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Episodic stridor with latex nipple use in a 2-month-old infant
CASE REPORT
Episodic Stridor With Latex Nipple Use in a 2-Month-Old Infant
From the Department of Pediatrics,* and the Division of Pediatric Emergency Medicine, Departments of Emergency Medicine and Pediatrics,‡ Strong Memorial Hospital, University of Rochester School of Medicine and Dentistry, Rochester, NY.
Robert J. Freishtat, MD* Julius G. K. Goepp, MD‡
Received for publication September 4, 2001. Revision received December 17, 2001. Accepted for publication January 9, 2002. Reprints not available from the authors. Address for correspondence: Robert J. Freishtat, MD, Emergency Medicine and Trauma Center, Children’s National Medical Center, 111 Michigan Avenue, NW, Washington, DC 20010; 202-884-2971, fax 202-884-3573; E-mail [email protected]. Copyright © 2002 by the American College of Emergency Physicians. 0196-0644/2002/$35.00 + 0 47/1/122771 doi:10.1067/mem.2002.122771
APRIL 2002
39:4
ANNALS OF EMERGENCY MEDICINE
Latex allergy in the pediatric population is most commonly identified in patients who have undergone multiple operations for neural tube defects or exstrophic genitourinary anomalies. However, there are a significant number of children who, without the usual risk factors, clinically and/or serologically appear to be latex allergic. There is sporadic information in the medical literature regarding reactions to latex allergens in household items, especially in patients younger than 1 year old. Several recent reports even support the existence of reactions to latex pacifiers. We report a case of an atopic 2-month-old infant who experienced the previously unreported reaction of repeated stridor on exposure to a latex nipple while feeding. It is important that clinicians recognize stridor as a potential reaction to latex in infants. [Freishtat RJ, Goepp JGK. Episodic stridor with latex nipple use in a 2-month-old infant. Ann Emerg Med. April 2002;39:441-443.] INTRODUCTION
Latex allergy in the pediatric population is most commonly identified in patients who have undergone multiple operations for neural tube defects or exstrophic genitourinary anomalies. However, there are a significant number of children who, without the usual risk factors, clinically and/or serologically appear to be latex allergic. Several other groups of pediatric patients at higher risk for latex allergy than the general population include premature infants and atopic patients, among others.1-4 The clinical spectrum of latex allergy ranges from localized urticaria to severe systemic reactions, including respiratory distress and shock.3 The antigens responsible for these reactions, in addition to being found in latex gloves and other medical equipment, have been isolated from such items as balloons, rubber bands, shoe soles, pacifiers, and baby bottle nipples.3 There are only sporadic reports of reactions, consisting of an atopic rash and nasal congestion, to the latex allergens in these items
4 4 1
EPISODIC STRIDOR WITH LATEX NIPPLE USE Freishtat & Goepp
in patients younger than 1 year old.3 A report supports the existence of reactions to latex pacifiers with a persistent cough.5 However, latex-associated stridor has never been reported in this age group. We describe a case of an atopic 2-month-old infant who experienced the previously unreported reaction of repeated stridor on exposure to a latex nipple while feeding. CASE REPORT
A 60-day-old full-term female infant presented to the emergency department with stridor and wheezing. The infant breast-fed without difficulty for her first 3 weeks of life. At that time, she began feeding soy formula with a latex nipple. Concurrently, the mother began to notice increasing nasal congestion, a facial rash, and noisy breathing with feedings. Concerned about possible formula sensitivity, the pediatrician switched the infant to a hydrolyzed protein formula. Despite this, the baby’s noisy breathing during feeds intensified. The pediatrician again changed her feeds, this time to a different brand of soy formula. Forty-eight hours after this last formula switch, the infant arrived in the ED audibly stridulous, with tongue thrusting, diffuse wheezing, and upper airway congestion. On presentation, her respiratory rate was 38 breaths/min, and she was fully saturated in room air. Her symptoms resolved shortly after her arrival, before any medical intervention. Her mother related the child’s history of symptoms identical to those on presentation. The onset of stridor occurred several minutes after the beginning of each feeding. Her bottles typically lasted 20 to 30 minutes, with peak symptoms toward the middle of the feeding, lasting until 10 minutes after the end of each feed. She always had gradual but complete resolution of her stridor and remained asymptomatic between feedings. After resolution of the presenting episode, the infant’s vital signs were completely normal. Her physical examination was remarkable only for a fine, pink papular rash, resembling atopic dermatitis, over her face, neck, and chest. Her lungs were clear, and heart sounds were normal. Findings on a chest radiograph were normal. Soft-tissue radiographs of her neck, which were obtained to rule out extrinsic airway deviation or narrowing, revealed no abnormality. After the negative initial workup, under close observation, the mother fed the child the same soy formula through the same latex nipple she used at home. The infant fed without difficulty for 10 minutes, at which time
