Atopy Patch Test in the Diagnosis of Food Allergens in Infants with Allergic Proctocolitis Compared with Elimination/Introduction C.

Allergic proctocolitis is a cell-dependent food allergy that is present in both breast and formula-fed infants. The presence of blood with different amounts in the stool is the main manifestation of the disease. Different results have been published on the accuracy and specificity of the atopic patch test (APT). The purpose of this study was to evaluate the results of the APT and compare them with those obtained in the food elimination/introduction (E/I) challenge, as the gold standard of confirming the allergy. Twenty-eight patients (18 boys, 10 girls, <1 year) with allergic proctocolitis were recruited in this study. The mean age of the disease onset and enrolling the study were 2.23±1.7 and 5.25±2.19 months, respectively. After performing APT with fresh foods, an E/I challenge was done in a patient with positive tests, and results were analyzed. APT was positive in 14/28 (50%) individuals. The most common foods detected by APT in all of the individuals were: milk (10/28), rice (5/28), soy (4/28), and egg white (4/28), while in E/I challenge in the APT-positive individuals were: milk (8/10), rice (3/5), egg white (1/4), and soy (0/4). APT was positive in half of the infants<1 year with allergic proctocolitis and there was no significant correlation between the APT results and the E/I challenge test for all foods. Comparing the results of APT and E/I challenge methods showed a convergence between the milk and rice sensitivity, thus we suppose APT to be a useful tool in identifying these two allergens in cell-mediated food allergies like allergic proctocolitis.

Food protein-induced allergic proctocolitis may have distinct phenotypes.

BACKGROUND: Food protein-induced allergic proctocolitis (FPIAP) is a non-immunoglobulin E (IgE)-mediated food allergy, which presents with bloody mucoid stool in infants. Although IgE-mediated allergy and sensitizations to offending foods have been described in other non-IgE-mediated food allergies, it has not been investigated in FPIAP. OBJECTIVE: To investigate IgE-mediated allergy and sensitization to offending foods in FPIAP. METHODS: Patients (n = 204) were retrospectively recruited and grouped as FPIAP (n = 180; FPIAP with or without the symptoms of IgE-mediated food hypersensitivity to offending and nonoffending foods at initial consultation), FPIAP-IgE sensitization to offending foods (n = 17), and FPIAP-transition to IgE-mediated allergy to offending foods (n = 7). The study was performed in accordance with the protocol approved by the local ethical committee of the Hacettepe University. RESULTS: The median age of onset of symptoms and the development of tolerance was 2 months (interquartile range [IQR], 1.0-3.0) and 12 months (IQR, 10.0-14.0), respectively, and of the patients with skin prick test or serum specific IgE tests (n = 196), 38 (19.4%) had evidence of IgE sensitization to offending foods at the initial consultation or during follow-up; 17 (8.6%) had IgE sensitization, 7 (3.6%) indicated a transition to IgE-mediated allergy to FPIAP-induced foods. The median age of tolerance development of the FPIAP-transition group (19 months, IQR, 18.0-29.0) was significantly later than that of the FPIAP group (11 months, IQR, 10.0-14.0; P < .001) and the FPIAP-IgE sensitization group (11.0 months, IQR, 9.5-12.0; P < .001). Tolerance was observed within the study period in almost all the patients. CONCLUSION: Children with FPIAP may have sensitization or develop IgE-mediated allergy over time to offending foods. In addition, IgE sensitization in FPIAP does not have an unfavorable effect on tolerance development; however, the transition to an IgE-mediated phenotype may delay tolerance for a brief time.

Non-IgE-Mediated Gastrointestinal Food Allergies in Children: An Update.

Non-immunoglobulin E-mediated gastrointestinal food allergic disorders (non-IgE-GI-FA) include food protein-induced enterocolitis syndrome (FPIES), food protein-induced enteropathy (FPE) and food protein-induced allergic proctocolitis (FPIAP), which present with symptoms of variable severity, affecting the gastrointestinal tract in response to specific dietary antigens. The diagnosis of non-IgE-GI-FA is made clinically, and relies on a constellation of typical symptoms that improve upon removal of the culprit food. When possible, food reintroduction should be attempted, with the documentation of symptoms relapse to establish a conclusive diagnosis. Management includes dietary avoidance, nutritional counselling, and supportive measures in the case of accidental exposure. The prognosis is generally favorable, with the majority of cases resolved before school age. Serial follow-up to establish whether the acquisition of tolerance has occurred is therefore essential in order to avoid unnecessary food restriction and potential consequent nutritional deficiencies. The purpose of this review is to delineate the distinctive clinical features of non-IgE-mediated food allergies presenting with gastrointestinal symptomatology, to summarize our current understanding of the pathogenesis driving these diseases, to discuss recent findings, and to address currents gaps in the knowledge, to guide future management opportunities.

