Agnieszka Kosmowska, Krystyna Mowszet, Barbara Iwańczak

448A. KOSMOWSKA, K. MOWSZET, B. IWAŃCZAKamong the most disturbing symptoms were anxie−ty (17.85%, 5 cases), disturbed sleep (17.85%,5 children), and recurrent otitis media (7.15%,2 children). Recurrent diarrhea was observed in5 patients (17.85%) (Table 1).The frequency of the symptoms listed abovewas similar in children with and without food al−lergy. With the exception of atopic dermatitis,which was more frequent in children with food al−lergy, there were no statistically significant diffe−rences (Table 1).Family history of allergy was reported in 6 ca−ses (21.42%), polinosis in parents or siblings andcow’s milk allergy in siblings being the most fre−quent.The results of selected laboratory tests are pre−sented in Table 2. Anemia was the most frequentlyobserved disturbance and was diagnosed in42.85% (12 children); in 8 cases (28.57%) it wasaccompanied by a decreased iron level. Eosinophi−lia was observed in 17.85% of cases. In 14.28%(4 children) total serum IgE was elevated, in22.14% (9 children) the skin prick test with nativefood allergens was positive, most frequently withcow’s milk protein (5 children, 29.41%), egg yolk(4 children, 23.52%), and egg white (3 children,17.64%). Increased total IgE and positive skinprick tests were observed exclusively in childrenwith food allergy, with the difference in frequencyon the border of significance and significant, res−pectively. A trial of cow’s milk allergen elimina−tion for three to six months followed by provoca−tion with allergen was positive in 12 children(42.85%). Clinical observation and the tests de−scribed above confirmed food allergy in 12 chil−dren (42.85%), with a prevalence of boys (9 vs. 3).Table 1. Clinical symptoms accompanying GERDTabela 1. Objawy kliniczne towarzyszące GERDClinical symptoms Total Children Children with Statistic(Objawy kliniczne) (Ogółem) with GERD GERD and significancen = 28 – without food food allergy (Istotnośća (%) allergy (Dzieci z GERD statystyczna)(Dzieci z GERD i alergią (b−c)bez alergii pokarmową)pokarmowej) n = 12n = 16 c (%)b (%)Regurgitation(Ulewania) 22 (78.57) 12 (75) 10 (83.3) ns.Vomiting(Wymioty) 18 (64.28) 11 (68.75) 7 (58.3) ns.Anorexia(Brak łaknienia) 12 (42.85) 5 (31.25) 7 (58.3) ns.Malnutrition(Niedożywienie) 10 (35.7) 4 (25) 6 (50) ns.Atopic dermatits(Zmiany skórne typu a.z.s.) 9 (32.14) 0 (0) 9 (75) 0.001Recurrent bronchitis and pneumonia(Nawracające zapalenia oskrzeli i płuc) 9 (32.14) 4 (25) 5 (41.6) ns.Chronic cough(Przewlekły kaszel) 7 (25) 4 (25) 3 (25) ns.Irritability(Rozdrażnienie) 5 (17.85) 2 (12.5) 3 (25) ns.Sleeping disturbances(Niespokojny sen) 5 (17.85) 3 (18.75) 2 (16.6) ns.Recurrent diarrhoea(Nawracające biegunki) 5 (17.85) 1 (6.25) 4 (33.3) ns.Otitis media(Zapalenia ucha środkowego) 2 (7.14) 1 (6.25) 1 (8.3) ns.Astma oskrzelowa(Bronchial asthma) 2 (7.14) 1 (6.25) 1 (8.3) ns.Nieżyt nosa(Rhinitis) 2 (7.14) 0 (0) 2 (16.6) ns.

