Severe forms of food allergy | Jornal de Pediatria

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array:1 [ "pt" => array:1 [ "titulo" => "Formas graves de alergia alimentar" ] ] "textoCompleto" => "IntroductionSevere food allergy refers to the abnormal immune response to a certain food in a susceptible host, causing life-threatening clinical syndromes to the latter.<a class="elsevierStyleCrossRef" href="#bib0110">1</a> These reactions are reproducible each time the food is ingested and, most of the time, are dose-independent.<a class="elsevierStyleCrossRef" href="#bib0110">1</a> They comprise food-induced anaphylaxis, which is mediated by IgE and the acute form of the food-protein-induced enterocolitis syndrome (FPIES), thought to be mediated by cells.<a class="elsevierStyleCrossRef" href="#bib0115">2</a>Anaphylactic reactions to eggs and fish have been described since the 16th and 17th centuries. Decades ago, it was a rare event, but a progressive increase in its prevalence has been observed; currently, severe food allergy is the main cause of emergency care due to anaphylaxis.<a class="elsevierStyleCrossRef" href="#bib0120">3</a> Milk, eggs, peanuts, nuts, walnuts, wheat, sesame seeds, crustaceans, fish, and fruit are some of the foods that can precipitate allergic emergencies.In Brazil, a survey aimed at allergists indicated food allergy as the second cause of anaphylaxis. The main culprits were cow's milk and egg whites in infants and preschoolers, and crustaceans in older children, adolescents, and adults.<a class="elsevierStyleCrossRef" href="#bib0125">4</a> In a meta-analysis of the literature, the estimated incidence of fatality in high-income countries due to food anaphylaxis in children under 19 years of age was 3.25 per million persons/year.<a class="elsevierStyleCrossRef" href="#bib0130">5</a> The early establishment of the correct and immediate diagnosis and treatment by the emergency pediatrician can prevent lethality and effectively save lives.The objective of this article is to guide the physician in the diagnostic and therapeutic management of severe forms of food allergy, based on an active search in the Medline database using the terms “severe food allergies,” “anaphylaxis and food allergy,” and “food protein induced enterocolitis” within the last ten years; the search comprised the title, abstract, and keyword fields. The review and recommendation articles that were useful, according to the authors’ evaluation, were selected for reading in full to support the article scope.The two food allergy situations that lead the patient to emergency care are food anaphylaxis and FPIES, which are clinical entities with different presentations and management and will be approached sequentially in this article. However, in both approaches, the emphasis will be on the pathophysiology and associated aspects in the diagnosis, emergency treatment, and patient guidance.Anaphylaxis due to food allergyPhysiopathology and associated aspectsFood anaphylaxis is the severe IgE-mediated reaction to food, in which generalized and life-threatening vasodilation occurs. The release of vasoactive mediators into the bloodstream can lead to vascular collapse, anaphylaxis, and shock. Vasodilation is accompanied by hypotension and hypoperfusion, which can compromise vital organs such as the brain and heart, resulting in ischemia and death. When cardiovascular symptoms, such as hypotension and shock, and neurological symptoms, such as mental confusion, loss of consciousness, and sphincter relaxation are present, the risk of death is high. Epinephrine administration and lower limb elevation, restoring vascular tonus and venous return, are life-saving measures.<a class="elsevierStyleCrossRef" href="#bib0125">4</a>Anaphylaxis occurs with the progressive increase in vascular permeability, in which relatively minor symptoms appear earlier and foretell a potentially fatal condition. It all starts with the exposure to a food allergen, which forms a bivalent binding with the specific IgE that is fixated in the high-affinity receptors of mast cells. Through the ion channels, this binding leads to reticular activation and to the release of mediators such as histamine (the main mediator of erythema and pruritus) and several other potent neo- and pre-formed vasodilators, which cause edema in the superficial and deep dermis and subcutaneous cell tissue, resulting in urticaria and angioedema. In the digestive system, this process causes nausea, vomiting, and diarrhea and, in the respiratory tract, intense coryza, sneezing, coughing, bronchospasm, laryngeal edema, and even apnea.<a class="elsevierStyleCrossRefs" href="#bib0125">4,6,7</a>The presence of generalized urticaria and angioedema are often the initial symptoms, indicating that vasodilation and bronchoconstriction are imminent and the patient must be identified and treated urgently to restore the vascular tonus.<a class="elsevierStyleCrossRefs" href="#bib0145">8,9</a> The association with asthma increases reaction severity, and response to treatment is much more difficult. It has been observed that up to 75% of the patients with fatal anaphylaxis had concomitant asthma.<a class="elsevierStyleCrossRefs" href="#bib0135">6,7,9</a>Sometimes, severe food allergy develops during exercise, in association with a specific food (up to 4h after ingestion), characterizing a food-dependent exercise-induced anaphylaxis. Exercise may promote increased absorption of the inadequately processed allergen and/or promote the degranulation of sensitized basophils and mast cells, or further promote an over-synthesis of arachidonic acid metabolites.<a class="elsevierStyleCrossRef" href="#bib0155">10</a> In this case, anaphylaxis results from the association of food and exercise, while food or exercise, alone, are well tolerated. Wheat is the most common allergen, but other grains, nuts, and other foods have also been implicated.<a class="elsevierStyleCrossRefs" href="#bib0125">4,10</a>Food-dependent exercise-induced anaphylaxis may be precipitated by associated factors, such as the consumption of anti-inflammatories, especially aspirin, and the use of alcohol, which is common among adolescents.<a class="elsevierStyleCrossRefs" href="#bib0155">10,11</a>The severity of food allergic reactions will depend on the amount of ingested allergen, its stability against digestion, and epithelial permeability.<a class="elsevierStyleCrossRefs" href="#bib0155">10,11</a> Associated factors, such as age, drug use at the reaction onset, persistence of severe allergic rhinitis, history of previous anaphylaxis, exercise, and concomitant diseases, must be considered.<a class="elsevierStyleCrossRefs" href="#bib0155">10,11</a> The dose and type of food allergen that sensitizes and causes severe food allergy may vary between individuals, and may even vary in the same individual on different occasions. When the food allergen is hidden, it can result in delayed identification of the culprit agent and greater risk for patients.<a class="elsevierStyleCrossRef" href="#bib0160">11</a>Adolescents are at increased risk of fatal anaphylaxis because of greater difficulty in following the exclusion diet. Acute infectious diseases facilitate mast cell degranulation and favor the onset of severe food anaphylaxis in the presence of the specific allergen. Similarly, excessively hot showers and use of fever medication may predispose to more severe reactions, as they alter intestinal permeability.<a class="elsevierStyleCrossRef" href="#bib0160">11</a>In infants, cow's milk protein is the most common precipitating agent of food anaphylaxis, but egg, soybean, and other proteins may also be implicated.<a class="elsevierStyleCrossRefs" href="#bib0110">1,4</a> In schoolchildren and adolescents, allergies to crustaceans, fish, peanuts, walnuts, and cashews predominate as potentially life-threatening situations.<a class="elsevierStyleCrossRef" href="#bib0125">4</a> Wheat is the most common precipitant of exercise-dependent food-induced anaphylaxis, through a protein fraction found in gluten, 5-omega gliadin.<a class="elsevierStyleCrossRef" href="#bib0155">10</a>Diagnosis of food anaphylaxisThe diagnosis of food anaphylaxis is relatively easy to attain. It is important to emphasize that, because it is a potentially fatal allergic reaction, it should be treated as a medical emergency with the immediate administration of epinephrine; therefore, the diagnosis should be associated with prompt treatment, so that the results are favorable.<a class="elsevierStyleCrossRefs" href="#bib0135">6,7</a> Food anaphylaxis occurs suddenly, within a few minutes or a few hours after food intake, with intense pruritus and generalized erythematous plaques that tend to converge. This picture is often accompanied by lip, eye, or even tongue and uvula angioedema, followed by further involvement of at least one of the following organ systems: respiratory (dyspnea, wheezing/bronchospasm, stridor, hypoxemia), cardiovascular (hypotension, hypotonia, shock), gastrointestinal (nausea, vomiting, abdominal pain), and neurological (mental confusion, lipothymia, loss of consciousness). In up to 20% of cases, anaphylaxis can occur with two or more of these affected organ systems, but without cutaneous involvement, which makes the diagnosis much more difficult.<a class="elsevierStyleCrossRefs" href="#bib0125">4,6</a> Anaphylaxis should be mainly differentiated from vaso-vagal syndrome (in this case, the skin is cold, pale, and moist), from an acute crisis of severe asthma, and from post-feeding generalized acute urticaria, which, as previously mentioned, can be considered and managed as anaphylaxis.<a class="elsevierStyleCrossRefs" href="#bib0125">4,6,8,9,11</a>Although urticaria and angioedema are common signs of food allergic reactions, especially during anaphylaxis, it is important to note that their absence does not exclude the possibility of severe food allergy. Up to 20% of cases of food anaphylaxis may present without cutaneous symptoms, and the absence of these symptoms may result in late identification and treatment delay, as well as increased lethality.<a class="elsevierStyleCrossRef" href="#bib0145">8</a>In addition to classical food anaphylaxis, it is important to recognize food-dependent exercise-induced anaphylaxis. The initial symptoms are fatigue, heat, redness, pruritus, and urticaria, which can sometimes subside when the patient interrupts the physical activity and rests; other times, when the exercise continues, angioedema, gastrointestinal symptoms, laryngeal edema, bronchospasm, hypotension, and shock might occur.<a class="elsevierStyleCrossRef" href="#bib0155">10</a>When there is doubt regarding the diagnosis of anaphylaxis, the measurement of tryptase levels (collected during or shortly after the event resolution), when available, may be used to subsequently confirm the diagnosis. The measurement of the IgE specific for the food allergen components should be performed later.<a class="elsevierStyleCrossRef" href="#bib0125">4</a>Emergency treatment of food anaphylaxisThe management of anaphylaxis should be performed promptly. The patient should receive oxygen via face mask or catheter and be placed in dorsal decubitus with elevated lower limbs (Trendelenburg position), and epinephrine should be administered intramuscularly in the vastus lateralis. Venous puncture should be performed as soon as possible to maintain blood volume, but always after performing the three fundamental procedures mentioned, without delay. When in doubt, the drug should be promptly administered to prevent fatal anaphylaxis; particularly for food allergies, it is a life-saving drug and reduces the likelihood of hospitalization.<a class="elsevierStyleCrossRef" href="#bib0140">7</a> The action mechanism occurs through the alpha-adrenergic effect that reverses peripheral vasodilation, significantly reduces mucosal edema, upper airway obstruction (laryngeal edema), as well as hypotension and shock, in addition to reducing symptoms of urticaria/angioedema. Its β-adrenergic properties increase myocardial contractility, cardiac output, and coronary flow, and have a potent bronchodilator action.<a class="elsevierStyleCrossRefs" href="#bib0125">4,6</a> The intramuscular route is preferable, as it reaches peak concentrations faster than the subcutaneous route, and is ten times safer than the bolus intravenous route; additionally, without any risk of loss of time, the rich vascularization of this muscle allows the medication to be readily absorbed with an immediate effect, even in a state of circulatory insufficiency.<a class="elsevierStyleCrossRefs" href="#bib0125">4,6,12</a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the guidelines for managing food anaphylaxis in the emergency room. Adrenalin should be used at a dose of 0.01mg/kg intramuscularly (IM) up to a maximum dose of 0.3mg/kg in children. If the initial response is insufficient, after 5 to 15min, the dose may be repeated one or more times. It is estimated that up to 20% of treated patients may require a second dose. Late administration may lead to an increased risk of hospitalization, insufficient cardiac perfusion, hypoxic-ischemic encephalopathy, and death. The pharmacological action also includes transient pallor, tremor, anxiety, and palpitations, which, although perceived as an adverse effect, is similar to the physiological reaction of acute stress.