Microbiota in non-IgE-mediated food allergy.

PURPOSE OF REVIEW: To perform a nonsystematic review of the literature on the microbiota in the different types of non-IgE-mediated food allergy. RECENT FINDINGS: The commonest non-IgE-mediated disorders managed by allergists include: eosinophilic esophagitis, food protein-induced enteropathy, food protein-induced enterocolitis syndrome, and food protein-induced allergic proctocolitis. The review of the literature describes how at phylum level we observe an increase of Proteobacteria in eosinophilic esophagitis esophageal microbiota and in food protein-induced enterocolitis syndrome, and food protein-induced allergic proctocolitis gut microbiota, while we observe an increase of Bacteroidetes in healthy controls. Several studies endorse the concept that a bloom of Proteobacteria in the gut reflects dysbiosis or an unstable gut microbial community structure. In several studies, the type of diet, the use of probiotics and in a single experience the use of fecal microbiota transplantation has produced significant variations of the microbiota. SUMMARY: Genetic factors alone cannot account for the rapid rise in food allergy prevalence and the microbiome might be contributing to allergy risk. Our review showed that common features of the pathological microbiota among different types of non-IgE-mediated food allergy can be identified. These evidences suggest a possible role of the microbiota in the pathogenesis and non-IgE-mediated food allergies and the need to understand the effects of its modulation on the disorders themselves.

Unique features of non-IgE-mediated gastrointestinal food allergy during infancy in Japan.

PURPOSE OF REVIEW: An increase in incidence of unique phenotypic non-IgE-mediated gastrointestinal food allergies (non-IgE GIFAs) has occurred in Japan ahead of Western countries. There are differences in clinical features of non-IgE GIFAs in Western and Japanese patients. As this phenotype has now come to be recognized internationally, we describe it in this review. RECENT FINDINGS: A large number of Japanese patients with non-IgE GIFAs present with vomiting accompanied by bloody stool, putting them between food protein-induced enterocolitis syndrome (FPIES) and food protein-induced allergic proctocolitis. Some neonates and early infants with non-IgE GIFAs who present with fever and elevated C-reactive protein have symptoms consistent with severe systemic bacterial infections (e.g., sepsis). Some of these cases have now been defined in international guidelines as chronic FPIES. Eosinophils might be involved in the inflammatory process observed. The incidence of FPIES and food protein-induced allergic proctocolitis is increasing in Western countries and likely worldwide, after it has increased in Japan. SUMMARY: The phenotype observed in Japan shows distinct clinical features compared with the classical phenotype, that is, increased levels of eosinophils, suggestive of 'eosinophilic shift' alongside symptomatic differences, making it difficult to categorize.

Alergia a las proteínas de leche de vaca no mediada por IgE: documento de consenso de la Sociedad Española de Gastroenterología, Hepatología y Nutrición Pediátrica (SEGHNP), la Asociación Española de Pediatría de Atención Primaria (AEPAP), la Sociedad Española de Pediatría Extrahospitalaria y Atención Primaria (SEPEAP) y la Sociedad Española de Inmunología Clínica, Alergología y Asma Pediátrica (SEICAP) / Non-IgE-mediated cow's milk allergy: Consensus document of the Spanish Society of Paediatric Gastroenterology, Hepatology, and Nutrition (SEGHNP), the Spanish Association of Paediatric Primary Care (AEPAP), the Spanish Society of Extra-hospital Paediatrics and Primary Health Care (SEPEAP), and the Spanish Society of Paediatric ClinicaL Immunology, Allergy, and Asthma (SEICAP)

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Eosinofilia grave en lactante con proctocolitis alérgica / Severe eosinophilia in breast feeding infant with allergic proctocolitis

La eosinofilia en el recién nacido puede ser secundaria a múltiples etiologías. Presentamos el caso de un recién nacido que presentó eosinofilia severa, rectorragia y desmedro como manifestación de proctocolitis alérgica a proteínas de leche de vaca. Hacemos el diagnóstico diferencial de la eosinofilia en el período neonatal