4 4 2
she developed symptoms identical to those on presentation. Ten minutes after completing the bottle, her symptoms resolved completely, without intervention. After this witnessed event, an esophagram was performed that revealed no extrinsic compression of the esophagus or evidence of gastroesophageal reflux. Because of the severity of her symptoms, the infant was admitted to the hospital for observation and further evaluation. At the time of admission, the mother revealed her own history of atopy, including an episode of anaphylaxis to latex in a dental office. At that point, it was suspected that the latex in the nipple might have been playing a role in the child’s symptoms. Accordingly, the child’s next feeding was performed by the mother under close observation, without any deviation from previous feedings, except the use of a latexfree silicone-based nipple. The child did not experience any respiratory symptoms during or after this feeding. Additionally, her respiratory examination remained normal during all subsequent feedings with the latex-free nipple. Flexible laryngoscopy revealed only a clinically insignificant, thin laryngeal web. She also had normal results on testing for total serum immunoglobulin E (IgE; IMx Total IgE by MEIA, Abbott Laboratories, Abbott Park, IL) and radioallergosorbent (RAST; Mayo Laboratories, Rochester, MN) tests for latex, milk, and soy. By 5 months of age, with the continued use of a latexfree nipple, there had been no further symptoms associated with feeding. Results of serologic allergy testing remained normal. DISCUSSION
The strong clinical association between feeding through a latex-containing nipple and this child’s episodes of respiratory distress, as well as the complete disappearance of symptoms when a latex-free nipple was used, support the diagnosis of symptomatic latex allergy in this case. This child’s reaction is unusual in that episodic stridor with latex exposure has not been previously reported in this age group. These episodes appeared to be anaphylactic or possibly maternal immunoglobulin G (IgG)–driven anaphylactoid reactions. These 2 types of reactions are clinically indistinguishable. In very young infants such as this child, allergic reactions of either type are infrequently noted. Additionally, the pathophysiology of allergy in this age group has not been clearly delineated. It is clear, however,
ANNALS OF EMERGENCY MEDICINE
39:4 APRIL 2002
EPISODIC STRIDOR WITH LATEX NIPPLE USE Freishtat & Goepp
from several case reports published in the past 2 decades, that very young infants can mount anaphylactic and anaphylactoid reactions to agents like cow’s milk derivatives in maternal breast milk, a wheat rusk used in feeding, and dextran in the bacillus Calmette-Guérin (BCG) vaccine.6-9 It is also well documented that latex can be the inciting agent in cases of anaphylaxis in the pediatric population.1,3,4 Latex pacifiers and nipples contain water-soluble latex allergens capable of inducing an allergic response in latex-allergic patients.10 Directly related to latex pacifier use, 3 Finnish children with severe atopic dermatitis and documented latex allergy improved after withdrawal of their latex pacifiers.11 Our clinical diagnosis of latex allergy in this case may be called into question because of the absence of serologic indicators. There are some data available in this age group to establish the sensitivity, specificity, and positive and negative predictive values of serologic tests for allergy, although they are certainly not optimal for allergy confirmation.12,13 In the general population, however, these values have been found to vary widely. In vitro testing, in general, can be falsely negative 20% to 40% of the time and therefore may not be reliable.14 In the previously mentioned cases of anaphylaxis to cow’s milk protein and a wheat rusk, the patients had normal findings on serologic testing at the time of their diagnoses.9 In addition, 2 of the aforementioned cases involved patients in this age group with reactions that were maternally IgG driven.6,7 In summary, we report a previously unreported presentation of latex allergy in a very young infant. In light of the limitations of serologic studies in this age group and of the strong association between repeated challenge and withdrawal of latex with this child’s symptoms, we believe that our patient manifested a genuine latex allergy. Clinicians should be aware of the possibility of latex allergy in very young infants and of the potential variations in presenting signs and symptoms.