<a class="elsevierStyleCrossRef" href="#bib0140">7</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The use of secondary drugs is described in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. Antihistamines are known to prevent pruritus and urticaria, but they do not alleviate respiratory symptoms, hypotension, or shock. Thus, similarly to corticosteroids, they are adjuvant drugs that are not indicated for the initial treatment. Corticosteroids may help prevent the secondary phase of anaphylaxis, which might recur within 12–24h after the initial event, but this biphasic presentation is considerably less common in food allergy anaphylaxis. In cases of asthma crises, the use of inhaled beta-2 agonists should be considered.<a class="elsevierStyleCrossRef" href="#bib0140">7</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>In patients with a history of very severe anaphylaxis, it is recommended to start treatment with epinephrine soon after the probable ingestion and onset of the first symptom (even when they are mild symptoms, such as itching of the face/mouth, mild gastric discomfort, or nausea), because the rapid progression to severe anaphylaxis is expected and usual.<a class="elsevierStyleCrossRef" href="#bib0140">7</a> The same conduct is prudent and recommended for children at risk of developing food anaphylaxis with uncontrolled asthma.<a class="elsevierStyleCrossRef" href="#bib0160">11</a>Recommendations to patients after hospital dischargeOnce the patient has been treated, it is essential to identify the possible food culprits. A patient with anaphylaxis should remain on observation for 12–24h, as a secondary delay response may occur; the patient should also be advised to avoid exercises for the next seven days. Prescription of oral corticosteroids (prednisone or prednisolone at a dose of 1–2mg/kg/day, with a maximum dose of 40mg/day) for five to seven days and of second generation antihistamines for at least seven days (e.g., fexofenadine at a dose of 2.5mL twice daily for children under 6 years, 5mL twice daily for those older than 6 years, or 1120mg tablet, twice daily for adolescents). It is also prudent to avoid physical activity in the week following the episode.<a class="elsevierStyleCrossRef" href="#bib0125">4</a>For food-dependent exercise-induced anaphylaxis, which occurs primarily in adolescents, it is also recommended to refer the patient to a specialist. At the outpatient level, it will be assessed whether the IgE specific to the possibly involved food is positive, whether symptoms occur when this food is ingested in the absence of physical activity, and whether symptoms occur during exercise without ingestion of the implicated food.<a class="elsevierStyleCrossRef" href="#bib0155">10</a>The subsequent management of severe IgE-mediated food allergy consists mainly of an exclusion diet for a given period. The proposal of an allergen-specific immunotherapy for food anaphylaxis, especially with baked milk (as cake or cookies) aiming to prevent anaphylaxis, is still an experimental treatment undergoing evaluation.<a class="elsevierStyleCrossRefs" href="#bib0120">3,13</a>An important recommendation to the family of a patient who suffered severe anaphylaxis is the need to carry self-injecting epinephrine. These devices are available at fixed doses (0.15mg for children up to 30kg, 0.3mg for older children/adolescents) and are indicated, especially in cases of high risk of antigenic exposure. Unfortunately, the expiration dates for these devices are limited, their cost is high, and they are not available in Brazil and in other countries.<a class="elsevierStyleCrossRef" href="#bib0125">4</a>Where self-injectable epinephrine is not available, doses of epinephrine prepared and assembled by the health care provider according to the patient's weight, in insulin syringes, adequately protected from sunlight and well-conditioned, may be offered to the patient and/or appropriately-trained family members. A scheme that can be simply and safely used intramuscularly is as follows: up to 10kg, 0.1mL IM; 10–20kg, 0.2mL IM; and >20kg, 0.3mL IM. Similarly, caution should be taken not to miss the dose when handling the syringe; patients should be informed that they should be replaced every two to three months, to avoid loss of the drug's effect due to environmental exposure.<a class="elsevierStyleCrossRefs" href="#bib0140">7,14</a> It is important that family, teachers, and community leaders increasingly recognize the early signs and know how to handle anaphylaxis with self-injectable epinephrine or even arrange and practice the use of syringe containing the medication, when this presentation is not available (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<a class="elsevierStyleCrossRefs" href="#bib0175">14,15</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Food protein induced enterocolitis syndrome (FPIES)Pathogenesis and associated aspectsThe pathogenesis of non-IgE mediated food allergies has yet to be clarified, because endoscopies and biopsies are not routinely performed. FPIES has been the most assessed allergy; several studies have suggested a key role of T-cells, with secretion of proinflammatory cytokines that may alter intestinal permeability.<a class="elsevierStyleCrossRef" href="#bib0115">2</a> Although neutrophilia and thrombocytosis occur in patients with acute FPIES, the role of these cells in the pathogenic mechanism has not yet been established. The IgEs against allergy-causing foods are not typically detected; however, in a subgroup of children, they may be present in the acute phase or during its evolution.<a class="elsevierStyleCrossRef" href="#bib0185">16</a> These patients tend to develop a longer course and, in some cases, progress to IgE-mediated allergy.<a class="elsevierStyleCrossRef" href="#bib0115">2</a> The neuroendocrine pathway appears to play a role in the pathogenesis of FPIES, based on the efficacy of ondansetron, a serotonin antagonist receptor (5-HT3), in the management of FPIES acute reaction.<a class="elsevierStyleCrossRefs" href="#bib0190">17,18</a>Acute FPIES is characterized by uncontrollable vomiting, pallor and/or lethargy within 1–4h after the food ingestion. Diarrhea may occur within 5–10h after ingestion, particularly in young infants with a more severe phenotype (less than 30% are children older than one year). The acute FPIES event may be the first manifestation or it may occur when the food allergen is introduced after a period of exclusion in patients with the chronic form; it would be an episode of acute FPIES occurring in the chronic form of the disease.Chronic FPIES shares clinical characteristics with food-induced enteropathy, such as malabsorption syndromes, anemia, diarrhea, and vomiting in children younger than nine months of age; however, in these patients, diarrhea is a more prominent symptom, but it does not lead to metabolic disturbances and severe dehydration as in acute FPIES. FPIES also occurs in older children and adults, due to exposure to fish or shrimp. In contrast to food protein-induced proctocolitis, FPIES is rare in exclusively breastfed children.<a class="elsevierStyleCrossRef" href="#bib0200">19</a>FPIES caused by solid foods typically occurs later than that caused by cow's milk and soy milk, probably related to the time of their introduction into the child's diet. Most FPIES patients respond to a single food (65–80%), usually cow's milk or soy. However, patients with FPIES caused by cow's milk/soy might react to solids. In the United States, up to 50% of patients with cow's milk/soy allergy react to both foods, and about one-third of patients with cow's milk and/or soy allergy react to solids.<a class="elsevierStyleCrossRef" href="#bib0200">19</a>Most children with FPIES to solids respond to several foods; chiefly those with FPIES caused by rice, oats, or barley have symptoms related to other grains. Patients with FPIES to multiple foods are less common in Japan, Australia, and Italy. These differences may reflect specific dietary habits in each country, and reinforce the hypothesis that early introduction of cow's milk and soybeans is a risk factor for FPIES caused by these proteins and foods at older ages.<a class="elsevierStyleCrossRef" href="#bib0200">19</a>Diagnosis of FPIESThe diagnosis of FPIES is based on clinical history, recognition of clinical symptoms, exclusion of other etiologies, and oral challenge test (OCT) under medical supervision. Although the OCT is the gold standard, most patients do not need to undergo confirmation, especially if they have a history of severe reactions and become asymptomatic after removal of the suspected protein. However, challenge tests are required to determine FPIES resolution or to confirm chronic FPIES.<a class="elsevierStyleCrossRef" href="#bib0205">20</a> The diagnostic criteria for FPIES are shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>The differential diagnosis of FPIES is extensive and includes infectious diseases, other food allergies, and intestinal obstruction, as well as neurological and metabolic diseases (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>). The initial episodes are often diagnosed as acute, viral, or septic gastroenteritis, when profound lethargy and hypotension occurs, and there is a high leukocyte count with a left shift. Many other conditions can also be considered in the differential diagnosis, especially in infants with repeated and prolonged episodes of vomiting. Metabolic disorders are present and lead to dehydration, lethargy, as well as metabolic acidosis.<a class="elsevierStyleCrossRef" href="#bib0210">21</a><elsevierMultimedia ident="tbl0025"></elsevierMultimedia>Emergency treatment of acute FPIESEmergency treatment of acute FPIES is based on three main points<a class="elsevierStyleCrossRefs" href="#bib0195">18,19</a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1)Hydroelectrolytic resuscitation – 10–20mL/kg body weight in bolus;</li><li class="elsevierStyleListItem" id="lsti0010">2)Administration of methylprednisolone – 1mg/kg body weight IV, maximum of 60–80mg;</li><li class="elsevierStyleListItem" id="lsti0015">3)Ondansetron IV or IM – 0.15mg/kg body weight.</li></ul>After these initial conducts in the emergency unit, the patient should remain hospitalized, maintaining the venoclysis for hydration and loss replacement, monitoring of vital signs (pulse, temperature, capillary filling time, heart rate, and blood pressure). Additional doses of ondansetron may be necessary, as well as corrections of hydroelectrolytic disorders, based on losses. Complementary exams should be requested: whole blood count with platelets, ionogram, and gasometry.Patient guidance after hospital dischargeThe management of non-IgE food allergy is empirical due to the limited evidence and the divergences in many areas of its pathophysiology. Food protein elimination diet is paramount. In FPIES, exclusive breastfeeding must be preserved. Protein hydrolysate formulas are generally well tolerated, although approximately 20% of patients may require amino acid formulas.<a class="elsevierStyleCrossRef" href="#bib0205">20</a> Follow-up with a specialist is indicated for specific care, especially for nutritional guidance and symptom control during and shortly after hospital admission.Conflicts of interestThe authors declare no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres938158" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Data sources" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Summary of data" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec911902" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres938157" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Fontes dos dados" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Síntese dos dados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec911901" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Anaphylaxis due to food allergy" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Physiopathology and associated aspects" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis of food anaphylaxis" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Emergency treatment of food anaphylaxis" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Recommendations to patients after hospital discharge" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Food protein induced enterocolitis syndrome (FPIES)" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Pathogenesis and associated aspects" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Diagnosis of FPIES" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Emergency treatment of acute FPIES" ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "Patient guidance after hospital discharge" ] ] ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-05-02" "fechaAceptado" => "2017-06-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec911902" "palabras" => array:3 [ 0 => "Severe forms of food allergy" 1 => "Food anaphylaxis" 2 => "Food-protein-induced enterocolitis syndrome" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec911901" "palabras" => array:3 [ 0 => "Formas graves de alergia alimentar" 1 => "Anafilaxia alimentar" 2 => "Síndrome da enterocolite induzida pela proteína alimentar" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectivesTo guide the diagnostic and therapeutic management of severe forms of food allergy. Data sourcesSearch in the Medline database using the terms “severe food allergy,” “anaphylaxis and food allergy,” “generalized urticaria and food allergy,” and “food protein-induced enterocolitis syndrome” in the last ten years, searching in the title, abstract, or keyword fields. Summary of dataFood allergy can be serious and life-threatening. Milk, eggs, peanuts, nuts, walnuts, wheat, sesame seeds, shrimp, fish, and fruit can precipitate allergic emergencies. The severity of reactions will depend on associated cofactors such as age, drug use at the onset of the reaction, history and persistence of asthma and/or severe allergic rhinitis, history of previous anaphylaxis, exercise, and associated diseases. For generalized urticaria and anaphylaxis, intramuscular epinephrine is the first and fundamental treatment line. For the treatment in acute phase of food-induced enterocolitis syndrome in the emergency setting, prompt hydroelectrolytic replacement, administration of methylprednisolone and ondansetron IV are necessary. It is important to recommend to the patient with food allergy to maintain the exclusion diet, seek specialized follow-up and, in those who have anaphylaxis, to emphasize the need to carry epinephrine. ConclusionSevere food allergy may occur in the form of anaphylaxis and food-protein-induced enterocolitis syndrome, which are increasingly observed in the pediatric emergency room; hence, pediatricians must be alert so they can provide the immediate diagnosis and treatment." