Volume 118 Number 1
the age range closer to the currently recommended age were significantly lower than in the younger infants given two doses. These and previous 2, 3 observations provide an optimistic outlook for eventual prevention of invasive Hib infection in infants with sickle cell disease after two or more doses of conjugate vaccine. For now, follow-up or consideration of booster doses may be indicated for children with sickle cell diseases who were vaccinated according to the current single-dose schedule. REFERENCES 1. Zarkowsky HS, Gallagher D, Gill FM, et al. Bacteremia in sickle hemoglobinopathies. J PEDIATR 1986;109:579-85. 2. Gigliotti F, Feldman S, Wang WC, Day SW, Brunson G. Immunization of young infants with sickle cell diseases with a Haemophilus influenzae type b saccharid~diphtheria CRM197 protein conjugate vaccine. J PEDiATR1989;114:1006. 3. Badoual J, Begue P, Beauvais M, ct al. Immune response to Haemophilus influenzae type b (Hib) capsular polysaccharide-tetanus toxoid conjugate (PRP-T) vaccine in children with sickle cell disease [Abstract 49]. Interscience Conference on Antimicrobial Agents and Chemotherapy, Houston, Tex., October 1989. 4. Frank AL, Labotka R J, Ran S, et al. Haemophilus influenzae type b immunization of children with sickle cell diseases. Pediatrics 1988;82:571-5. 5. Lepow ML, Barkin RM, Berkowitz CD, et al. Safety and im-
Clinical and laboratory observations
6.
7.
8.
9.
10.
11.
71
munogenicity of Haemophilus influenzae type b polysaccharide-diphtlieria toxoid conjugate vaccine (PRP-D) in infants. J Infect Dis 1987;156:591-5. Lepow ML, Samuelson JS, Gordon LK. Safety and immunogenicity of Haemophilus influenzae type b polysaccharide diphtheria toxoid conjugate vaccine in infants 9 to 15 months of age. J PEDIATR 1985;106:185-9. Berk0witz CD, Ward JI, Meier K, et al. Safety and immunogenicity of Haemophilus influenzae type b polysacchar!de diphtheria toxoid conjugate vaccine in children 15-24 months of age. J PEDIATR 1987;110:509-14. Lenoir AA, Granoff PD, Granoff DM. Immunogenicity of Haemophilus influenzae type b polysaccharide-Neisseria meningitidis outer membrane protein vaccine in 2- to 6month-old infants. Pediatrics 1987;80:283-7. Anderson PW, Pichichero ME, Insel RA~ et al. Vaccines conSisting of periodate-cleaved oligosaccharides from the capsule of Haemophilus influenzae type b coupled to a protein carrier: structural and temporal requirements for priming in the human infant. J Immunol 1986;137:1181-6. Centers for Disease Control. Supplementary statement: change in administration schedule for Haemophilus influenzae b conjugate vaccines. MMWR 1990;39:232-3. Rubin LG. Anticapsular antibody requirements for protection against experimental Haemophilus influenzae type b bacteremia after splenectomy. Infect Immunol 1988;56:984-6.
12. EskolaJ, Peltola H, Takala AK, et al. Efficacy of Haemophilus influenzae type b polysaccharide-diphtheria toxoid conjugate vaccine in infancy. N Engl J Med 1987;317:717-22.
