Review for 10.1186/1471-230X-11-82 (2011)

Reviewer's report
Title:Allergic proctocolitis refractory to maternal oligoantigenic diet in exclusively
breast-fed infants: a clinical observation.
Version: 2Date:14 March 2011
Reviewer: Ralf G heine
Reviewer's report:
The authors describe an interesting series of 14 exclusively breast-fed infants
with haematochezia due to likely food protein-induced proctocolitis. All infants
underwent skin prick testing and atopy patch testing, as well as endoscopies. All
infants had failed a trial of a maternal elimination diet. Skin prick tests were
negative, suggesting a non-IgE-mediated form of food allergy. Patch testing was
positive to breast milk in all cases, and to a mix of food allergens in some of the
infants. Infants were commenced on amino acid-based formula and had full
clinical resolution of normalisation of mucosal inflammation on repeat endoscopy.
Major compulsory revisions:
There are some areas that require further clarification:
• What was the proportion of non-responders to a maternal elimination diet? In
our experience, the majority of infants will have resolution or significant clinical
improvement in response to dietary elimination of cow’s milk and egg, and rarely
cow’s milk, egg and wheat. Non-responders typically respond to extensively
hydrolysed formula, and only a minority of infants require amino acid-based
formula (AAF). Was extensively hydrolysed formula tried in any of the infants?
• The clinical information provided in Table 1 is only in summary form and makes
it quite difficult for the reader and reviewer to assess the clinical presentation,
diagnostic work-up and response to dietary intervention. As only 14 patients were
involved it would be better or present a detailed summary table, including age,
gender, age of presentation, clinical features, skin test findings, patch test
findings, duration and type of maternal elimination diet etc.
• Details of the elimination diet are missing. How strict was the diet, how long was
the diet administered? How was compliance with the diet monitored? Was a
dietitian involved? How was non-response defined?
• Why was AAF chosen as the first line treatment? Publications generally suggest
that an extensively hydrolysed formula is sufficient in infants who have failed a
maternal elimination diet? Was failure due to non-compliance?
• The patch test to cow’s milk was only positive in 7/14 patients. Do the authors
feel that cow’s milk was involved as one of the offending food antigens in all
infants? The authors did not discuss whether the diagnostic properties (sensitivity
of 50%?) of patch testing are helpful in this clinical setting. How did patch testing
to breast milk help in the diagnostic workup of infants? Was patch testing to
breast milk performed before or after the maternal elimination diet. Are control
data available on atopy patch testing to breast milk in infants without allergic
proctocolitis?
• The discussion is quite broad and should mainly be based on the findings of the
case series. How did atopy patch testing add to the diagnostic work-up of
patients or alter the management of patients. Should all infants with positive
patch tests to breast milk commence an elemental diet? At what point has a
maternal elimination diet failed? What is the role of extensively hydrolysed
formula vs amino acid-based formula. How should the weaning diet be structured
(fruit, vegetables, meats, fish, grains?)
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Needs some language corrections before being
published
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have no competing interests.