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Data sources" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Summary of data" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "ObjetivosAbordar o manejo diagnóstico e terapêutico das formas graves de alergia alimentar. Fontes dos dadosBusca ativa na base de dados Medline dos te rmos “severe food allergies”, “anaphylaxis and food allergy” e “food protein-induced enterocolitis” nos últimos dez anos e com busca nos campos título, resumo ou palavra-chave. Síntese dos dadosA alergia alimentar pode ser grave e ameaçadora à vida. Leite, ovo, amendoim, castanha, noz, trigo, gergelim, crustáceo, peixe e frutas podem precipitar emergências alérgicas. A gravidade das reações vai depender de fatores associados tais como idade, uso de medicamentos no início da reação, persistência de asma e/ou rinite alérgica grave, história de prévia anafilaxia, exercício e doenças intercorrentes. Para anafilaxia, a adrenalina intramuscular é uma indicação bem estabelecida. Para o tratamento da síndrome da enterocolite induzida pela proteína alimentar na fase aguda no setor de emergência, faz-se necessária a pronta reposição hidroeletrolítica, a administração de metilprednisolona e odansetrona IV. Importante recomendar ao paciente com o diagnóstico de alergia alimentar grave que mantenha a dieta de exclusão, procure acompanhamento especializado e, naqueles que apresentaram anafilaxia, enfatizar a necessidade de portar adrenalina. ConclusãoAlergia alimentar grave pode se manifestar como anafilaxia ou síndrome da enterocolite induzida por proteína alimentar em fase aguda as quais, por serem condições cada vez mais presentes e reconhecidas no setor de emergência pediátrica, demandam diagnóstico e tratamento imediatos." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Fontes dos dados" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Síntese dos dados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Sarinho ES, Lins MG. Severe forms of food allergy. J Pediatr (Rio J). 2017;93:53–9." ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "LL, lower limbs; IV, intravenous; IM, intramuscular.Adapted and modified by Lockey et al.<a class="elsevierStyleCrossRef" href="#bib0165">12</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Conduct/Therapeutic agent \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recommendations \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maintain vital signs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Check A (airway), B (breathing), C (circulation), and M (Mind - sensory) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Maintain adequate position (dorsal decubitus with elevated LL). Getting up or sitting down suddenly is associated with fatal outcomes (“empty ventricle syndrome”). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Epinephrine 1:1000 (1mg/mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Children: 0.01mg/kg up to a maximum of 0.3mg IM, in the anterolateral thigh. Adolescents: 0.2–0.5mg (maximum dose) IM, in the anterolateral thigh. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Administer immediately and repeat if necessary, every 5–15min. Monitor toxicity (heart rate) Epinephrine at dilutions of 1:10,000 or 1:100,000 should be administered only IV in cases of cardiorespiratory arrest or profound hypotension that did not respond to volume expansion or multiple IM injections of epinephrine. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Volume expansion Saline solution Ringer's lactate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Children: 5–10mL/kg IV in the first 5min and 30mL/kg in the first hour Adolescents: 1–2L rapidly IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Infusion rate is regulated by pulse and blood pressure. Establish IV access with the highest caliber possible. Monitor volume overload \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oxygen (O2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Under nasal cannula or mask \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">If O2 sat <95%, more than one dose of epinephrine is necessary \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1586505.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Conduct and main therapeutic agents in anaphylaxis treatment." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "IV, intravenous; IM, intramuscular; OR, oral route; anti-H1, antihistamine H1; anti-H2, antihistamine H2.Adapted and modified by Lockey et al.<a class="elsevierStyleCrossRef" href="#bib0165">12</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Agent \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">β2-Agonists Salbutamol sulfate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Inhaled medications: Metered-dose inhaler with a spacer (100 mcg/jet) Children: 50 mcg/kg/dose=1 jet/2kg; Maximum dose: ten jets Adolescents: four to eight jets, every 20min Nebulizer: Solution for nebulization: drops (5mg/mL) Children: 0.07–0.15mg/kg every 20min up to three doses Adults/Adolescents: 2.5–5.0mg, every 20min, for three doses Maximum dose: 5mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bronchospasm reversal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Antihistaminic agents Promethazine Diphenhydramine Ranitidine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"> Children: 1mg/kg IV up to a maximum of 50mg Adolescents: 25–50mg IV Children: 1mg/kg Adolescents: 12.5–50mg IV in up to 10min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Anti-H1 agents associated with anti-H2 may be more effective than anti-H1 alone Oral dose may be sufficient for milder episodes Secondary role that has not yet been well determined. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Steroids Methylprednisolone Prednisone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"> 1–2mg/kg/day IV 0.5–1mg/kg/day, OR, maximum 40mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"> Dosage standardization not established Prevention of biphasic reactions? \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1586502.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Secondary medications in the treatment of anaphylaxis." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recommendations \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">-The family, the school and the community should collaborate to prevent patient exposure to the food allergen. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">-Criteria and training for early recognition and management of symptoms of probable anaphylaxis is desirable and feasible to be carried out in the family, school, and community. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">-Patients with a previous history of anaphylaxis should carry self-injectable epinephrine. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">-In cases of high risk and no available self-injectable epinephrine, carrying epinephrine in a capped insulin syringe after training may be a valid conduct. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">-Patient with food-dependent, exercise-induced anaphylaxis should avoid physical activity for 4h after the inducer food, which is wheat, in most cases. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">-Patients with food-dependent exercise-induced anaphylaxis should also avoid precipitating reaction factors such as alcohol and non-steroidal antiinflammatory drug use, especially aspirin, when ingesting the allergen food. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">-Patients at risk for anaphylaxis should have a metal plaque in their arm or a card identifying which food they are allergic to. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1586506.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Preventive recommendations for food anaphylaxis for family, teachers, and community leaders." ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "FPIES, food protein-induced enterocolitis syndrome." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. Age less than 2 years old on first presentation (frequent but not mandatory) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. Exposure to suspected foods triggers projectile vomiting, pallor, lethargy in 2–4h Symptoms last a few hours and resolve, usually within 6h Diarrhea may be present, less frequent, and appears in 5–10h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. Absence of symptoms that suggest an IgE-mediated reaction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4. The exclusion from the diet of the involved protein resolves the symptoms \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5. Re-exposure or oral challenge test triggers symptoms within 2–4h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Two exposures are required to establish the definitive diagnosis without the need to perform the challenge test \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1586504.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Current criteria used for the diagnosis of FPIES." ] ] 4 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "FPIES, food protein-induced enterocolitis syndrome." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Infections \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Allergy \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Digestive tract disorders \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Others \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Viral gastroenteritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Other non-IgE mediated food allergies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Gastroesophageal reflux disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neurological disorders (Encephalopathy or hemorrhage) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hirschsprung's disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cardiac diseases (cardiomyopathies, arrhythmias, congenital cardiopathies) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Bacterial gastroenteritis (Shigella, salmonella, campylobacter, Yersinia)</td><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Acute IgE-mediated reaction (anaphylaxis)</td><td class="td" title="table-entry " align="left" valign="top">Intestinal invagination \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Exogenous intoxication \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Volvulus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Inborn errors of metabolism \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertrophic pyloric stenosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Congenital methemoglobinemia. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Celiac disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Necrotizing enterocolitis Meckel diverticulum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1586503.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Main clinical situations in the differential diagnosis of FPIES." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0110" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Food allergy: review, classification and diagnosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. 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Review article