Eosinophilia in newborn is caused for several causes. We presented a newborn who showed severe eosinofilia, rectorrhagia and lose weight due to allergic proctocolitis. We revised the differencial diagnosis of eosinophilia in newborn

Food Protein-Induced Proctocolitis. The shadow of allergic disorders

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Marcadores de inflamación y desarrollo de tolerancia en la proctocolitis alérgica / Markers of inflammation and tolerance development in allergic proctocolitis

Antecedentes: Con el incremento de la proctocolitis alérgica inducida por proteínas de la dieta (PAIPD), son necesarios estudios que aclaren su fisiopatología y determinar marcadores no invasivos y sencillos para el diagnóstico y la evaluación del desarrollo de tolerancia. No hallamos estudios publicados sobre la función del índice de neutrófilos/linfocitos (INL) y el volumen plaquetario medio (VPM), que son marcadores no invasivos fácilmente medibles, en pacientes con PAIPD. Objetivos: Determinar la relación entre el INL y el VPM con el diagnóstico y desarrollo de tolerancia en niños con PAIPD. Métodos: Estudio transversal retrospectivo, los datos se obtuvieron del sistema de registros médicos, los síntomas y los resultados de laboratorio de los pacientes con diagnóstico de PAIPD fueron controlados en los consultorios de alergia y gastroenterología. Se compararon valores del hemograma al momento del diagnóstico con el grupo de niños sanos de edad y sexo similares. Resultados: Entre los 59 pacientes con diagnóstico de PAIPD, los varones representaron el 47,4% y las niñas, el 52,6%. El VPM y el volumen plaquetario relativo (VPR) eran significativamente más altos entre los pacientes con PAIPD en comparación con el grupo de referencia (n: 67) (p < 0,001). Asimismo, VPM y el VPR fueron significativamente elevados en pacientes que no desarrollaron tolerancia comparados con los que la desarrollaron (p= 0,01). Con el INL no hubo diferencias entre los grupos. Conclusiones: El VPM y el VPR se consideraron marcadores adecuados para predecir el pronóstico de los pacientes con PAIPD dado que son rápidos, costo-efectivos y fáciles de medir.

Background. Today, as a result of an increase in the frequency of food protein-induced allergic proctocolitis (FPIAP), there is a need for studies not only to enlighten the pathophysiology of the disease but also to determine simple, non-invasive markers in both diagnosis, and evaluation of the development of tolerance. No study has been found in the literature about the place of neutrophil/lymphocyte ratio (NLR) and mean platelet volume (MPV), which are easy to calculate and non-invasive markers. Objectives. The purpose is to determine the relation between NLR and MPV with the diagnosis and development of tolerance in children with FPIAP. Methods. In this retrospective cross-sectional study, clinical, demographic symptoms and laboratory findings of patients, monitored with FPIAP diagnosis in allergy and gastroenterology clinics, were acquired from the patient record system. Hemogram values at the time of diagnosis were compared with the values of healthy children of the same age and gender. Results. Among 59 patients diagnosed with FPIAP, males constitute 47.4% and females constitute 52.6%. MPV and platelet crit (PCT) values were significantly high when compared to the control group (n: 67) in FPIAP cases (p <0.001). Also, MPV and PCT values were significantly high in non-tolerance developing cases when compared to developing ones (p= 0.01). Conclusions. Contrary to NLR, MPV and PCT values have been considered to be good markers in predicting prognosis in cases with FPIAP since they are quick, cost effective and easy to calculate.

Markers of inflammation and tolerance development in allergic proctocolitis. / Marcadores de inflamación y desarrollo de tolerancia en la proctocolitis alérgica.

