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CASE REPORT
Treatment of Chronic Atopy and Irritable Bowel Syndrome
in a 7-year-old: A Case Report
Kathleen O’Neil-Smith, MD; FAARM; Melissa S. Barber, MSc
Abstract
Irritable bowel syndrome and atopic conditions can
co-occur in children and appear to be associated with
alterations in the gut microbiota and immune function.
A 7-y-old girl was frequently sent home from school
due to symptoms related to her long-standing urticaria
and gastrointestinal complaints. She was evaluated by
Kathleen O’Neil-Smith, MD, FAARM, is owner and chief
medical officer at Treat Wellness in Newton,
Massachusetts. Melissa S. Barber, MSc, is a research
associate at Integrative Medicine Institute in Portland,
Oregon.
Corresponding author: Kathleen O’Neil-Smith, MD
E-mail address: treatwellness@yahoo.com
I
rritable bowel syndrome (IBS) and atopic conditions,
when present in children, can affect school
performance, social function, and quality of life,
which, in turn, can impart a time and cost burden on
parents.1,2 IBS and atopy may be interrelated through
alterations in the gut microbiota and immune function.3,8
Therapeutic options include medications, cognitive
behavioral therapy, hypnotherapy, probiotics, and dietary
and lifestyle modifications.9-12 Although no single effective
intervention has emerged from clinical trials, select
laboratory testing may guide treatment of conditions
underlying IBS symptomology.9 In this case, a 7-year-old
girl presents with a long-standing history of atopy and
gastrointestinal complaints. The identification of abnormal
specialty diagnostic biomarkers guided treatment.
48 Integrative Medicine • Vol. 16, No. 4 • August 2017
pediatric gastroenterologists and allergists; however, she
did not respond to treatment. The successful approach
to this patient’s treatment included dietary modifications
and probiotics guided by clinical insight gleaned from
often-overlooked diagnostic biomarkers.
Case Presentation
This 7-year-old female of European and Lebanese
descent was first seen in December 2013 (Figure 1). Her
chief complaints were intermittent, diffuse urticaria and
gastrointestinal symptoms. She was frequently sent home
from school—sometimes weekly. The patient’s parents had
taken her to multiple specialists—pediatricians,
gastroenterologists, and allergists. At 4 years of age, she
was seen by a pediatric gastroenterologist at Boston
Children’s Hospital and had a normal endoscopic
evaluation. She was, however, started on a proton pump
inhibitor (omeprazole). She had no reduction of symptoms
while on the medication. Repeat allergy testing by multiple
allergy specialists was also normal.
Her medical history was significant for urticaria,
atopic dermatitis, exercise-induced asthma, and aphthous
stomatitis that began in early childhood. She experienced
nausea and severe gastrointestinal pain daily with frequent
excess gas, diarrhea, and constipation. She had a family
history of gastrointestinal complaints and autoimmune
diseases.
The patient was on multiple medications before her
first appointment with an internist with expertise in
functional medicine. These included a proton pump
inhibitor, diphenhydramine (prn), albuterol inhaler for
exercise-induced asthma, and montelukast for seasonal
allergies.
O’Neil-Smith—Chronic Atopy and IBS
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Timeline.

Chief Complaint: 7-y-old girl with a history of atopy and IBS-M; family history positive for autoimmune
disorders

Perinatal Background
Normal pregnancy, vaginal delivery, 2006
breast-fed
Early Childhood
Diagnoses/Symptoms: Aphthous
stomatitis, atopy (urticaria, dermatitis,
2010
asthma), GI pain, diarrhea, constipation
Medical Visits: Pediatrician,
gastroenterologist, allergist
Treatments: Tubes (×2) – chronic OM

GI Evaluation: Boston Children’s; normal

endoscopy, Celiac negative
Treatment: Omeprazole 2011–2013
Outcome: No change
Allergy Testing: Inconclusive

Missed school on multiple occasions due to

2013 12/13 Initial Visit – Internist
her symptoms
(functional medicine)
Repeat Allergy Testing: Inconclusive Diagnostic Assessment: Laboratory
evaluations
Treatment: Gluten and dairy-free diet;
avoid aggravating foods

02/14 F/U Visit

2014 Diagnoses: Urticaria, IBS-M
Treatment:
• Gluten- and dairy-free diet, green
leafy vegetables
• Probiotic, vitamin D3, multivitamin

04/14–06/14 F/U Visits

Symptoms: No symptoms of urticaria or
IBS-M
Treatment: Continue previous treatment

06/15 F/U Visits

Symptoms: No symptoms of urticaria
or IBS-M unless there were dietary
indiscretions
Treatment: Continue previous treatment

Outcome: Urticaria & IBS-M controlled with diet; symptoms recurrence

associated with dietary indiscretions

Abbreviations: IBS-M, irritable bowel syndrome with mixed bowel pattern; GI, gastrointestinal; OM, otitis media;
F/U, follow-up.