7. Rudin C, Gunthard J, Halter C, et al. Anaphylactoid reaction to BCG vaccine containing high molecular weight dextran. Eur J Pediatr. 1995;154:941-942. 8. Lifschitz CH, Hawkins HK, Guerra C, et al. Anaphylactic shock due to cow’s milk hypersensitivity in a breast-fed infant. J Pediatr Gastroenterol Nutr. 1988;7:141-144. 9. Rudd P, Manuel P, Walker-Smith J. Anaphylactic shock in an infant after feeding wheat rusk: a transient phenomenon. Postgrad Med J. 1981;57:794-795. 10. Wrangsjo K, Montelius J, Eriksson M. Teats and pacifiers—an allergy risk for infants? Contact Dermatitis. 1992;27:192-193. 11. Makinen-Kiljunen S, Sorva R, Juntunen-Backman K. Latex dummies as allergens. Lancet. 1992;339:1608-1609. 12. Majamaa H, Moisio P, Holm K, et al. Wheat allergy: diagnostic accuracy of skin prick and patch tests and specific IgE. Allergy. 1999;54:851-856. 13. Tucke J, Posch A, Baur X, et al. Latex type I sensitization and allergy in children with atopic dermatitis. Evaluation of cross-reactivity to some foods. Pediatr Allergy Immunol. 1999;10:160167. 14. Ownby DR. Tests for IgE antibody. In: Bierman CW, Pearlman DS, Shapiro GG, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, PA: WB Saunders; 1996:144-156.
REFERENCES 1.
Frankland AW. Latex-allergic children. Pediatr Allergy Immunol. 1999;10:152-159.
2. Kwittken PL, Sweinberg SK, Campbell DE, et al. Latex hypersensitivity in children: clinical presentation and detection of latex-specific immunoglobulin E. Pediatrics. 1995;95:693-699. 3. Landwehr LP, Boguniewicz M. Current perspectives on latex allergy. J Pediatr. 1996;128:305-312. 4. Sorva R, Makinen-Kiljunen S, Suvilehto K, et al. Latex allergy in children with no known risk factor for latex sensitization. Pediatr Allergy Immunol. 1995;6:36-38. 5. Venuta A, Bertolani PP, Francomano M, et al. Do pacifiers cause latex allergy? Allergy. 1999;54:1007. 6. Rudin C, Amacher A, Berglund A. Anaphylactoid reaction to BCG vaccination [letter]. Lancet. 1991;337:377.
APRIL 2002
39:4
ANNALS OF EMERGENCY MEDICINE
4 4 3
Episodic Stridor With Latex Nipple Use in a 2-Month-Old Infant
From the Department of Pediatrics,* and the Division of Pediatric Emergency Medicine, Departments of Emergency Medicine and Pediatrics,‡ Strong Memorial Hospital, University of Rochester School of Medicine and Dentistry, Rochester, NY.
Robert J. Freishtat, MD* Julius G. K. Goepp, MD‡
Received for publication September 4, 2001. Revision received December 17, 2001. Accepted for publication January 9, 2002. Reprints not available from the authors. Address for correspondence: Robert J. Freishtat, MD, Emergency Medicine and Trauma Center, Children’s National Medical Center, 111 Michigan Avenue, NW, Washington, DC 20010; 202-884-2971, fax 202-884-3573; E-mail [email protected]. Copyright © 2002 by the American College of Emergency Physicians. 0196-0644/2002/$35.00 + 0 47/1/122771 doi:10.1067/mem.2002.122771
APRIL 2002
39:4
ANNALS OF EMERGENCY MEDICINE
Latex allergy in the pediatric population is most commonly identified in patients who have undergone multiple operations for neural tube defects or exstrophic genitourinary anomalies. However, there are a significant number of children who, without the usual risk factors, clinically and/or serologically appear to be latex allergic. There is sporadic information in the medical literature regarding reactions to latex allergens in household items, especially in patients younger than 1 year old. Several recent reports even support the existence of reactions to latex pacifiers. We report a case of an atopic 2-month-old infant who experienced the previously unreported reaction of repeated stridor on exposure to a latex nipple while feeding. It is important that clinicians recognize stridor as a potential reaction to latex in infants. [Freishtat RJ, Goepp JGK. Episodic stridor with latex nipple use in a 2-month-old infant. Ann Emerg Med. April 2002;39:441-443.] INTRODUCTION
Latex allergy in the pediatric population is most commonly identified in patients who have undergone multiple operations for neural tube defects or exstrophic genitourinary anomalies. However, there are a significant number of children who, without the usual risk factors, clinically and/or serologically appear to be latex allergic. Several other groups of pediatric patients at higher risk for latex allergy than the general population include premature infants and atopic patients, among others.1-4 The clinical spectrum of latex allergy ranges from localized urticaria to severe systemic reactions, including respiratory distress and shock.3 The antigens responsible for these reactions, in addition to being found in latex gloves and other medical equipment, have been isolated from such items as balloons, rubber bands, shoe soles, pacifiers, and baby bottle nipples.3 There are only sporadic reports of reactions, consisting of an atopic rash and nasal congestion, to the latex allergens in these items