BACKGROUND: Today, as a result of an increase in the frequency of food protein-induced allergic proctocolitis (FPIAP), there is a need for studies not only to enlighten the pathophysiology of the disease but also to determine simple, non-invasive markers in both diagnosis, and evaluation of the development of tolerance. No study has been found in the literature about the place of neutrophil/lymphocyte ratio (NLR) and mean platelet volume (MPV), which are easy to calculate and non-invasive markers. OBJECTIVES: The purpose is to determine the relation between NLR and MPV with the diagnosis and development of tolerance in children with FPIAP. METHODS: In this retrospective cross-sectional study, clinical, demographic symptoms and laboratory findings of patients, monitored with FPIAP diagnosis in allergy and gastroenterology clinics, were acquired from the patient record system. Hemogram values at the time of diagnosis were compared with the values of healthy children of the same age and gender. RESULTS: Among 59 patients diagnosed with FPIAP, males constitute 47.4% and females constitute 52.6%. MPV and platelet crit (PCT) values were significantly high when compared to the control group (n: 67) in FPIAP cases (p < 0.001). Also, MPV and PCT values were significantly high in non-tolerance developing cases when compared to developing ones (p= 0.01). CONCLUSIONS: Contrary to NLR, MPV and PCT values have been considered to be good markers in predicting prognosis in cases with FPIAP since they are quick, cost effective and easy to calculate.

ANTECEDENTES: Con el incremento de la proctocolitis alérgica inducida por proteínas de la dieta (PAIPD), son necesarios estudios que aclaren su fisiopatología y determinar marcadores no invasivos y sencillos para el diagnóstico y la evaluación del desarrollo de tolerancia. No hallamos estudios publicados sobre la función del índice de neutrófilos/linfocitos (INL) y el volumen plaquetario medio (VPM), que son marcadores no invasivos fácilmente medibles, en pacientes con PAIPD. OBJETIVOS: Determinar la relación entre el INL y el VPM con el diagnóstico y desarrollo de tolerancia en niños con PAIPD. MÉTODOS: Estudio transversal retrospectivo, los datos se obtuvieron del sistema de registros médicos, los síntomas y los resultados de laboratorio de los pacientes con diagnóstico de PAIPD fueron controlados en los consultorios de alergia y gastroenterología. Se compararon valores del hemograma al momento del diagnóstico con el grupo de niños sanos de edad y sexo similares. RESULTADOS: Entre los 59 pacientes con diagnóstico de PAIPD, los varones representaron el 47,4% y las niñas, el 52,6%. El VPM y el volumen plaquetario relativo (VPR) eran significativamente más altos entre los pacientes con PAIPD en comparación con el grupo de referencia (n: 67) (p < 0,001). Asimismo, VPM y el VPR fueron significativamente elevados en pacientes que no desarrollaron tolerancia comparados con los que la desarrollaron (p= 0,01). Con el INL no hubo diferencias entre los grupos. CONCLUSIONES: El VPM y el VPR se consideraron marcadores adecuados para predecir el pronóstico de los pacientes con PAIPD dado que son rápidos, costo-efectivos y fáciles de medir.

Tolerance development in food protein-induced allergic proctocolitis: single centre experience

BACKGROUND: Food protein-induced allergic proctocolitis (FPIAP) is characterised by inflammation of the distal colon in response to one or more food proteins. It is a benign condition of bloody stools in a well-appearing infant, with usual onset between one and four weeks of age. OBJECTIVE: Our objective was to examine the clinical properties of patients with FPIAP, tolerance development time as well as the risk factors that affect tolerance development. METHODS: The clinical symptoms, offending factors, laboratory findings, methods used in the diagnosis and tolerance development for 77 patients followed in the Paediatric Allergy and Gastroenterology Clinics with the diagnosis of FPIAP during January 2010-January 2015 were examined in our retrospective cross-sectional study. RESULTS: The starting age of the symptoms was 3.3±4.7 months (0-36). Milk was found as the offending substance for 78% of the patients, milk and egg for 13% and egg for 5%. Mean tolerance development time of the patients was 14.7±11.9 months (3-66 months). Tolerance developed before the age of one year in 40% of the patients. Tolerance developed between the age of 1-2 years in 27%, between the age of 2-3 years in 9% and after the age of 3 years in 5% of the patients. CONCLUSIONS: Smaller onset age and onset of symptoms during breastfeeding were found associated with early tolerance development. In the majority of the patients, FPIAP resolves before the age of one year, however in some of the patients this duration may be much longer

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Food Protein Induced Proctocolitis: A Benign Condition with an Obscure Immunologic Mechanism.

Food protein-induced proctocolitis (FPIP) is the most common colonic manifestation of food allergy in infants, accounting for up to 60% of exclusively breast-fed children. The causative foods derived from the mother's diet, which are then excreted in her milk. The suggested risk factors for the development of FPIP are an immature immune system, altered intestinal permeability and other factors that activate local immune function, such as genetic susceptibility in combination with particularly sensitizing foods. FPIP is an enhanced immune responsiveness of some infants to very small amounts of food antigens, inducing an inflammatory mucosal response, mediated by T cells.