Severe forms of food allergy

Formas graves de alergia alimentar

Emanuel Sarinhoa,b,c,

Corresponding author

emanuel.sarinho@gmail.com

Corresponding author.

, Maria das Graças Moura Linsa,d

a Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil

b Universidade Federal de Pernambuco (UFPE), Programa de Residência Médica em Alergia e Imunologia, Recife, PE, Brazil

c Sociedade Brasileira de Pediatria, Departamento de Alergia, Rio de Janeiro, RJ, Brazil

d Universidade Federal de Pernambuco (UFPE), Programa de Residência Médica em Gastropediatria, Recife, PE, Brazil

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Severe food allergy refers to the abnormal immune response to a certain food in a susceptible host&#44; causing life-threatening clinical syndromes to the latter&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> These reactions are reproducible each time the food is ingested and&#44; most of the time&#44; are dose-independent&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> They comprise food-induced anaphylaxis&#44; which is mediated by IgE and the acute form of the food-protein-induced enterocolitis syndrome &#40;FPIES&#41;&#44; thought to be mediated by cells&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Anaphylactic reactions to eggs and fish have been described since the 16th and 17th centuries&#46; Decades ago&#44; it was a rare event&#44; but a progressive increase in its prevalence has been observed&#59; currently&#44; severe food allergy is the main cause of emergency care due to anaphylaxis&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a> Milk&#44; eggs&#44; peanuts&#44; nuts&#44; walnuts&#44; wheat&#44; sesame seeds&#44; crustaceans&#44; fish&#44; and fruit are some of the foods that can precipitate allergic emergencies&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In Brazil&#44; a survey aimed at allergists indicated food allergy as the second cause of anaphylaxis&#46; The main culprits were cow&#39;s milk and egg whites in infants and preschoolers&#44; and crustaceans in older children&#44; adolescents&#44; and adults&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a> In a meta-analysis of the literature&#44; the estimated incidence of fatality in high-income countries due to food anaphylaxis in children under 19 years of age was 3&#46;25 per million persons&#47;year&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">5</span></a> The early establishment of the correct and immediate diagnosis and treatment by the emergency pediatrician can prevent lethality and effectively save lives&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The objective of this article is to guide the physician in the diagnostic and therapeutic management of severe forms of food allergy&#44; based on an active search in the Medline database using the terms &#8220;severe food allergies&#44;&#8221; &#8220;anaphylaxis and food allergy&#44;&#8221; and &#8220;food protein induced enterocolitis&#8221; within the last ten years&#59; the search comprised the title&#44; abstract&#44; and keyword fields&#46; The review and recommendation articles that were useful&#44; according to the authors&#8217; evaluation&#44; were selected for reading in full to support the article scope&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The two food allergy situations that lead the patient to emergency care are food anaphylaxis and FPIES&#44; which are clinical entities with different presentations and management and will be approached sequentially in this article&#46; However&#44; in both approaches&#44; the emphasis will be on the pathophysiology and associated aspects in the diagnosis&#44; emergency treatment&#44; and patient guidance&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Anaphylaxis due to food allergy</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Physiopathology and associated aspects</span><p id="par0030" class="elsevierStylePara elsevierViewall">Food anaphylaxis is the severe IgE-mediated reaction to food&#44; in which generalized and life-threatening vasodilation occurs&#46; The release of vasoactive mediators into the bloodstream can lead to vascular collapse&#44; anaphylaxis&#44; and shock&#46; Vasodilation is accompanied by hypotension and hypoperfusion&#44; which can compromise vital organs such as the brain and heart&#44; resulting in ischemia and death&#46; When cardiovascular symptoms&#44; such as hypotension and shock&#44; and neurological symptoms&#44; such as mental confusion&#44; loss of consciousness&#44; and sphincter relaxation are present&#44; the risk of death is high&#46; Epinephrine administration and lower limb elevation&#44; restoring vascular tonus and venous return&#44; are life-saving measures&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Anaphylaxis occurs with the progressive increase in vascular permeability&#44; in which relatively minor symptoms appear earlier and foretell a potentially fatal condition&#46; It all starts with the exposure to a food allergen&#44; which forms a bivalent binding with the specific IgE that is fixated in the high-affinity receptors of mast cells&#46; Through the ion channels&#44; this binding leads to reticular activation and to the release of mediators such as histamine &#40;the main mediator of erythema and pruritus&#41; and several other potent neo- and pre-formed vasodilators&#44; which cause edema in the superficial and deep dermis and subcutaneous cell tissue&#44; resulting in urticaria and angioedema&#46; In the digestive system&#44; this process causes nausea&#44; vomiting&#44; and diarrhea and&#44; in the respiratory tract&#44; intense coryza&#44; sneezing&#44; coughing&#44; bronchospasm&#44; laryngeal edema&#44; and even apnea&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4&#44;6&#44;7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The presence of generalized urticaria and angioedema are often the initial symptoms&#44; indicating that vasodilation and bronchoconstriction are imminent and the patient must be identified and treated urgently to restore the vascular tonus&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">8&#44;9</span></a> The association with asthma increases reaction severity&#44; and response to treatment is much more difficult&#46; It has been observed that up to 75&#37; of the patients with fatal anaphylaxis had concomitant asthma&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">6&#44;7&#44;9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Sometimes&#44; severe food allergy develops during exercise&#44; in association with a specific food &#40;up to 4<span class="elsevierStyleHsp" style=""></span>h after ingestion&#41;&#44; characterizing a food-dependent exercise-induced anaphylaxis&#46; Exercise may promote increased absorption of the inadequately processed allergen and&#47;or promote the degranulation of sensitized basophils and mast cells&#44; or further promote an over-synthesis of arachidonic acid metabolites&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> In this case&#44; anaphylaxis results from the association of food and exercise&#44; while food or exercise&#44; alone&#44; are well tolerated&#46; Wheat is the most common allergen&#44; but other grains&#44; nuts&#44; and other foods have also been implicated&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4&#44;10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Food-dependent exercise-induced anaphylaxis may be precipitated by associated factors&#44; such as the consumption of anti-inflammatories&#44; especially aspirin&#44; and the use of alcohol&#44; which is common among adolescents&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The severity of food allergic reactions will depend on the amount of ingested allergen&#44; its stability against digestion&#44; and epithelial permeability&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">10&#44;11</span></a> Associated factors&#44; such as age&#44; drug use at the reaction onset&#44; persistence of severe allergic rhinitis&#44; history of previous anaphylaxis&#44; exercise&#44; and concomitant diseases&#44; must be considered&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">10&#44;11</span></a> The dose and type of food allergen that sensitizes and causes severe food allergy may vary between individuals&#44; and may even vary in the same individual on different occasions&#46; When the food allergen is hidden&#44; it can result in delayed identification of the culprit agent and greater risk for patients&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">11</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Adolescents are at increased risk of fatal anaphylaxis because of greater difficulty in following the exclusion diet&#46; Acute infectious diseases facilitate mast cell degranulation and favor the onset of severe food anaphylaxis in the presence of the specific allergen&#46; Similarly&#44; excessively hot showers and use of fever medication may predispose to more severe reactions&#44; as they alter intestinal permeability&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">11</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In infants&#44; cow&#39;s milk protein is the most common precipitating agent of food anaphylaxis&#44; but egg&#44; soybean&#44; and other proteins may also be implicated&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">1&#44;4</span></a> In schoolchildren and adolescents&#44; allergies to crustaceans&#44; fish&#44; peanuts&#44; walnuts&#44; and cashews predominate as potentially life-threatening situations&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a> Wheat is the most common precipitant of exercise-dependent food-induced anaphylaxis&#44; through a protein fraction found in gluten&#44; 5-omega gliadin&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Diagnosis of food anaphylaxis</span><p id="par0070" class="elsevierStylePara elsevierViewall">The diagnosis of food anaphylaxis is relatively easy to attain&#46; It is important to emphasize that&#44; because it is a potentially fatal allergic reaction&#44; it should be treated as a medical emergency with the immediate administration of epinephrine&#59; therefore&#44; the diagnosis should be associated with prompt treatment&#44; so that the results are favorable&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">6&#44;7</span></a> Food anaphylaxis occurs suddenly&#44; within a few minutes or a few hours after food intake&#44; with intense pruritus and generalized erythematous plaques that tend to converge&#46; This picture is often accompanied by lip&#44; eye&#44; or even tongue and uvula angioedema&#44; followed by further involvement of at least one of the following organ systems&#58; respiratory &#40;dyspnea&#44; wheezing&#47;bronchospasm&#44; stridor&#44; hypoxemia&#41;&#44; cardiovascular &#40;hypotension&#44; hypotonia&#44; shock&#41;&#44; gastrointestinal &#40;nausea&#44; vomiting&#44; abdominal pain&#41;&#44; and neurological &#40;mental confusion&#44; lipothymia&#44; loss of consciousness&#41;&#46; In up to 20&#37; of cases&#44; anaphylaxis can occur with two or more of these affected organ systems&#44; but without cutaneous involvement&#44; which makes the diagnosis much more difficult&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4&#44;6</span></a> Anaphylaxis should be mainly differentiated from vaso-vagal syndrome &#40;in this case&#44; the skin is cold&#44; pale&#44; and moist&#41;&#44; from an acute crisis of severe asthma&#44; and from post-feeding generalized acute urticaria&#44; which&#44; as previously mentioned&#44; can be considered and managed as anaphylaxis&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4&#44;6&#44;8&#44;9&#44;11</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Although urticaria and angioedema are common signs of food allergic reactions&#44; especially during anaphylaxis&#44; it is important to note that their absence does not exclude the possibility of severe food allergy&#46; Up to 20&#37; of cases of food anaphylaxis may present without cutaneous symptoms&#44; and the absence of these symptoms may result in late identification and treatment delay&#44; as well as increased lethality&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">8</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In addition to classical food anaphylaxis&#44; it is important to recognize food-dependent exercise-induced anaphylaxis&#46; The initial symptoms are