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Food protein–induced enterocolitis syndrome in an exclusively breast-fed infant—an uncommon entity

Published:February 10, 2012DOI:https://doi.org/10.1016/j.jaci.2011.12.1000
      To the Editor:
      We read with interest the report by Monti et al
      • Monti G.
      • Castagno E.
      • Liguori S.A.
      • Lupica M.M.
      • Tarasco V.
      • Viola S.
      • et al.
      Food protein–induced enterocolitis syndrome by cow's milk proteins passed through breast milk.
      of the only published case of food protein–induced enterocolitis syndrome (FPIES) triggered by cow's milk protein in breast milk. We can also report a case of acute soy FPIES in an exclusively breast-fed infant.
      At age 5 months, the infant received his first bottle of soy formula. Two hours later, he developed profuse vomiting, pallor, and diarrhea. A peripheral blood neutrophilia (6.7 × 109/L; normal 0.5-4.4 × 109/L) was noted following the administration of intravenous fluids. Two weeks later, after drinking soy formula again, he developed profuse vomiting and pallor 2 hours later.
      At age 6 months, the infant remained exclusively breast-fed. One evening, the infant's mother consumed a large serving of soy ice cream for the first time, having previously consumed soy only in processed foods. The child was not breast-fed overnight. Twelve hours later, the mother breast-fed the infant, and 3 hours after the feed, the infant developed profuse vomiting, pallor, and cyanosis and became floppy. The infant was evaluated in our clinic, the skin prick to soy was negative (0 mm), and a diagnosis of soy FPIES was made.
      Unlike the case described by Monti et al,
      • Monti G.
      • Castagno E.
      • Liguori S.A.
      • Lupica M.M.
      • Tarasco V.
      • Viola S.
      • et al.
      Food protein–induced enterocolitis syndrome by cow's milk proteins passed through breast milk.
      our case did not have clinical features consistent with chronic FPIES despite the mother continuing to ingest soy in processed foods. Soy isoflavones are soy proteins found in high concentration in soy foods and are reliable biomarkers of human soy consumption.
      • Franke A.A.
      • Halm B.M.
      • Custer L.J.
      • Tatsumura Y.
      • Hebshi S.
      Isoflavones in breastfed infants after mothers consume soy.
      Excretion of isoflavones into breast milk occurs in a dose-dependent manner, and peak concentrations occur 10 to 14 hours after soy ingestion.
      • Franke A.A.
      • Halm B.M.
      • Custer L.J.
      • Tatsumura Y.
      • Hebshi S.
      Isoflavones in breastfed infants after mothers consume soy.
      We speculate that our case had FPIES after a breast-feeding since the mother ingested a large quantity of soy and soy excretion in breast milk was at a time when peak concentrations are reported to occur.
      Our unit recently published our 16-year experience of FPIES.
      • Mehr S.
      • Kakakios A.
      • Frith K.
      • Kemp A.S.
      Food protein-induced enterocolitis syndrome: 16-year experience.
      We collated further unpublished data whether the pediatrician or allergist had recommended exclusion of the triggering food from the maternal diet. Of the 34 mothers, 21 lactating mothers were instructed to continue to eat the implicated food, in 7 cases it is unclear what advice was given, in 3 cases the infants were not being breast-fed, and in only 3 cases the mother was told to exclude the food trigger in her diet. Although we cannot determine how many of the 21 mothers continued to eat the triggering food, no infant represented to our clinic with a history of breast-milk–induced FPIES. Over the last 3 years (2008-2011), we have evaluated a further 21 breast-fed infants with a history of acute FPIES. No acute FPIES case occurred following a breast-feeding, and in all cases, mothers were eating the implicated food before the initial FPIES reaction without adverse consequences.
      Since food protein(s) in breast milk are detected in variable minute amounts,
      • Vadas P.
      • Wai Y.
      • Burks W.
      • Perelman B.
      Detection of peanut allergens in breast milk of lactating women.
      FPIES triggered by food proteins in breast milk appears to be uncommon, and FPIES to multiple food protein(s) can occur,
      • Nowak-Wegrzyn A.
      • Sampson H.A.
      • Wood R.A.
      • Sicherer S.H.
      Food protein-induced enterocolitis syndrome caused by solid food proteins.
      we would only advocate the removal of the trigger food(s) from the maternal diet if there is a supportive history of breast-milk–triggered reactions.

      References

        • Monti G.
        • Castagno E.
        • Liguori S.A.
        • Lupica M.M.
        • Tarasco V.
        • Viola S.
        • et al.
        Food protein–induced enterocolitis syndrome by cow's milk proteins passed through breast milk.
        J Allergy Clin Immunol. 2011; 127: 679-680
        • Franke A.A.
        • Halm B.M.
        • Custer L.J.
        • Tatsumura Y.
        • Hebshi S.
        Isoflavones in breastfed infants after mothers consume soy.
        Am J Clin Nutr. 2006; 84: 406-413
        • Mehr S.
        • Kakakios A.
        • Frith K.
        • Kemp A.S.
        Food protein-induced enterocolitis syndrome: 16-year experience.
        Pediatrics. 2009; 123: e459-e464
        • Vadas P.
        • Wai Y.
        • Burks W.
        • Perelman B.
        Detection of peanut allergens in breast milk of lactating women.
        JAMA. 2001; 285: 1746-1748
        • Nowak-Wegrzyn A.
        • Sampson H.A.
        • Wood R.A.
        • Sicherer S.H.
        Food protein-induced enterocolitis syndrome caused by solid food proteins.
        Pediatrics. 2003; 111: 829-835

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