Assessment of the Frequency of Food Allergy in Children with Gastroesophageal Reflux Disease 449Tabela 2. Abnormal results of selected diagnostic investigationsTable 2. Wybrane nieprawidłowości w badaniach dodatkowychAbnormal results Total Children Children with Statistic(Nieprawidłowe wyniki) (Ogółem) with GERD GERD and significancen = 28 – without food food allergy (Istotnośća (%) allergy (Dzieci z GERD statystyczna)(Dzieci z GERD i alergią (b−c)bez alergii pokarmową)pokarmowej) n = 12n = 16 c (%)b (%)Anaemia(Niedokrwistość) 12 (42.85) 7 (43.75) 5 (41.66) ns.Sideropenia(Sideropenia) 8 (28.57) 4 (25) 4 (33.3) ns.Eosinophilia(Eozynofilia) 5 (17.85) 1 (6.25) 4 (33.3) ns.Increased total IgE blood concentration(Podwyższone stężenie IgE całk. w surowicy) 4 (14.28) 0 (0) 4 (33.3) 0.0513Positive skin prick tests results(Dodatnie testy skórne z natywnymialergenami pokarmowymi)* 9/17 (52.94) 0/5 (0) 9/12 (75) 0.0045* skin prick tests were carried out in 17 children.* testy skórne wykonano u 17 dzieci.n – number.n – liczba badanych.ns. – not significant.ns. – nieistotny.DiscussionThe coexistence of GERD with food allergy inchildren under 3 years old is a frequent phenome−non. As shown in present study, food allergy is ob−served in 42.85% of children with pathological ga−stroesophageal reflux (in 38.89% of the infantsand 50% of the children aged 13–36 months). Ac−cording to Iacono et al. [14], who conducted a stu−dy on infants, food allergy was diagnosed in41.8% of children with pathological gastroesopha−geal reflux. Semeniuk et al. [16] found cow’s milkallergy in 43% of children aged 2–15 months withgastroesophageal reflux. Janiszewska and Czer−wionka−Szaflarska [12] studied a large group ofchildren aged 1–16 years (excluding infants) withdiagnosed acidic gastresophageal reflux based on24−hour esophageal pH−metry and in 48% of thecases found IgE−dependent food allergy.The frequency of gastroesophageal reflux inchildren with diagnosed food allergy is also simi−lar: 30–40% according to Semeniuk et al. [6] and46.5% according to Kamer et al. [4]. The resultsobtained in present study resemble those of otherauthors.Graphical analysis of the pH−metric recordingin most cases allows for the distinction betweenprimary and secondary pathological gastroesopha−geal reflux. In described material the authors obse−rved a typical biphasic pattern, which correlatedwith feeding in about 25% of the children withfood allergy. In the remaining cases the pH−metricpattern was different, which suggests primary ga−stroesophageal reflux coexisting with food allergy.Attention was first drawn to the typical pattern ofthe esophageal pH tracing in children with coexi−sting food allergy and pathological gastroesopha−geal reflux by Iacono et al. [14] and Cavataio et al.[5, 15]. It should be emphasized that the clinicalpictures of food allergy and gastroesophageal re−flux disease in the group of the youngest childrenis similar (regurgitation, vomiting, recurrent respi−ratory tract infections, unsatisfying body mass in−crease). Diarrhea and rhinitis were slightly morefrequently observed in children with coexistingfood allergy and GERD than in isolated pathologi−cal gastroesophageal reflux (the difference not stati−stically significant). Atopic dermatitis was statisti−cally significantly more frequent in the first group.The obtained results are of great practical va−lue. The recognition of an allergic background ofGERD permits effective therapy. The therapeuticmethods used in the treatment of primary gastroe−sophageal reflux, i.e. positional therapy, increased

450A. KOSMOWSKA, K. MOWSZET, B. IWAŃCZAKdensity of formulas, prokinetic drugs, and protonpump inhibitors, applied to secondary gastroeso−phageal reflux caused by food allergy do not yieldimprovement. The most important stage in thetreatment of the latter condition should be the in−troduction of elimination diet and, in some cases,anti−allergic drugs.In described group of children with GERD co−existing with food allergy the authors observedsubsiding or at least significant alleviation of clini−cal symptoms after the introduction of eliminationdiet, anti−allergic drugs and, in some cases, proki−netics.Based on the study described above, it can beconcluded that in the group of children aged 3–36months with GERD, food allergy was observedsignificantly more frequently (42.8%) than in thegeneral population (2–4%). In 25% of the childrena biphasic pattern of the esophageal pH tracing, ty−pical for food allergy, was observed.References[1] Salvatore S, Vandenplas Y: Gastroesophageal reflux and cow milk allergy – is there a link? Pediatrics 2002, 110,972–984.