fatigue&#44; heat&#44; redness&#44; pruritus&#44; and urticaria&#44; which can sometimes subside when the patient interrupts the physical activity and rests&#59; other times&#44; when the exercise continues&#44; angioedema&#44; gastrointestinal symptoms&#44; laryngeal edema&#44; bronchospasm&#44; hypotension&#44; and shock might occur&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">When there is doubt regarding the diagnosis of anaphylaxis&#44; the measurement of tryptase levels &#40;collected during or shortly after the event resolution&#41;&#44; when available&#44; may be used to subsequently confirm the diagnosis&#46; The measurement of the IgE specific for the food allergen components should be performed later&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Emergency treatment of food anaphylaxis</span><p id="par0090" class="elsevierStylePara elsevierViewall">The management of anaphylaxis should be performed promptly&#46; The patient should receive oxygen via face mask or catheter and be placed in dorsal decubitus with elevated lower limbs &#40;Trendelenburg position&#41;&#44; and epinephrine should be administered intramuscularly in the vastus lateralis&#46; Venous puncture should be performed as soon as possible to maintain blood volume&#44; but always after performing the three fundamental procedures mentioned&#44; without delay&#46; When in doubt&#44; the drug should be promptly administered to prevent fatal anaphylaxis&#59; particularly for food allergies&#44; it is a life-saving drug and reduces the likelihood of hospitalization&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a> The action mechanism occurs through the alpha-adrenergic effect that reverses peripheral vasodilation&#44; significantly reduces mucosal edema&#44; upper airway obstruction &#40;laryngeal edema&#41;&#44; as well as hypotension and shock&#44; in addition to reducing symptoms of urticaria&#47;angioedema&#46; Its &#946;-adrenergic properties increase myocardial contractility&#44; cardiac output&#44; and coronary flow&#44; and have a potent bronchodilator action&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4&#44;6</span></a> The intramuscular route is preferable&#44; as it reaches peak concentrations faster than the subcutaneous route&#44; and is ten times safer than the bolus intravenous route&#59; additionally&#44; without any risk of loss of time&#44; the rich vascularization of this muscle allows the medication to be readily absorbed with an immediate effect&#44; even in a state of circulatory insufficiency&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4&#44;6&#44;12</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the guidelines for managing food anaphylaxis in the emergency room&#46; Adrenalin should be used at a dose of 0&#46;01<span class="elsevierStyleHsp" style=""></span>mg&#47;kg intramuscularly &#40;IM&#41; up to a maximum dose of 0&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;kg in children&#46; If the initial response is insufficient&#44; after 5 to 15<span class="elsevierStyleHsp" style=""></span>min&#44; the dose may be repeated one or more times&#46; It is estimated that up to 20&#37; of treated patients may require a second dose&#46; Late administration may lead to an increased risk of hospitalization&#44; insufficient cardiac perfusion&#44; hypoxic-ischemic encephalopathy&#44; and death&#46; The pharmacological action also includes transient pallor&#44; tremor&#44; anxiety&#44; and palpitations&#44; which&#44; although perceived as an adverse effect&#44; is similar to the physiological reaction of acute stress&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The use of secondary drugs is described in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; Antihistamines are known to prevent pruritus and urticaria&#44; but they do not alleviate respiratory symptoms&#44; hypotension&#44; or shock&#46; Thus&#44; similarly to corticosteroids&#44; they are adjuvant drugs that are not indicated for the initial treatment&#46; Corticosteroids may help prevent the secondary phase of anaphylaxis&#44; which might recur within 12&#8211;24<span class="elsevierStyleHsp" style=""></span>h after the initial event&#44; but this biphasic presentation is considerably less common in food allergy anaphylaxis&#46; In cases of asthma crises&#44; the use of inhaled beta-2 agonists should be considered&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">In patients with a history of very severe anaphylaxis&#44; it is recommended to start treatment with epinephrine soon after the probable ingestion and onset of the first symptom &#40;even when they are mild symptoms&#44; such as itching of the face&#47;mouth&#44; mild gastric discomfort&#44; or nausea&#41;&#44; because the rapid progression to severe anaphylaxis is expected and usual&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a> The same conduct is prudent and recommended for children at risk of developing food anaphylaxis with uncontrolled asthma&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Recommendations to patients after hospital discharge</span><p id="par0110" class="elsevierStylePara elsevierViewall">Once the patient has been treated&#44; it is essential to identify the possible food culprits&#46; A patient with anaphylaxis should remain on observation for 12&#8211;24<span class="elsevierStyleHsp" style=""></span>h&#44; as a secondary delay response may occur&#59; the patient should also be advised to avoid exercises for the next seven days&#46; Prescription of oral corticosteroids &#40;prednisone or prednisolone at a dose of 1&#8211;2<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#44; with a maximum dose of 40<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; for five to seven days and of second generation antihistamines for at least seven days &#40;<span class="elsevierStyleItalic">e&#46;g</span>&#46;&#44; fexofenadine at a dose of 2&#46;5<span class="elsevierStyleHsp" style=""></span>mL twice daily for children under 6 years&#44; 5<span class="elsevierStyleHsp" style=""></span>mL twice daily for those older than 6 years&#44; or 1120<span class="elsevierStyleHsp" style=""></span>mg tablet&#44; twice daily for adolescents&#41;&#46; It is also prudent to avoid physical activity in the week following the episode&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">For food-dependent exercise-induced anaphylaxis&#44; which occurs primarily in adolescents&#44; it is also recommended to refer the patient to a specialist&#46; At the outpatient level&#44; it will be assessed whether the IgE specific to the possibly involved food is positive&#44; whether symptoms occur when this food is ingested in the absence of physical activity&#44; and whether symptoms occur during exercise without ingestion of the implicated food&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The subsequent management of severe IgE-mediated food allergy consists mainly of an exclusion diet for a given period&#46; The proposal of an allergen-specific immunotherapy for food anaphylaxis&#44; especially with baked milk &#40;as cake or cookies&#41; aiming to prevent anaphylaxis&#44; is still an experimental treatment undergoing evaluation&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3&#44;13</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">An important recommendation to the family of a patient who suffered severe anaphylaxis is the need to carry self-injecting epinephrine&#46; These devices are available at fixed doses &#40;0&#46;15<span class="elsevierStyleHsp" style=""></span>mg for children up to 30<span class="elsevierStyleHsp" style=""></span>kg&#44; 0&#46;3<span class="elsevierStyleHsp" style=""></span>mg for older children&#47;adolescents&#41; and are indicated&#44; especially in cases of high risk of antigenic exposure&#46; Unfortunately&#44; the expiration dates for these devices are limited&#44; their cost is high&#44; and they are not available in Brazil and in other countries&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Where self-injectable epinephrine is not available&#44; doses of epinephrine prepared and assembled by the health care provider according to the patient&#39;s weight&#44; in insulin syringes&#44; adequately protected from sunlight and well-conditioned&#44; may be offered to the patient and&#47;or appropriately-trained family members&#46; A scheme that can be simply and safely used intramuscularly is as follows&#58; up to 10<span class="elsevierStyleHsp" style=""></span>kg&#44; 0&#46;1<span class="elsevierStyleHsp" style=""></span>mL IM&#59; 10&#8211;20<span class="elsevierStyleHsp" style=""></span>kg&#44; 0&#46;2<span class="elsevierStyleHsp" style=""></span>mL IM&#59; and &#62;20<span class="elsevierStyleHsp" style=""></span>kg&#44; 0&#46;3<span class="elsevierStyleHsp" style=""></span>mL IM&#46; Similarly&#44; caution should be taken not to miss the dose when handling the syringe&#59; patients should be informed that they should be replaced every two to three months&#44; to avoid loss of the drug&#39;s effect due to environmental exposure&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">7&#44;14</span></a> It is important that family&#44; teachers&#44; and community leaders increasingly recognize the early signs and know how to handle anaphylaxis with self-injectable epinephrine or even arrange and practice the use of syringe containing the medication&#44; when this presentation is not available &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">14&#44;15</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Food protein induced enterocolitis syndrome &#40;FPIES&#41;</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Pathogenesis and associated aspects</span><p id="par0135" class="elsevierStylePara elsevierViewall">The pathogenesis of non-IgE mediated food allergies has yet to be clarified&#44; because endoscopies and biopsies are not routinely performed&#46; FPIES has been the most assessed allergy&#59; several studies have suggested a key role of T-cells&#44; with secretion of proinflammatory cytokines that may alter intestinal permeability&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> Although neutrophilia and thrombocytosis occur in patients with acute FPIES&#44; the role of these cells in the pathogenic mechanism has not yet been established&#46; The IgEs against allergy-causing foods are not typically detected&#59; however&#44; in a subgroup of children&#44; they may be present in the acute phase or during its evolution&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">16</span></a> These patients tend to develop a longer course and&#44; in some cases&#44; progress to IgE-mediated allergy&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> The neuroendocrine pathway appears to play a role in the pathogenesis of FPIES&#44; based on the efficacy of ondansetron&#44; a serotonin antagonist receptor &#40;5-HT3&#41;&#44; in the management of FPIES acute reaction&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">17&#44;18</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Acute FPIES is characterized by uncontrollable vomiting&#44; pallor and&#47;or lethargy within 1&#8211;4<span class="elsevierStyleHsp" style=""></span>h after the food ingestion&#46; Diarrhea may occur within 5&#8211;10<span class="elsevierStyleHsp" style=""></span>h after ingestion&#44; particularly in young infants with a more severe phenotype &#40;less than 30&#37; are children older than one year&#41;&#46; The acute FPIES event may be the first manifestation or it may occur when the food allergen is introduced after a period of exclusion in patients with the chronic form&#59; it would be an episode of acute FPIES occurring in the chronic form of the disease&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Chronic FPIES shares clinical characteristics with food-induced enteropathy&#44; such as malabsorption syndromes&#44; anemia&#44; diarrhea&#44; and vomiting in children younger than nine months of age&#59; however&#44; in these patients&#44; diarrhea is a more prominent symptom&#44; but it does not lead to metabolic disturbances and severe dehydration as in acute FPIES&#46; FPIES also occurs in older children and adults&#44; due to exposure to fish or shrimp&#46; In contrast to food protein-induced proctocolitis&#44; FPIES is rare in exclusively breastfed children&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">FPIES caused by solid foods typically occurs later than that caused by cow&#39;s milk and soy milk&#44; probably