Anaphylaxis to casein hydrolysate formula John D. Saylor, MD, a n d Sami L. B a h n a , MD, DrPH, From the Department of Allergy and Immunology, Cleveland Clinic Foundation, Cleveland, Ohio
Cow milk is probably the most common allergen during infancy and early childhood; the estimated prevalence of cow milk allergy is 1% to 3% in bottle-fed infants. 1, 2 Bovine casein hydrolysate formula has been available for more than 40 years and has been commonly prescribed for infants allergic to cow milk. However, some subjects do not tolerate such formula. Because of the lack of appropriate documenPresented in part at the annual meeting of the American Academy of Pediatrics Section on Allergy and immunology, Chicago, Ill., Oct. 21-22, 1989. Submitted for publication May 31, 1990; accepted Aug. 8, 1990. Reprint requests: Sami L. Bahna, MD, Department of Allergy and Immunology, Cleveland Clinic Foundation A72, One Clinic Center, 9500 Euclid Ave., Cleveland, OH 44195-5035. 9/22/24468
tation and reporting, the medical profession at large has not been informed about the potential reactions to the hydrolysate formulas. We describe the clinical and immunologic findings in a child with cow milk allergy who had Systemic anaphylaxis after ingestion of a small quantity of casein hydrolysate formula. ELISA RAST
Enzyme-linked immunosorbent assay Radioallergosorbent test
]
See related article, p. 74. C A S E REPORT Our patient was apparently healthy until 12 months of age, when, within a few minutes of an accidental ingestion of a small quantity
72
Clinical and laboratory observations
The Journal of Pediatrics January 1991
Table I. Epicutaneous skin testing of a child with
Table II. Epicutaneous testing with antigens boiled 1
exquisite milk sensitivity (age 3 years 9 months)
hour in a child with exquisite milk sensitivity (age 4 years)
Reaction score
Food tested
>4+
Casein hydrolysate (Alimentum, Nutramigen), whey hydrolysate (Good Start) formulas Cow milk, peanut Halibut, lettuce, safflower seed, lamb, pork, sunflower seed Baker's yeast, carrot, green bean, barley, celery, lima bean, beef, egg white, onion, buckwheat, grape, white potato
4+ 3+ 2+
Testing antigen*
Reaction score
Skim cow milk Caseinate (1 mg/ml) /3-Lactoglobulin (1 mg/ml) Good Start formula Evaporated skim cow milk Nutramigen formula Alimentum formula Vivonex diet
>4+ >4+ >4+ >4+ 4+ 4+ 3+ 1+
Skin test reactions were scored from 0 to 4+ as compared with negative (diluent) and positive (histamine) results with control reactions. 3
* 1:20 wt/vol of ready-to-feed foods except as noted.
of homogenized cow milk, wheezing, generalized urticaria, and vomiting developed . He had been fed human milk exclusively for 5 months, and before this episode he had been given only his mother's milk, squash, and a few fruits. Because of her own allergies, the mother had not allowed cow milk or peanut in the house for several years. At 15 months of age the child was examined by an allergist, who noted a total serum IgE level of 225 IU/ml (normal for age
the age range closer to the currently recommended age were significantly lower than in the younger infants given two doses. These and previous 2, 3 observations provide an optimistic outlook for eventual prevention of invasive Hib infection in infants with sickle cell disease after two or more doses of conjugate vaccine. For now, follow-up or consideration of booster doses may be indicated for children with sickle cell diseases who were vaccinated according to the current single-dose schedule. REFERENCES 1. Zarkowsky HS, Gallagher D, Gill FM, et al. Bacteremia in sickle hemoglobinopathies. J PEDIATR 1986;109:579-85. 2. Gigliotti F, Feldman S, Wang WC, Day SW, Brunson G. Immunization of young infants with sickle cell diseases with a Haemophilus influenzae type b saccharid~diphtheria CRM197 protein conjugate vaccine. J PEDiATR1989;114:1006. 3. Badoual J, Begue P, Beauvais M, ct al. Immune response to Haemophilus influenzae type b (Hib) capsular polysaccharide-tetanus toxoid conjugate (PRP-T) vaccine in children with sickle cell disease [Abstract 49]. Interscience Conference on Antimicrobial Agents and Chemotherapy, Houston, Tex., October 1989. 4. Frank AL, Labotka R J, Ran S, et al. Haemophilus influenzae type b immunization of children with sickle cell diseases. Pediatrics 1988;82:571-5. 5. Lepow ML, Barkin RM, Berkowitz CD, et al. Safety and im-
Clinical and laboratory observations
6.
7.
8.
9.
10.
11.
