Sometimes You Need to Be Lucky – Bridget's Story
Since her birth Bridget had almost always been breast-fed; she drank cow's milk (CM) formula only during the first week after birth and at the 45th day of life, without showing any adverse reaction. When she was 4 months old, Bridget drank 120 ml of CM formula and then fell asleep for approximately 90 minutes. A few minutes after she woke up, she started to vomit repetitively and became hyporeactive, pale, hypotonic and so sleepy that her parents could not wake her up completely. Worried about her condition, Bridget's parents drove her to the nearest first aid station, where doctors monitored the baby's vital signs, including oximetry, blood pressure and heart rate, and found they were normal. A few hours later Bridget felt better and acted as though nothing unpleasant had happened. Doctors interpreted this episode as a vagal reaction associated with vomiting and suspected a probable diagnosis of gastroesophageal reflux disease (GERD), on the basis of the clinical history which reported sleep difficulties and opisthotonos. Therefore Bridget returned home with the suggestion of a gastroenterological consultation. At the end of the same day, she had a huge evacuation of liquid and acrid-smelling feces. Following the doctor's suggestion Bridget went to the pediatric gastroenterologist. He told Bridget's mother that her child had no gastroenterological problem and that she did not need to change anything in the baby's diet. In spite of that, Bridget's mother decided that exclusive breast-feeding would have been the safest solution, so she did not feed the child with artificial milk anymore. One day she met a young resident and told her her daughter's story. She was fortunate in that this young doctor attended the pediatric allergic center, so she suspected an allergy and planned a specialist examination for the baby. During the visit, skin prick tests (SPT) were performed and tested negative for CM proteins. An oral food challenge (OFC) was scheduled and performed in a day-hospital (DH) regimen, one month after the critical episode. During that day, the baby drank 60 ml of CM in one dose, which was half of the quantity that caused the previous reaction. Two hours after the ingestion, Bridget started to vomit and became pale and hyporeactive, but blood pressure was normal. These symptoms continued for 4 h and blood pressure decreased, especially the diastolic parameter, to below the physiological range (81/35 mmHg). The child received intravenous (iv.) fluids, hydrocortisone and intramuscular (im.) epinephrine. Six hours after CM ingestion Bridget was fine and returned home with the diagnosis of food protein-induced enterocolitis syndrome (FPIES) caused by CM, and the young resident's suspicion was confirmed. Bridget had to eliminate CM from her diet and, in case of lack of breast milk, she would have to replace it with a extensively casein-hydrolyzed formula. It was also suggested to perform two other OFCs in day-hospital regimens. The first one had to be performed soon with a mixture of cereals, legumes (including soy) and poultry, and the second at the age of 18 months with CM, to verify the possible achievement of tolerance.