Newborns with Bloody Stools—At the Crossroad between Efficient Management of Necrotizing Enterocolitis and Antibiotic Stewardship

The onset of bloody stools in neonates often results in antibiotic treatment for suspected necrotizing enterocolitis (NEC). Food protein-induced allergic proctocolitis (FPIAP) is an often-neglected differential diagnosis. We performed a retrospective analysis of antibiotic exposure at our tertiary center from 2011 to 2020 that included three time periods of differing antimicrobial stewardship goals. We compared these data with the conventional treatment guidelines (modified Bell’s criteria). In our cohort of 102 neonates with bloody stools, the length of antibiotic exposure was significantly reduced from a median of 4 to 2 days. The proportion of treated neonates decreased from 100% to 55% without an increase in negative outcomes. There were 434 antibiotic days. Following a management strategy according to modified Bell’s criteria would have led to at least 780 antibiotic days. The delayed initiation of antibiotic treatment was observed in 7 of 102 cases (6.9%). No proven NEC case was missed. Mortality was 3.9%. In conclusion, with FPIAP as a differential diagnosis of NEC, an observational management strategy in neonates with bloody stools that present in a good clinical condition seems to be justified. This may lead to a significant reduction of antibiotic exposure. Further prospective, randomized trials are needed to prove the safety of this observational approach.

Non-IgE-Mediated Gastrointestinal Food Protein-Induced Allergic Disorders. Clinical Perspectives and Analytical Approaches

Non-IgE-mediated gastrointestinal food allergy (non-IgE-GI-FA) is the name given to a series of pathologies whose main entities are food protein-induced allergic proctocolitis (FPIAP), food protein-induced enteropathy (FPE), and food protein-induced enterocolitis syndrome (FPIES). These are more uncommon than IgE-mediated food allergies, their mechanisms remain largely unknown, and their diagnosis is mainly done by clinical history, due to the lack of specific biomarkers. In this review, we present the latest advances found in the literature about clinical aspects, the current diagnosis, and treatment options of non-IgE-GI-FAs. We discuss the use of animal models, the analysis of gut microbiota, omics techniques, and fecal proteins with a focus on understanding the pathophysiological mechanisms of these pathologies and obtaining possible diagnostic and/or prognostic biomarkers. Finally, we discuss the unmet needs that researchers should tackle to advance in the knowledge of these barely explored pathologies.

Food protein induced allergic proctocolitis: The effect of maternal Mediterranean diet during pregnancy and breastfeeding

Background: The aim of the current investigation was to explore predisposing factors for food protein induced allergic proctocolitis (FPIAP) in Greek infants relevant in the maternal diet, during pregnancy and breastfeeding, as relevant knowledge is limited. Methods: A multicenter retrospective case-control study was conducted in 6 regions in Greece, with 96 mothers of infants with and 141 mothers of infants without a history of FPIAP. Maternal dietary habits during pregnancy and breastfeeding were evaluated with validated questionnaires: a) The Mediterranean Diet (MedDiet) Score, and b) The Mediterranean Oriented Culture Specific Semi-Quantitative Food Frequency Questionnaire. Statistical tests, modeling and exploration of the FPIAP risk in relation to the maternal diet using elastic net regression models were performed with R software and Studio. Results: FPIAP was associated with cow’s milk (83.6%), egg (7.3 %), and wheat, beef (6.4%) in the maternal diet. Adherence to MedDiet was similar among the mothers, but mothers of FPIAP infants consumed more vegetables (p=0.018) and olive oil (p=0.003). Elastic net prediction models showed that, in this Mediterranean population, increased consumption during pregnancy and lactation of common allergens, whole grain products, homemade food, fish and shellfish, fruit offered protection; conversely, high intake of vegetables, sugar and total fat, and non-stick/grilled cooking, increased the risk of FPIAP, as did high intake of salt and white flour during lactation. Conclusions: Components of a maternal Mediterranean diet can protect against FPIAP when traditional cooking methods are adopted and fish, fruit and whole wheat products are consumed frequently.