Maintenance of certification-CME review

Evaluation of vomiting and regurgitation in the infant

Clinical Vignette

An 11-month-old, white boy presents for evaluation of vomiting and difficulty feeding. The patient was born full term after an uncomplicated pregnancy. He was initially breastfed but was noted to have difficulty feeding, often crying at the breast and spitting up. Despite his mother eliminating multiple foods from her diet, his symptoms persisted. By 3 weeks of age, he had been transitioned to a partially hydrolyzed formula, prescribed a histamine₂-blocker, and evaluated by a gastroenterologist

Non–IgE-Mediated Gastrointestinal Food Reactions in Infants

In general, non–IgE-mediated dietary-induced enteropathies include proctitis or proctocolitis, enteropathy, and enterocolitis, which usually present early in life. Infants with dietary protein–induced proctitis generally seem healthy, with visible fresh blood that varies from specks or streaks to gross bleeding. A lack of other symptoms, such as vomiting or diarrhea, distinguishes this from IgE-mediated gastrointestinal food allergies. In contrast, more than 50% of patients with dietary

Food Allergies in Infants

Gastrointestinal immediate-type hypersensitivity is a form of IgE-mediated food allergy that can present at any age. Symptoms occur rapidly, generally within 2 hours of exposure, and can include nausea, abdominal pain, vomiting, and/or diarrhea. Although these symptoms may occur in isolation without other systemic symptoms, they are more commonly associated with reactions in other organ systems.

The eosinophilic gastroenteropathies (EoE, gastritis, gastroenteritis, and colitis) are collectively

Evaluation of Infants with Vomiting and Concern for Food Allergies

After excluding anatomical, metabolic, and infectious causes of vomiting, physicians often face a quandary in diagnosing gastrointestinal disease in infants. In general, diagnostic tests are not helpful in identifying food hypersensitivity in infants, and diagnosis, therefore, relies heavily on a detailed history and physical examination.

In the case of immediate IgE-mediated reactions, supportive tests, such as skin prick tests (SPTs) or specific IgE (sIgE) testing, are helpful in verifying

The Case Revisited

Because of his symptoms, the patient was advised to undergo an upper endoscopy and was referred to an allergy clinic for testing. Upper endoscopy revealed an esophageal mucosa with marked edema, white exudates, and a normal-appearing gastric body. Microscopic examination demonstrated more than 40 eosinophils per high-power field in both the proximal and distal esophagus, confirming the diagnosis of EoE. The SPTs revealed sensitivity to milk, egg, shellfish, peanut, cashew, almond, and sesame.

Conclusion

Vomiting and regurgitation are common pediatric concerns, and physicians should be aware of when reassurance, further testing, or empiric avoidance is appropriate. The patient in this report was referred twice for an allergy evaluation. The first was for concern of GERD related to cow's milk protein hypersensitivity, and the second was for an allergy evaluation in relation to newly diagnosed EoE.

The evaluation and management of this patient highlight a few key points in the care of infants