O’Neil-Smith—Chronic Atopy and IBS Integrative Medicine • Vol. 16, No. 4 • August 2017 49
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Diagnostic Assessment Table 1. NutrEval FMV Amino Acids

A nutritional evaluation assessed amino acids via a
first-morning void urine sample (NutrEval FMV Amino Concentration
Acids, Genova Diagnostics, Asheville, NC). (mmol/mol Reference
Immunoglobulin E (IgE) and immunoglobulin G (IgG) Biomarker Abnormalities creatinine) Range
food antibody assessments (Genova Diagnostics) and a Gastrointestinal Imbalance Markers
comprehensive fecal biomarker evaluation Dihydroxyphenylpropionic 14.9 ≤7.0
(GI Effects Comprehensive Stool Profile, Genova Acid
Diagnostics) were ordered at the initial visit in December 3-Hydroxyphenylacetic Acid 10.5 ≤9.2
2013 to assess the patient’s immune and gastrointestinal Arabinose 210 ≤132
function that may have contributed to her symptoms. Tartaric Acid 56 ≤20
Abnormal biomarkers are highlighted in Tables 1 and 2 Cellular & Mitochondrial Metabolites
revealing multiple abnormalities associated with Lactic Acid 20.5 3.7 to 14.6
inflammation, poor assimilation of nutrients, and a Pyruvic Acid 61 12 to 39
gastrointestinal microbe imbalance. It was determined α-Ketoglutaric Acid 83 12 to 55
this patient might benefit from changes in her diet and Malic Acid 3.3 ≤2.7
dietary supplementation. This patient was diagnosed with Neurotransmitter Metabolites
urticaria and irritable bowel syndrome-mixed subtype 5-OH-Indole Acetic Acid 48.1 6.4 to 24.3
(IBS-M) at her second visit. Kynurenic Acid 9.6 ≤9.2
Quinolinic Acid 15.2 ≤11.6
Therapeutic Interventions Vitamin Markers
The patient was recommended to follow a gluten-free
α-Ketoadipic Acid 2.5 ≤2.1
and dairy-free diet and avoid other potentially aggravating
α-Ketoisovaleric Acid 1.46 ≤0.85
foods at her first visit in December of 2013.
α-Ketoisocaproic Acid 1.23 ≤0.91
In February 2014, the patient reported that she
α-Keto-β-Methylvaleric 2.8 ≤2.3
continued to experience urticaria and had been sent home Acid
from school on several occasions. Repeat allergy testing
Glutaric Acid 1.02 ≤0.92
was unremarkable. At home, the patient adhered to a
Methylmalonic Acid 2.7 ≤2.2
gluten-free and dairy-free diet. Based on the results from
Xanthurenic Acid 1.5 ≤1.07
the diagnostic evaluations (Tables 1 and 2), the patient was
3-Hydroxypropionic Acid 26 6 to 23
recommended liquid Vitamin D3 4000 IU QD, a
3-Hydroxyisovaleric Acid 47 ≤38
multivitamin BID, and Aloe vera. The patient was also
Toxin & Detoxification Markers
recommended a probiotic powder (VSL No. 3) 225 billion
α-Ketophenylacetic Acid 0.52 ≤0.50
CFU, PO, QD, containing the following:
α-Hydroxyisobutyric Acid 12.7 ≤8.7
Streptococcus thermophiles; Bifidobacterium breve and
Orotic Acid 1.74 0.38 to 0.91
B lactis; and Lactobacillus acidophilus, L plantarum,
L paracasei, and L helveticus. The patient and her family
received physician counseling on the importance of Abbreviations: IgG, immunoglobulin G;
nutrition and lifestyle. She was encouraged to increase IgE, immunoglobulin E; FAA, food antibody assessment;
vegetable consumption, including green leafy vegetables. GI, gastrointestinal; SCFAs, short-chain fatty acids;
The proton pump inhibitor (omeprazole) and rescue LCFA, long-chain fatty acid.
inhaler (albuterol) were discontinued. The patient declined
the recommended Aloe vera. testing was attempted, but the patient had vasovagal
syncope episodes. The mother believed the rare urticaria
Follow-up and Outcomes and gastrointestinal symptoms to be associated with
In April 2014, the girl reported dramatic improvements consuming high-sugar foods.
with no episodes of hives or abdominal pain. The mother
adjusted dosing of the probiotic (between 100 and Discussion
225 billion CFU) and vitamin D3 (2000-4000 IU) with the Laboratory testing revealed that the patient had low
improvement in symptoms. The patient continued to levels of beneficial bacteria. Increasing evidence
follow a gluten and dairy-free diet at home. She experienced demonstrates a relationship between an altered gut
symptoms only when not adherent to her treatment microbiota, immune function, inflammation, and the
recommendations. development of atopic disease.3-5,8,13 This complex interplay
Continued improvement was noted at her June 2014 should be considered when treating allergic conditions
visit and 1 year later, in June 2015. She continues to take and IBS, one of the most common gastrointestinal
the probiotic, vitamin D3, and multivitamin. Follow-up disorders.6