related to the time of their introduction into the child&#39;s diet&#46; Most FPIES patients respond to a single food &#40;65&#8211;80&#37;&#41;&#44; usually cow&#39;s milk or soy&#46; However&#44; patients with FPIES caused by cow&#39;s milk&#47;soy might react to solids&#46; In the United States&#44; up to 50&#37; of patients with cow&#39;s milk&#47;soy allergy react to both foods&#44; and about one-third of patients with cow&#39;s milk and&#47;or soy allergy react to solids&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Most children with FPIES to solids respond to several foods&#59; chiefly those with FPIES caused by rice&#44; oats&#44; or barley have symptoms related to other grains&#46; Patients with FPIES to multiple foods are less common in Japan&#44; Australia&#44; and Italy&#46; These differences may reflect specific dietary habits in each country&#44; and reinforce the hypothesis that early introduction of cow&#39;s milk and soybeans is a risk factor for FPIES caused by these proteins and foods at older ages&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Diagnosis of FPIES</span><p id="par0160" class="elsevierStylePara elsevierViewall">The diagnosis of FPIES is based on clinical history&#44; recognition of clinical symptoms&#44; exclusion of other etiologies&#44; and oral challenge test &#40;OCT&#41; under medical supervision&#46; Although the OCT is the gold standard&#44; most patients do not need to undergo confirmation&#44; especially if they have a history of severe reactions and become asymptomatic after removal of the suspected protein&#46; However&#44; challenge tests are required to determine FPIES resolution or to confirm chronic FPIES&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a> The diagnostic criteria for FPIES are shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">The differential diagnosis of FPIES is extensive and includes infectious diseases&#44; other food allergies&#44; and intestinal obstruction&#44; as well as neurological and metabolic diseases &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46; The initial episodes are often diagnosed as acute&#44; viral&#44; or septic gastroenteritis&#44; when profound lethargy and hypotension occurs&#44; and there is a high leukocyte count with a left shift&#46; Many other conditions can also be considered in the differential diagnosis&#44; especially in infants with repeated and prolonged episodes of vomiting&#46; Metabolic disorders are present and lead to dehydration&#44; lethargy&#44; as well as metabolic acidosis&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a></p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Emergency treatment of acute FPIES</span><p id="par0170" class="elsevierStylePara elsevierViewall">Emergency treatment of acute FPIES is based on three main points<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">18&#44;19</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Hydroelectrolytic resuscitation &#8211; 10&#8211;20<span class="elsevierStyleHsp" style=""></span>mL&#47;kg body weight in bolus&#59;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Administration of methylprednisolone &#8211; 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg body weight IV&#44; maximum of 60&#8211;80<span class="elsevierStyleHsp" style=""></span>mg&#59;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#41;</span><p id="par0185" class="elsevierStylePara elsevierViewall">Ondansetron IV or IM &#8211; 0&#46;15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg body weight&#46;</p></li></ul></p><p id="par0190" class="elsevierStylePara elsevierViewall">After these initial conducts in the emergency unit&#44; the patient should remain hospitalized&#44; maintaining the venoclysis for hydration and loss replacement&#44; monitoring of vital signs &#40;pulse&#44; temperature&#44; capillary filling time&#44; heart rate&#44; and blood pressure&#41;&#46; Additional doses of ondansetron may be necessary&#44; as well as corrections of hydroelectrolytic disorders&#44; based on losses&#46; Complementary exams should be requested&#58; whole blood count with platelets&#44; ionogram&#44; and gasometry&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Patient guidance after hospital discharge</span><p id="par0195" class="elsevierStylePara elsevierViewall">The management of non-IgE food allergy is empirical due to the limited evidence and the divergences in many areas of its pathophysiology&#46; Food protein elimination diet is paramount&#46; In FPIES&#44; exclusive breastfeeding must be preserved&#46; Protein hydrolysate formulas are generally well tolerated&#44; although approximately 20&#37; of patients may require amino acid formulas&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a> Follow-up with a specialist is indicated for specific care&#44; especially for nutritional guidance and symptom control during and shortly after hospital admission&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicts of interest</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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            0 => "Formas graves de alergia alimentar"
            1 => "Anafilaxia alimentar"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To guide the diagnostic and therapeutic management of severe forms of food allergy&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Data sources</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Search in the Medline database using the terms &#8220;severe food allergy&#44;&#8221; &#8220;anaphylaxis and food allergy&#44;&#8221; &#8220;generalized urticaria and food allergy&#44;&#8221; and &#8220;food protein-induced enterocolitis syndrome&#8221; in the last ten years&#44; searching in the title&#44; abstract&#44; or keyword fields&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Summary of data</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Food allergy can be serious and life-threatening&#46; Milk&#44; eggs&#44; peanuts&#44; nuts&#44; walnuts&#44; wheat&#44; sesame seeds&#44; shrimp&#44; fish&#44; and fruit can precipitate allergic emergencies&#46; The severity of reactions will depend on associated cofactors such as age&#44; drug use at the onset of the reaction&#44; history and persistence of asthma and&#47;or severe allergic rhinitis&#44; history of previous anaphylaxis&#44; exercise&#44; and associated diseases&#46; For generalized urticaria and anaphylaxis&#44; intramuscular epinephrine is the first and fundamental treatment line&#46; For the treatment in acute phase of food-induced enterocolitis syndrome in the emergency setting&#44; prompt hydroelectrolytic replacement&#44; administration of methylprednisolone and ondansetron IV are necessary&#46; It is important to recommend to the patient with food allergy to maintain the exclusion diet&#44; seek specialized follow-up and&#44; in those who have anaphylaxis&#44; to emphasize the need to carry epinephrine&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Severe food allergy may occur in the form of anaphylaxis and food-protein-induced enterocolitis syndrome&#44; which are increasingly observed in the pediatric emergency room&#59; hence&#44; pediatricians must be alert so they can provide the immediate diagnosis and treatment&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Abordar o manejo diagn&#243;stico e terap&#234;utico das formas graves de alergia alimentar&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Fontes dos dados</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Busca ativa na base de dados Medline dos te rmos &#8220;severe food allergies&#8221;&#44; &#8220;anaphylaxis and food allergy&#8221; e &#8220;food protein-induced enterocolitis&#8221; nos &#250;ltimos dez anos e com busca nos campos t&#237;tulo&#44; resumo ou palavra-chave&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">S&#237;ntese dos dados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A alergia alimentar pode ser grave e amea&#231;adora &#224; vida&#46; Leite&#44; ovo&#44; amendoim&#44; castanha&#44; noz&#44; trigo&#44; gergelim&#44; crust&#225;ceo&#44; peixe e frutas podem precipitar emerg&#234;ncias al&#233;rgicas&#46; A gravidade das rea&#231;&#245;es vai depender de fatores associados tais como idade&#44; uso de medicamentos no in&#237;cio da rea&#231;&#227;o&#44; persist&#234;ncia de asma e&#47;ou rinite al&#233;rgica grave&#44; hist&#243;ria de pr&#233;via anafilaxia&#44; exerc&#237;cio e doen&#231;as intercorrentes&#46; Para anafilaxia&#44; a adrenalina intramuscular &#233; uma indica&#231;&#227;o bem estabelecida&#46; Para o tratamento da s&#237;ndrome da enterocolite induzida pela prote&#237;na alimentar na fase aguda no setor de emerg&#234;ncia&#44; faz-se necess&#225;ria a pronta reposi&#231;&#227;o hidroeletrol&#237;tica&#44; a administra&#231;&#227;o de metilprednisolona e odansetrona IV&#46; Importante recomendar ao paciente com o diagn&#243;stico de alergia alimentar grave que mantenha a dieta de exclus&#227;o&#44; procure acompanhamento especializado e&#44; naqueles que apresentaram anafilaxia&#44; enfatizar a necessidade de portar adrenalina&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Alergia alimentar grave pode se manifestar como anafilaxia ou s&#237;ndrome da enterocolite induzida por prote&#237;na alimentar em fase aguda as quais&#44; por serem condi&#231;&#245;es cada vez mais presentes e reconhecidas no setor de emerg&#234;ncia pedi&#225;trica&#44; demandam diagn&#243;stico e tratamento imediatos&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Sarinho ES&#44; Lins MG&#46; Severe forms of food allergy&#46; J Pediatr &#40;Rio J&#41;&#46; 2017&#59;93&#58;53&#8211;9&#46;</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">LL&#44; lower limbs&#59; IV&#44; intravenous&#59; IM&#44; intramuscular&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Adapted and modified by Lockey et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a></p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Conduct&#47;Therapeutic agent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Maintain vital signs</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Check A &#40;airway&#41;&#44; B &#40;breathing&#41;&#44; C &#40;circulation&#41;&#44; and M &#40;Mind - sensory&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Maintain adequate position &#40;dorsal decubitus with elevated LL&#41;&#46;<br>Getting up or sitting down suddenly is associated with fatal outcomes &#40;&#8220;empty ventricle syndrome&#8221;&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Epinephrine 1&#58;1000</span><br><span class="elsevierStyleItalic">&#40;1</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mg&#47;mL&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Children</span>&#58; 0&#46;01<span class="elsevierStyleHsp" style=""></span>mg&#47;kg up to a maximum of 0&#46;3<span class="elsevierStyleHsp" style=""></span>mg IM&#44; in the anterolateral thigh&#46;<br><span class="elsevierStyleItalic">Adolescents</span>&#58; 0&#46;2&#8211;0&#46;5<span class="elsevierStyleHsp" style=""></span>mg &#40;maximum dose&#41; IM&#44; in the anterolateral thigh&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Administer immediately and repeat if necessary&#44; every 5&#8211;15<span class="elsevierStyleHsp" style=""></span>min&#46; Monitor toxicity &#40;heart rate&#41;<br>Epinephrine at dilutions of 1&#58;10&#44;000 or 1&#58;100&#44;000 should be administered only IV in cases of cardiorespiratory arrest or profound hypotension that did not respond to volume expansion or multiple IM injections of epinephrine&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Children</span>&#58; 5&#8211;10<span class="elsevierStyleHsp" style=""></span>mL&#47;kg IV in the first 5<span class="elsevierStyleHsp" style=""></span>min and 30<span class="elsevierStyleHsp" style=""></span>mL&#47;kg in the first hour<br><span class="elsevierStyleItalic">Adolescents</span>&#58; 1&#8211;2<span class="elsevierStyleHsp" style=""></span>L rapidly IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Infusion rate is regulated by pulse and blood pressure&#46;<br>Establish IV access with the highest caliber possible&#46; Monitor volume overload&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Oxygen &#40;O</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Under nasal cannula or mask&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">If O<span class="elsevierStyleInf">2</span> sat &#60;95&#37;&#44; more than one dose of epinephrine is necessary&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">IV&#44; intravenous&#59; IM&#44; intramuscular&#59; OR&#44; oral route&#59; anti-H1&#44; antihistamine H1&#59; anti-H2&#44; antihistamine H2&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Adapted and modified by Lockey et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a></p>"