71
munogenicity of Haemophilus influenzae type b polysaccharide-diphtlieria toxoid conjugate vaccine (PRP-D) in infants. J Infect Dis 1987;156:591-5. Lepow ML, Samuelson JS, Gordon LK. Safety and immunogenicity of Haemophilus influenzae type b polysaccharide diphtheria toxoid conjugate vaccine in infants 9 to 15 months of age. J PEDIATR 1985;106:185-9. Berk0witz CD, Ward JI, Meier K, et al. Safety and immunogenicity of Haemophilus influenzae type b polysacchar!de diphtheria toxoid conjugate vaccine in children 15-24 months of age. J PEDIATR 1987;110:509-14. Lenoir AA, Granoff PD, Granoff DM. Immunogenicity of Haemophilus influenzae type b polysaccharide-Neisseria meningitidis outer membrane protein vaccine in 2- to 6month-old infants. Pediatrics 1987;80:283-7. Anderson PW, Pichichero ME, Insel RA~ et al. Vaccines conSisting of periodate-cleaved oligosaccharides from the capsule of Haemophilus influenzae type b coupled to a protein carrier: structural and temporal requirements for priming in the human infant. J Immunol 1986;137:1181-6. Centers for Disease Control. Supplementary statement: change in administration schedule for Haemophilus influenzae b conjugate vaccines. MMWR 1990;39:232-3. Rubin LG. Anticapsular antibody requirements for protection against experimental Haemophilus influenzae type b bacteremia after splenectomy. Infect Immunol 1988;56:984-6.
12. EskolaJ, Peltola H, Takala AK, et al. Efficacy of Haemophilus influenzae type b polysaccharide-diphtheria toxoid conjugate vaccine in infancy. N Engl J Med 1987;317:717-22.
Anaphylaxis to casein hydrolysate formula John D. Saylor, MD, a n d Sami L. B a h n a , MD, DrPH, From the Department of Allergy and Immunology, Cleveland Clinic Foundation, Cleveland, Ohio
Cow milk is probably the most common allergen during infancy and early childhood; the estimated prevalence of cow milk allergy is 1% to 3% in bottle-fed infants. 1, 2 Bovine casein hydrolysate formula has been available for more than 40 years and has been commonly prescribed for infants allergic to cow milk. However, some subjects do not tolerate such formula. Because of the lack of appropriate documenPresented in part at the annual meeting of the American Academy of Pediatrics Section on Allergy and immunology, Chicago, Ill., Oct. 21-22, 1989. Submitted for publication May 31, 1990; accepted Aug. 8, 1990. Reprint requests: Sami L. Bahna, MD, Department of Allergy and Immunology, Cleveland Clinic Foundation A72, One Clinic Center, 9500 Euclid Ave., Cleveland, OH 44195-5035. 9/22/24468
tation and reporting, the medical profession at large has not been informed about the potential reactions to the hydrolysate formulas. We describe the clinical and immunologic findings in a child with cow milk allergy who had Systemic anaphylaxis after ingestion of a small quantity of casein hydrolysate formula. ELISA RAST
Enzyme-linked immunosorbent assay Radioallergosorbent test
]
See related article, p. 74. C A S E REPORT Our patient was apparently healthy until 12 months of age, when, within a few minutes of an accidental ingestion of a small quantity
72
Clinical and laboratory observations
The Journal of Pediatrics January 1991
Table I. Epicutaneous skin testing of a child with
Table II. Epicutaneous testing with antigens boiled 1
exquisite milk sensitivity (age 3 years 9 months)
hour in a child with exquisite milk sensitivity (age 4 years)
Reaction score
Food tested
>4+
Casein hydrolysate (Alimentum, Nutramigen), whey hydrolysate (Good Start) formulas Cow milk, peanut Halibut, lettuce, safflower seed, lamb, pork, sunflower seed Baker's yeast, carrot, green bean, barley, celery, lima bean, beef, egg white, onion, buckwheat, grape, white potato
4+ 3+ 2+
Testing antigen*
Reaction score
Skim cow milk Caseinate (1 mg/ml) /3-Lactoglobulin (1 mg/ml) Good Start formula Evaporated skim cow milk Nutramigen formula Alimentum formula Vivonex diet
>4+ >4+ >4+ >4+ 4+ 4+ 3+ 1+
Skin test reactions were scored from 0 to 4+ as compared with negative (diluent) and positive (histamine) results with control reactions. 3
* 1:20 wt/vol of ready-to-feed foods except as noted.
of homogenized cow milk, wheezing, generalized urticaria, and vomiting developed . He had been fed human milk exclusively for 5 months, and before this episode he had been given only his mother's milk, squash, and a few fruits. Because of her own allergies, the mother had not allowed cow milk or peanut in the house for several years. At 15 months of age the child was examined by an allergist, who noted a total serum IgE level of 225 IU/ml (normal for age