50 Integrative Medicine • Vol. 16, No. 4 • August 2017 O’Neil-Smith—Chronic Atopy and IBS
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Table 2. IgG and IgE FAA and GI Effects (12/2013)

Diagnostic Biomarker
Test Date Abnormalities Diagnostic Significance Diagnoses Interventions

IgE FAA 12/23/2013 • High total IgE • Unclear • No food, mold,

levels (211, or inhalant
RR: ≤87.0 IU/mL) allergies

IgG FAA 12/23/2013 • Normal • Normal testing • No food

sensitivities

• Low levels of • Maldigestion & • Gluten-free diet

beneficial bacteria
• High putrefactive
SCFAs
GI Effects 01/23/2014 • High LCFA and
total fat levels
• Low acetate
• High lactoferrin
malabsorption • Dairy-free diet
• Impaired nutrient • Avoid acidic foods
production • Gut microflora • Increase green leafy
• Impaired immune disturbances vegetable intake
function • Probiotics
• Altered gut microbiota • Vitamin D3
• Multivitamin
• Inflammation

Abbreviations: IgG, immunoglobulin G; IgE, immunoglobulin E; FAA, food antibody assessment; GI, gastrointestinal;
SCFAs, short-chain fatty acids; LCFA, long-chain fatty acid.

This patient’s improvement in her atopic and IBS
symptoms coincided with reducing gluten and dairy from
her diet and adding a probiotic, vitamin D3, and a
multivitamin. Low-FODMAP (fermentable oligosaccharides,
disaccharides, monosaccharides and polyols) diets and low
LFSD (low fermentable substrate diet) have been shown to be
helpful in alleviating IBS-related symptoms.14,15 Randomized
controlled trials have shown an association of
Lactobacillus rhamnosus, L brevis, and a probiotic mixture
containing Bifidobacterium infantis, B breve, and B longum
with a reduction or resolution of pain, decreased pain
frequency, and improved quality of life in children with
IBS.10,16-19 The growing importance of the gut microbiota in a
variety of conditions raises questions regarding the role of
probiotics in treatment.20 It is possible the dietary changes
and the probiotic supported the improvements in this
patient’s symptoms.
Despite previous assessments from other providers
including gastroenterologists and allergists, no effective
treatment had been identified. Evaluation of this patient’s
complex and recurrent symptoms and the identification of
laboratory biomarker abnormalities supported this
patient’s diagnosis of urticaria and IBS-M.
Some limitations noted in this case report include not
testing for calprotectin and C-reactive protein (CRP)
levels (higher calprotectin and CRP levels occur in patients
with inflammatory bowel disease as opposed to IBS).21,22
Testing for interleukin 10 and interleukin 12 and
transforming growth factor-β may have also informed
understanding of the inflammatory profile of the patient
and supported diagnosis.7,23 Children with IBS have a
4 times higher risk of having celiac disease than children
without IBS, which may have explained her symptomology;
however, she tested negative for celiac disease.24 Nonceliac
gluten sensitivity may have also been a possible diagnosis,
but because symptom resolution seemed to better correlate
with limiting sugar intake as opposed to gluten, it is
unlikely.25 The multifaceted interventions make it difficult
to draw conclusions about the effectiveness of any one
component.
Vlieger et al26 tracked that the prevalence of
complementary and alternative medicine (CAM) use
was nearly at 40% of children visiting pediatric
gasteroenterology clinics in 9 hospitals. Predictors of
CAM use were a perceived low effect of or adverse effects
from conventional therapy, school absenteeism, and
children aged ≤11 years.26 Clinicians and researchers have
acknowledged that IBS and atopic conditions are complex,
inflammatory processes with heterogeneous etiologies,
and that they difficult to treat.8,9,11
Conclusion
This case suggests a role for laboratory biomarker
assessment in the treatment of chronic atopy and IBS-M. In
children, this may be important in preventing social disability.
This patient was able to control her symptoms and able to
regularly attend school with dietary modifications.
Learning Points
• Laboratory biomarker testing can help guide
successful treatment of chronic atopy and IBS.
• Chronic atopy and IBS may be comorbidities and
should be considered when patients are diagnosed
with one of these conditions.
• Dietary interventions can play a role in modifying
chronic atopy and IBS.