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">&#946;2-Agonists</span><br><span class="elsevierStyleItalic">Salbutamol sulfate</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Inhaled medications&#58;<br>Metered-dose inhaler with a spacer &#40;100 mcg&#47;jet&#41;<br><span class="elsevierStyleItalic">Children</span>&#58; 50 mcg&#47;kg&#47;dose<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1 jet&#47;2<span class="elsevierStyleHsp" style=""></span>kg&#59; Maximum dose&#58; ten jets<br><span class="elsevierStyleItalic">Adolescents</span>&#58; four to eight jets&#44; every 20<span class="elsevierStyleHsp" style=""></span>min<br><br>Nebulizer&#58; Solution for nebulization&#58; drops &#40;5<span class="elsevierStyleHsp" style=""></span>mg&#47;mL&#41;<br><span class="elsevierStyleItalic">Children</span>&#58; 0&#46;07&#8211;0&#46;15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg every 20<span class="elsevierStyleHsp" style=""></span>min up to three doses<br><span class="elsevierStyleItalic">Adults&#47;Adolescents</span>&#58; 2&#46;5&#8211;5&#46;0<span class="elsevierStyleHsp" style=""></span>mg&#44; every 20<span class="elsevierStyleHsp" style=""></span>min&#44; for three doses<br>Maximum dose&#58; 5<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bronchospasm reversal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Antihistaminic agents</span><br><span class="elsevierStyleHsp" style=""></span>Promethazine<br><span class="elsevierStyleHsp" style=""></span>Diphenhydramine<br><br><span class="elsevierStyleHsp" style=""></span>Ranitidine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><br><span class="elsevierStyleItalic">Children</span>&#58; 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg IV up to a maximum of 50<span class="elsevierStyleHsp" style=""></span>mg<br><span class="elsevierStyleItalic">Adolescents</span>&#58; 25&#8211;50<span class="elsevierStyleHsp" style=""></span>mg IV<br><br><span class="elsevierStyleItalic">Children</span>&#58; 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg<br><span class="elsevierStyleItalic">Adolescents</span>&#58; 12&#46;5&#8211;50<span class="elsevierStyleHsp" style=""></span>mg IV in up to 10<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anti-H1 agents associated with anti-H2 may be more effective than anti-H1 alone<br>Oral dose may be sufficient for milder episodes<br>Secondary role that has not yet been well determined&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Steroids</span><br><span class="elsevierStyleHsp" style=""></span>Methylprednisolone<br><span class="elsevierStyleHsp" style=""></span>Prednisone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><br>1&#8211;2<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day IV<br>0&#46;5&#8211;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#44; OR&#44; maximum 40<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><br>Dosage standardization not established<br>Prevention of biphasic reactions&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Secondary medications in the treatment of anaphylaxis&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
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            "identificador" => "at3"
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">-<span class="elsevierStyleHsp" style=""></span>The family&#44; the school and the community should collaborate to prevent patient exposure to the food allergen&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">-<span class="elsevierStyleHsp" style=""></span>Criteria and training for early recognition and management of symptoms of probable anaphylaxis is desirable and feasible to be carried out in the family&#44; school&#44; and community&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">-<span class="elsevierStyleHsp" style=""></span>Patients with a previous history of anaphylaxis should carry self-injectable epinephrine&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">-<span class="elsevierStyleHsp" style=""></span>In cases of high risk and no available self-injectable epinephrine&#44; carrying epinephrine in a capped insulin syringe after training may be a valid conduct&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">-<span class="elsevierStyleHsp" style=""></span>Patient with food-dependent&#44; exercise-induced anaphylaxis should avoid physical activity for 4<span class="elsevierStyleHsp" style=""></span>h after the inducer food&#44; which is wheat&#44; in most cases&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">-<span class="elsevierStyleHsp" style=""></span>Patients with food-dependent exercise-induced anaphylaxis should also avoid precipitating reaction factors such as alcohol and non-steroidal antiinflammatory drug use&#44; especially aspirin&#44; when ingesting the allergen food&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">-<span class="elsevierStyleHsp" style=""></span>Patients at risk for anaphylaxis should have a metal plaque in their arm or a card identifying which food they are allergic to&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Preventive recommendations for food anaphylaxis for family&#44; teachers&#44; and community leaders&#46;</p>"
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      ]
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        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">FPIES&#44; food protein-induced enterocolitis syndrome&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&#46; Age less than 2 years old on first presentation &#40;frequent but not mandatory&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&#46; Exposure to suspected foods triggers projectile vomiting&#44; pallor&#44; lethargy in 2&#8211;4<span class="elsevierStyleHsp" style=""></span>h<br>Symptoms last a few hours and resolve&#44; usually within 6<span class="elsevierStyleHsp" style=""></span>h<br>Diarrhea may be present&#44; less frequent&#44; and appears in 5&#8211;10<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&#46; Absence of symptoms that suggest an IgE-mediated reaction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&#46; The exclusion from the diet of the involved protein resolves the symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&#46; Re-exposure or oral challenge test triggers symptoms within 2&#8211;4<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Two exposures are required to establish the definitive diagnosis without the need to perform the challenge test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Current criteria used for the diagnosis of FPIES&#46;</p>"
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        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">FPIES&#44; food protein-induced enterocolitis syndrome&#46;</p>"
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              "tabla" => array:1 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Infections&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Allergy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Digestive tract disorders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Viral gastroenteritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Other non-IgE mediated food allergies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Gastroesophageal reflux disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurological disorders &#40;Encephalopathy or hemorrhage&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sepsis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hirschsprung&#39;s disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cardiac diseases &#40;cardiomyopathies&#44; arrhythmias&#44; congenital cardiopathies&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Bacterial gastroenteritis &#40;<span class="elsevierStyleItalic">Shigella&#44; salmonella&#44; campylobacter&#44; Yersinia</span>&#41;</td><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Acute IgE-mediated reaction &#40;anaphylaxis&#41;</td><td class="td" title="table-entry  " align="left" valign="top">Intestinal invagination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exogenous intoxication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Volvulus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Inborn errors of metabolism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertrophic pyloric stenosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Congenital methemoglobinemia&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Celiac disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Necrotizing enterocolitis<br>Meckel diverticulum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Main clinical situations in the differential diagnosis of FPIES&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:21 [
            0 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Food allergy&#58; review&#44; classification and diagnosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46; Cianferoni"
                            1 => "J&#46;M&#46; Spergel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2332/allergolint.09-RAI-0138"
                      "Revista" => array:6 [
                        "tituloSerie" => "Allergol Int"
                        "fecha" => "2009"
                        "volumen" => "58"
                        "paginaInicial" => "457"
                        "paginaFinal" => "466"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19847094"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Food protein-induced enterocolitis syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46; Nowak-Wegrzyn"
                            1 => "E&#46; Jarocka-Cyrta"
                            2 => "A&#46;P&#46; Moschione Castro"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.18176/jiaci.0149"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Investig Allergol Clin Immunol"
                        "fecha" => "2017"
                        "volumen" => "27"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28603089"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Food allergy&#58; past&#44; present and future"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "H&#46;A&#46; Sampson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.alit.2016.08.006"
                      "Revista" => array:6 [
                        "tituloSerie" => "Allergol Int"
                        "fecha" => "2016"
                        "volumen" => "65"
                        "paginaInicial" => "363"
                        "paginaFinal" => "369"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27613366"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Sarinho E&#44; Antunes A&#44; Pastorino A&#44; Ribeiro M&#44; Porto Neto A&#44; Kuschnir FC&#44; et al&#46; Guia pr&#225;tico de atualiza&#231;&#227;o&#58; Departamento de Alergia da SBP&#46; Available from&#58; <a href="http://www.sbp.com.br/src/uploads/2012/12/Alergia-GuiaPratico-Anafilaxia-Final.pdf">http&#58;&#47;&#47;www&#46;sbp&#46;com&#46;br&#47;src&#47;uploads&#47;2012&#47;12&#47;Alergia-GuiaPratico-Anafilaxia-Final&#46;pdf</a> &#91;accessed 08&#46;05&#46;17&#93;&#46;"
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Incidence of fatal food anaphylaxis in people with food allergy&#58; a systematic review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "T&#46; Umasunthar"
                            1 => "J&#46; Leonardi-Bee"
                            2 => "M&#46; Hodes"
                            3 => "P&#46;J&#46; Turner"
                            4 => "C&#46; Gore"
                            5 => "P&#46; Habibi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/cea.12211"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Exp Allergy"
                        "fecha" => "2013"
                        "volumen" => "43"
                        "paginaInicial" => "1333"
                        "paginaFinal" => "1341"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24118190"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "6"
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Article information

