527–37. 2. vanGinkelR,ReitsmaJB,Bu¨llerHA,etal.Childhoodconstipation: 16. LewisSJ,HeatonKW.Stoolformscaleasausefulguidetointestinal longitudinal follow-up beyond puberty. Gastroenterology 2003;125: transittime.ScandJGastroenterol1997;32:920–4. 357–63. 17. OdzeRD,WershilBK,LeichtnerAM,etal.Allergiccolitisininfants. 3. CarroccioA,IaconoG.Chronicconstipationandfoodhypersensitiv- JPediatr1995;126:163–70. ity—anintriguingrelationship.AlimentPharmacol2006;24:1295–304. 18. InanM,AydinerCY,TokucB,etal.Factorsassociatedwithchildhood 4. DavidsonM, KuglerMM, BauerCH. Diagnosisandmanagementin constipation.JPaediatrChildHealth2007;43:700–6. children with severe and protracted constipation and obstipation. 19. DaherS,TahanS,Sole´ D,etal.Cow’smilkproteinintoleranceand JPediatr1963;62:261–5. chronic constipation in children. Pediatr Allergy Immunol 2001; 5. TremolieresJ,VernierJJ.Effectofdeproteinizedmilkserumincon- 12:339–42. stipationandcolibacillosis.ConcoursMed1956;78:2085–6. 20. ShahN,LindleyK,MillaP.Cow’smilkandchronicconstipationin 6. ChinKC,TarlowMJ,AllfreeAJ.Allergytocows’milkpresentingas children.NEnglJMed1999;340:891–2. chronicconstipation.BrMedJ(ClinResEd)1983;287:1593. 21. Latcham F, Merino F, Lang A, et al. A consistent pattern of minor 7. Iacono G, Carroccio A, Cavataio F, et al. Chronic constipation as a immunodeficiencyandsubtleenteropathyinchildrenwithmultiplefood symptomofcowmilkallergy.JPediatr1995;126:34–9. allergy.JPediatr2003;143:39–47. 8. IaconoG,CavataioF,MontaltoG,etal.Intoleranceofcow’smilkand 22. Garcia-CareagaM,KernerJA.Gastrointestinalmanifestationsoffood chronicconstipationinchildren.NEnglJMed1998;339:1100–4. allergiesinpediatricpatients.NutrClinPract2005;20:526–35. 176 www.jpgn.org Copyright 2010 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
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