4 4 1
EPISODIC STRIDOR WITH LATEX NIPPLE USE Freishtat & Goepp
in patients younger than 1 year old.3 A report supports the existence of reactions to latex pacifiers with a persistent cough.5 However, latex-associated stridor has never been reported in this age group. We describe a case of an atopic 2-month-old infant who experienced the previously unreported reaction of repeated stridor on exposure to a latex nipple while feeding. CASE REPORT
A 60-day-old full-term female infant presented to the emergency department with stridor and wheezing. The infant breast-fed without difficulty for her first 3 weeks of life. At that time, she began feeding soy formula with a latex nipple. Concurrently, the mother began to notice increasing nasal congestion, a facial rash, and noisy breathing with feedings. Concerned about possible formula sensitivity, the pediatrician switched the infant to a hydrolyzed protein formula. Despite this, the baby’s noisy breathing during feeds intensified. The pediatrician again changed her feeds, this time to a different brand of soy formula. Forty-eight hours after this last formula switch, the infant arrived in the ED audibly stridulous, with tongue thrusting, diffuse wheezing, and upper airway congestion. On presentation, her respiratory rate was 38 breaths/min, and she was fully saturated in room air. Her symptoms resolved shortly after her arrival, before any medical intervention. Her mother related the child’s history of symptoms identical to those on presentation. The onset of stridor occurred several minutes after the beginning of each feeding. Her bottles typically lasted 20 to 30 minutes, with peak symptoms toward the middle of the feeding, lasting until 10 minutes after the end of each feed. She always had gradual but complete resolution of her stridor and remained asymptomatic between feedings. After resolution of the presenting episode, the infant’s vital signs were completely normal. Her physical examination was remarkable only for a fine, pink papular rash, resembling atopic dermatitis, over her face, neck, and chest. Her lungs were clear, and heart sounds were normal. Findings on a chest radiograph were normal. Soft-tissue radiographs of her neck, which were obtained to rule out extrinsic airway deviation or narrowing, revealed no abnormality. After the negative initial workup, under close observation, the mother fed the child the same soy formula through the same latex nipple she used at home. The infant fed without difficulty for 10 minutes, at which time
4 4 2
she developed symptoms identical to those on presentation. Ten minutes after completing the bottle, her symptoms resolved completely, without intervention. After this witnessed event, an esophagram was performed that revealed no extrinsic compression of the esophagus or evidence of gastroesophageal reflux. Because of the severity of her symptoms, the infant was admitted to the hospital for observation and further evaluation. At the time of admission, the mother revealed her own history of atopy, including an episode of anaphylaxis to latex in a dental office. At that point, it was suspected that the latex in the nipple might have been playing a role in the child’s symptoms. Accordingly, the child’s next feeding was performed by the mother under close observation, without any deviation from previous feedings, except the use of a latexfree silicone-based nipple. The child did not experience any respiratory symptoms during or after this feeding. Additionally, her respiratory examination remained normal during all subsequent feedings with the latex-free nipple. Flexible laryngoscopy revealed only a clinically insignificant, thin laryngeal web. She also had normal results on testing for total serum immunoglobulin E (IgE; IMx Total IgE by MEIA, Abbott Laboratories, Abbott Park, IL) and radioallergosorbent (RAST; Mayo Laboratories, Rochester, MN) tests for latex, milk, and soy. By 5 months of age, with the continued use of a latexfree nipple, there had been no further symptoms associated with feeding. Results of serologic allergy testing remained normal. DISCUSSION