ISSN: 00217557
Original language: English

DOI:10.1016/j.jped.2017.06.021

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Year/Month	Html	Pdf	Total

2024 November	7	2	9
2024 October	23	26	49
2024 September	41	34	75
2024 August	56	29	85
2024 July	52	37	89
2024 June	34	19	53
2024 May	30	11	41
2024 April	28	35	63
2024 March	25	14	39
2024 February	26	27	53
2024 January	25	22	47
2023 December	17	28	45
2023 November	22	31	53
2023 October	22	28	50
2023 September	24	42	66
2023 August	17	18	35
2023 July	36	16	52
2023 June	50	13	63
2023 May	35	17	52
2023 April	16	14	30
2023 March	34	16	50
2023 February	27	14	41
2023 January	16	25	41
2022 December	38	26	64
2022 November	25	25	50
2022 October	40	35	75
2022 September	22	30	52
2022 August	19	29	48
2022 July	23	24	47
2022 June	20	27	47
2022 May	25	32	57
2022 April	37	35	72
2022 March	32	39	71
2022 February	11	19	30
2022 January	10	16	26
2021 December	15	17	32
2021 November	8	15	23
2021 October	8	26	34
2021 September	7	13	20
2021 August	4	6	10
2021 July	2	2	4
2021 June	8	13	21
2021 May	6	12	18
2021 April	6	20	26
2021 March	8	12	20
2021 February	4	8	12
2021 January	5	13	18
2020 December	12	11	23
2020 November	9	9	18
2020 October	4	3	7
2020 September	10	12	22
2020 August	0	2	2
2020 July	5	6	11
2020 June	2	2	4
2020 May	3	4	7
2020 April	8	15	23
2020 March	3	9	12
2020 February	5	6	11
2020 January	11	12	23
2019 December	7	4	11
2019 November	9	5	14
2019 October	6	13	19
2019 September	6	11	17
2019 August	7	8	15
2019 July	6	6	12
2019 June	5	10	15
2019 May	2	5	7
2019 April	10	8	18
2019 March	3	4	7
2019 February	2	9	11
2019 January	4	11	15
2018 December	5	4	9
2018 November	20	3	23
2018 October	106	15	121
2018 September	48	6	54
2018 August	7	6	13
2018 July	11	4	15
2018 June	9	2	11
2018 May	9	3	12
2018 April	2	3	5
2018 March	16	3	19
2018 February	12	4	16
2018 January	12	4	16
2017 December	3	1	4
2017 November	6	5	11
2017 October	1	15	16

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