Tolerance development in food protein-induced allergic proctocolitis: Single centre experience.

BACKGROUND: Food protein-induced allergic proctocolitis (FPIAP) is characterised by inflammation of the distal colon in response to one or more food proteins. It is a benign condition of bloody stools in a well-appearing infant, with usual onset between one and four weeks of age. OBJECTIVE: Our objective was to examine the clinical properties of patients with FPIAP, tolerance development time as well as the risk factors that affect tolerance development. METHODS: The clinical symptoms, offending factors, laboratory findings, methods used in the diagnosis and tolerance development for 77 patients followed in the Paediatric Allergy and Gastroenterology Clinics with the diagnosis of FPIAP during January 2010-January 2015 were examined in our retrospective cross-sectional study. RESULTS: The starting age of the symptoms was 3.3±4.7 months (0-36). Milk was found as the offending substance for 78% of the patients, milk and egg for 13% and egg for 5%. Mean tolerance development time of the patients was 14.7±11.9 months (3-66 months). Tolerance developed before the age of one year in 40% of the patients. Tolerance developed between the age of 1-2 years in 27%, between the age of 2-3 years in 9% and after the age of 3 years in 5% of the patients. CONCLUSIONS: Smaller onset age and onset of symptoms during breastfeeding were found associated with early tolerance development. In the majority of the patients, FPIAP resolves before the age of one year, however in some of the patients this duration may be much longer.

Gastrointestinal food allergy in Ghanaian children: a case series.

BACKGROUND: Food allergy is an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food. Food allergies are classified into three types: Ig(immunoglobulin)E mediated, mixed IgE and cell mediated and cell-mediated non IgE mediated. Gastrointestinal (GIT) food allergy has classically encompassed a number of different clinical entities: food protein-induced enterocolitis syndrome (FPIES), food protein-induced proctocolitis (FPIP), food protein-induced enteropathy and eosinophilic gastrointestinal disorders (EGID). CASE PRESENTATIONS: These are 5 cases of infants and toddlers who presented with various features of gastrointestinal food allergies, the commonest of which is lower gastrointestinal bleed. Two infants on exclusive breast feeding, presented with lower gastrointestinal bleeding and these resolved with maternal dietary milk and all dairy elimination. The third infant had rectal bleeding at age 6 months after the introduction of infant formula. The bleeding and eczema resolved with the introduction of hydrolyzed formula. One of the toddlers presented with severe eczema and malnutrition which improved with 6 food elimination. The last case had massive lower gastrointestinal bleed which resulted in hemicolectomy with no improvement until dietary elimination was instituted. CONCLUSION: Gastrointestinal food allergy is not uncommon in children in Ghana. A high index of suspicion is required to make the right diagnosis, to minimize morbidity and unnecessary therapy. SOURCE OF FUNDING: None.

Deposiciones sanguinolentas iniciadas en los primeros días de vida / Bloody stools started in the first days of life

La proctocolitis alérgica del lactante es un trastorno caracterizado por la presencia de deposiciones mucosanguinolentas en los dos primeros meses de vida, pudiendo aparecer en los primeros días de vida. Anteriormente, relacionado con niños alimentados con lactancia artificial, en los últimos años se observa un aumento de la incidencia en niños alimentados con lactancia materna exclusiva debido al paso de proteínas de leche de vaca a la leche de la madre. Recién nacido a término, alimentado con lactancia materna exclusiva inicia a los dos días de vida deposiciones con hebras de sangre de forma intermitente. Todos los estudios realizados resultan normales. La clínica mejora progresivamente tras la eliminación de las proteínas de leche de vaca de la dieta de la madre, por lo que se diagnostica de proctocolitis alérgica. El diagnóstico se basa en la clínica, la desaparición de los síntomas al retirar las proteínas de leche de vaca de la dieta, y en la reaparición de éstos al reintroducirla. Los niños mantienen buen estado general en todo momento, siendo la gran mayoría tolerantes a la leche de vaca al año de vida, por lo que se considera una patología de buen pronóstico.