The strong clinical association between feeding through a latex-containing nipple and this child’s episodes of respiratory distress, as well as the complete disappearance of symptoms when a latex-free nipple was used, support the diagnosis of symptomatic latex allergy in this case. This child’s reaction is unusual in that episodic stridor with latex exposure has not been previously reported in this age group. These episodes appeared to be anaphylactic or possibly maternal immunoglobulin G (IgG)–driven anaphylactoid reactions. These 2 types of reactions are clinically indistinguishable. In very young infants such as this child, allergic reactions of either type are infrequently noted. Additionally, the pathophysiology of allergy in this age group has not been clearly delineated. It is clear, however,
ANNALS OF EMERGENCY MEDICINE
39:4 APRIL 2002
EPISODIC STRIDOR WITH LATEX NIPPLE USE Freishtat & Goepp
from several case reports published in the past 2 decades, that very young infants can mount anaphylactic and anaphylactoid reactions to agents like cow’s milk derivatives in maternal breast milk, a wheat rusk used in feeding, and dextran in the bacillus Calmette-Guérin (BCG) vaccine.6-9 It is also well documented that latex can be the inciting agent in cases of anaphylaxis in the pediatric population.1,3,4 Latex pacifiers and nipples contain water-soluble latex allergens capable of inducing an allergic response in latex-allergic patients.10 Directly related to latex pacifier use, 3 Finnish children with severe atopic dermatitis and documented latex allergy improved after withdrawal of their latex pacifiers.11 Our clinical diagnosis of latex allergy in this case may be called into question because of the absence of serologic indicators. There are some data available in this age group to establish the sensitivity, specificity, and positive and negative predictive values of serologic tests for allergy, although they are certainly not optimal for allergy confirmation.12,13 In the general population, however, these values have been found to vary widely. In vitro testing, in general, can be falsely negative 20% to 40% of the time and therefore may not be reliable.14 In the previously mentioned cases of anaphylaxis to cow’s milk protein and a wheat rusk, the patients had normal findings on serologic testing at the time of their diagnoses.9 In addition, 2 of the aforementioned cases involved patients in this age group with reactions that were maternally IgG driven.6,7 In summary, we report a previously unreported presentation of latex allergy in a very young infant. In light of the limitations of serologic studies in this age group and of the strong association between repeated challenge and withdrawal of latex with this child’s symptoms, we believe that our patient manifested a genuine latex allergy. Clinicians should be aware of the possibility of latex allergy in very young infants and of the potential variations in presenting signs and symptoms.
7. Rudin C, Gunthard J, Halter C, et al. Anaphylactoid reaction to BCG vaccine containing high molecular weight dextran. Eur J Pediatr. 1995;154:941-942. 8. Lifschitz CH, Hawkins HK, Guerra C, et al. Anaphylactic shock due to cow’s milk hypersensitivity in a breast-fed infant. J Pediatr Gastroenterol Nutr. 1988;7:141-144. 9. Rudd P, Manuel P, Walker-Smith J. Anaphylactic shock in an infant after feeding wheat rusk: a transient phenomenon. Postgrad Med J. 1981;57:794-795. 10. Wrangsjo K, Montelius J, Eriksson M. Teats and pacifiers—an allergy risk for infants? Contact Dermatitis. 1992;27:192-193. 11. Makinen-Kiljunen S, Sorva R, Juntunen-Backman K. Latex dummies as allergens. Lancet. 1992;339:1608-1609. 12. Majamaa H, Moisio P, Holm K, et al. Wheat allergy: diagnostic accuracy of skin prick and patch tests and specific IgE. Allergy. 1999;54:851-856. 13. Tucke J, Posch A, Baur X, et al. Latex type I sensitization and allergy in children with atopic dermatitis. Evaluation of cross-reactivity to some foods. Pediatr Allergy Immunol. 1999;10:160167. 14. Ownby DR. Tests for IgE antibody. In: Bierman CW, Pearlman DS, Shapiro GG, et al, eds. Allergy, Asthma, and Immunology From Infancy to Adulthood. 3rd ed. Philadelphia, PA: WB Saunders; 1996:144-156.
REFERENCES 1.
Frankland AW. Latex-allergic children. Pediatr Allergy Immunol. 1999;10:152-159.
2. Kwittken PL, Sweinberg SK, Campbell DE, et al. Latex hypersensitivity in children: clinical presentation and detection of latex-specific immunoglobulin E. Pediatrics. 1995;95:693-699. 3. Landwehr LP, Boguniewicz M. Current perspectives on latex allergy. J Pediatr. 1996;128:305-312. 4. Sorva R, Makinen-Kiljunen S, Suvilehto K, et al. Latex allergy in children with no known risk factor for latex sensitization. Pediatr Allergy Immunol. 1995;6:36-38. 5. Venuta A, Bertolani PP, Francomano M, et al. Do pacifiers cause latex allergy? Allergy. 1999;54:1007. 6. Rudin C, Amacher A, Berglund A. Anaphylactoid reaction to BCG vaccination [letter]. Lancet. 1991;337:377.
APRIL 2002
39:4
ANNALS OF EMERGENCY MEDICINE
4 4 3