[2] Hill DJ, Heine RG, Cameron DJ, Catto−Smith AG, Chow CW, Francis DE, Hosking CS: Role of food prote−in intolerance in infants with persistent distress attributed to reflux esophagitis. J Pediatr 2000, 136, 641–647.[3] Cavataio F, Caroccio A, Iacono G: Milk−induced reflux in infants less than one year of age. J Pediatr Gastroen−terol Nutr 2000, 30, S36–44.[4] Kamer B, Chilarski A, Lange A, Piaseczna−Piotrowska A: Gastresophageal reflux in infants with food allergy.Med Sci Monit 2000, 6, 348–352.[5] Cavataio F, Iacono G, Montalto G, Soresi M, Tumminello M, Carroccio A: Clinical and pH−metric characte−ristics of gastro−oesophageal reflux secondary to cow’s milk protein allergy. Arch Dis Child 1996, 75, 51–56.[6] Semeniuk J, Tryniszewska E, Wasilewska J, Kaczmarski M: Food allegry: a causative factor of gastroesopha−geal reflux in children [Alergia pokarmowa – czynnik przyczynowy wstecznego odpływu żołądkowo−przełyko−wego u dzieci]. Terapia 1998, 5, 16–19.[7] Czerwionka−Szaflarska M, Zielińska I: Coexistence of gastroesophageal reflux in children with allergic condi−tions [Współistnienie odpływu żołądkowo−przełykowego u dzieci ze schorzeniami alergicznymi]. Acta Pneumo−nol Allergol Pediatr 1998, 2, 27–28.[8] Staiano A, Troncone R, Simeone D, Mayer M, Finelli E, Cella A, Auricchio S: Differentiation of cows’ milkintolerance and gastro−oesophageal reflux. Arch Dis Child 1995, 73, 439–442.[9] Mowszet K, Iwańczak B, Matusiewicz K, Blitek A: Gastroesophageal reflux in food allergies in children [Re−fluks żołądkowo−przełykowy w alergii pokarmowej u dzieci]. Nowa Pediatr 2000, 21, 22–23.[10] Zawadzki S, Czerwionka−Szaflarska M, Zielińska J, Mierzwa G, Bała G: The value of pH−metric studies indiagnosing gastroesophageal reflux in children and adolescents with typical and non specific clinical symptoms ofesophageal reflux disease [Wartość badania pH−metrycznego w rozpoznawaniu refluksu żołądkowo−przełykowe−go u dzieci i młodzieży z typowymi i nieswoistymi objawami klinicznymi choroby refluksowej przełyku]. PolMerk Lek 2002, 13, 116–118.[11] Czerwionka−Szaflarska M, Janiszewska T, Zielińska I, Nowak A: The frequency of coexistence of IgE−depen−dent over−sensitivity and gastroesophageal reflux in children and adolescents – reliminary research results[Częstość współistnienia IgE−zależnej nadwrażliwości z odpływem żołądkowo−przełykowym u dzieci i młodzie−ży – wstępne wyniki badań]. Przegl Pediatr 2003, 33, 297–302.[12] Janiszewska T, Czerwionka−Szaflarska M: IgE−dependent allergy: an intensifying factor of gastroesophagealreflux in children and adolescents [IgE−zależna alergia – czynnik nasilający odpływ żołądkowo−przełykowyu dzieci i młodzieży]. Med Wieku Rozwoj 2003, 7, 211–222.[13] Korzon M, Brodzicki J: The clinical aspects of gastroesophageal reflux in children [Aspekty kliniczne refluksużołądkowo−przełykowego u dzieci. Gastroenterol Pol 1998, 5, 481–485.[14] Iacono G, Carroccio A, Cavataio F, Montalto G, Kazmierska I, Lorello D, Soresi M, Notarbartolo A: Ga−stroesophageal reflux and cow’s milk allergy in infants: A prospective study. J Allergy Clin Immunol 1996, 97,822–827.[15] Cavataio F et al.: Gastroesophageal reflux associated with cow’s milk allergy in infants. Which diagnostic exa−minations are useful? Am J Gastroenterol 1996, 6, 1215–1220.[16] Semeniuk J, Kaczmarski M, Nowowiejska B, Białkoz I, Lebensztejn D: Food allergy as a cause of gastroeso−phageal reflux in the youngest children [Alergia pokarmowa przyczyną refluksu żołądkowo−przełykowego u dzie−ci najmłodszych]. Pediatr Pol 2000, 75,793–802.[17] Vandenplas Y, Verghote M, Kaufman L, Hauser B: Reflux esophagitis and esophageal pH monitoring in dis−tressed infants. Int Pediatr 2004, 19, 98–102.

Assessment of the Frequency of Food Allergy in Children with Gastroesophageal Reflux Disease 451Address for correspondence:Agnieszka KosmowskaKatedra i Klinika Pediatrii, Gastroenterologii i Żywienia AMul. M. Skłodowskiej−Curie 50/5250−369 WrocławPolandTel.: +48 071 32 00 803e−mail: nzjgaspe@ak.am.wroc.plConflict of interest: None declared.Received: 17.11.2005Revised: 17.01.2006Accepted: 17.02.2006Praca wpłynęła do Redakcji: 17.11.2005 r.Po recenzji: 17.01.2006 r.Zaakceptowano do druku: 17.02.2006 r.