Allergic colitis is a pathology characterized by blood in faeces, appeared in first two months of life, but it can also appear during the first days of life. Previously it was related with children with non breastfeeding, however in the last years incidence is increasing in children with breastfeeding. This is explained with the presence of cow’s milk proteins in human’s milk. Newborn term, fed with exclusive breastfeeding, starts at second day of life blood in faeces, intermittently. The studies done are normal. The symptoms improve progressively after removing the cow’s milk proteins of the mother’s diet, so the child is diagnosed with allergic protocolitis. Diagnosis is based on the symptoms, the improvement with the removal of the cow’s milk protein of the diet, and the worsening when they are reintroduced. The children conserve good general condition every moment, almost all of them tolerate cow’s milk when they are one year old, and so it is considered pathology of well prognosis.

Alergia alimentaria en la edad pediátrica, conceptos actuales / Food allergies in paediatrics: Current concepts

En la actualidad se engloba en el concepto de reacción alérgica tanto aquellas cuyo mecanismo inmunológico depende de una reacción mediada por IgE, como las que implican a otros mecanismos inmunitarios como las células T reguladoras. Existen situaciones clínicas muy diferenciadas, como son las clásicas de la reacciones inmediatas (IgE mediadas), como urticaria, angioedema, vómitos inmediatos, dolor abdominal, síntomas respiratorios tanto de vías altas (afonía o rinitis), como de vías bajas (sibilancias o disnea), síntomas cardiovasculares y la reacción que implica a más de un órgano, como la anafilaxia que puede ser choque anafiláctico si hay afectación cardiovascular; la clínica producida por las reacciones no mediadas por IgE suele ser más insidiosa en su comienzo, así vómitos pasadas 2 h de la ingesta del alimento en las enterocolitis, diarreas al cabo de días o semanas de iniciar el alimento, dermatitis al cabo de un tiempo de iniciar el alimento; en estos casos es más difícil relacionar dicha clínica directamente con el alimento. En este artículo pretendemos clarificar algunos conceptos como sensibilización/alergia, alérgeno/fuente alergénica o la relación de diversas situaciones clínicas con la alergia a alimento para ayudar así al pediatra, por una parte, a efectuar dietas estrictas en caso de sospecha fundada de relación causa efecto con el alimento y, por otra, a no inducir dietas innecesarias que, muchas veces, se prolongan durante un tiempo excesivo y pueden provocar importantes deficiencias nutricionales en los niños

The concept of allergic reaction currently includes all those where an immunological reaction depends on a reaction mediated by IgE, as well as those that involve other immune mechanisms, such as T-cell regulators. There are many different clinical situations, like the classic immediate reactions (IgE mediated) such as urticaria, angioedema, immediate vomiting, abdominal pain, both upper respiratory (aphonia or rhinitis) and lower (wheezing or dyspnoea) symptom, and cardiovascular symptoms. The reactions that involve more than one organ, such as anaphylaxis, which could be an anaphylactic shock if there is cardiovascular involvement. The clinical signs and symptoms produced by non-IgE mediated reactions are usually more insidious in how they start, such as vomiting hours after the ingestion of food in enterocolitis, diarrhoea after days or weeks from starting food, dermatitis sometime after starting food. In these cases it is more difficult to associate these clinical symptoms directly with food. In this article, we attempt to clarify some concepts such as sensitisation/allergy, allergen/allergenic source, or the relationship of different clinical situations with food allergy, in order to help the paediatrician on the one hand, to prescribe strict diets in case of a suspicion based on the cause/effect relationship with the food, and on the other hand not to introduce unnecessary diets that very often have to last an excessively long time, and could lead to nutritional deficiencies in the children

Paediatric non-IgE mediated food allergy: guide for practitioners.

AIM: Food avoidance in children is increasingly common due to concerns about allergy. We aim to review the current literature on paediatric non-IgE mediated food allergy including what is known about pathophysiology, diagnosis, management and prognosis of common and severe presentations. Considerations regarding appropriate formula selection are also presented. METHODS: Common non-IgE mediated conditions were searched through common medical databases. Thorough review of available literature was then synthesised and critically appraised. RESULTS: Current understanding of immunological mechanisms of most non-IgE mediated conditions remains elusive. Most conditions are outgrown in childhood and have a good prognosis. Dietary modification for some conditions is important to ensure safety. They are not recommended in all situations due to potentially harmful consequences. CONCLUSION: Assessment of children with concerns regarding non-IgE mediated conditions requires a thorough history and is generally not supported by reliable diagnostic tests. Caution is warranted when advising families to undertake dietary exclusions unless well supported by the evidence and ensuring benefits outweigh any potential harm.