O’Neil-Smith—Chronic Atopy and IBS Integrative Medicine • Vol. 16, No. 4 • August 2017 51
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Patient Perspective 19. Horvath A, Dziechciarz P, Szajewska H. Meta-analysis: Lactobacillus

rhamnosus GG for abdominal pain-related functional gastrointestinal
“For many years we had been trying to help our disorders in childhood. Aliment Pharmacol Ther. 2011;33(12):1302-1310.
daughter who had hives and stomach aches. Each doctor 20. Thomas D, Greer F. Clinical report--probiotics and prebiotics in pediatrics.
Pediatrics. 2010;126(6):1217-1231.
looked through his or her individual lens, and it seemed to 21. Waugh N, Cummins E, Royle P, et al. Faecal calprotectin testing for
go nowhere and was quite frustrating. Dr Kathy seemed to differentiating amongst inflammatory and non-inflammatory bowel diseases:
Systematic review and economic evaluation. Health Technol Assess.
look at the whole picture beginning with the gut. Through 2013;17(55):1-211.
her, we have made major strides in understanding and 22. Chang MH, Chou JW, Chen SM, et al. Faecal calprotectin as a novel
biomarker for differentiating between inflammatory bowel disease and
controlling our daughter’s medical conditions.” irritable bowel syndrome. Mol Med Rep. 2014;10(1):522-526.
23. Shulman RJ, Jarrett ME, Cain KC, Broussard EK, Heitkemper MM.
Associations among gut permeability, inflammatory markers, and symptoms
Acknowledgements in patients with irritable bowel syndrome. J Gastroenterol. 2014;49(11):1467-
This case report was prepared according to the CARE Guidelines.27 Signed consent 1476.
was obtained from the patient’s mother for the publication of this case report. 24. Cristofori F, Fontana C, Magistà A, et al. Increased prevalence of celiac
disease among pediatric patients with irritable bowel syndrome: A 6-year
Author Disclosure Statement prospective cohort study. JAMA Pediatr. 2014;168(6):555-560.
The authors declare that no conflicts of interest exist. Kathleen O’Neil Smith 25. Makharia A, Catassi C, Makharia GK. The overlap between irritable bowel
provided the medical care described in this case report, coordinated initial syndrome and non-celiac gluten sensitivity: A clinical dilemma. Nutrients.
evaluation and data collection, reviewed and revised the manuscript, and approved 2015;7(12):10417-10426.
the final manuscript as submitted. Melissa S. Barber reviewed the deidentified 26. Vlieger AM, Blink M, Tromp E BM. Use of complementary and alternative
medical records; participated in drafting, reviewing, and revising the manuscript; medicine by pediatric patients with functional and organic gastrointestinal
and approved the final manuscript as submitted. Both authors approved the final d i s e a s e s : R e s u l t s f r o m a mu l t i c e nt e r s u r v e y. Pe d i at r i c s .
2008;122(2):e446-e451.
manuscript as submitted and agree to be accountable for all aspects of the work.
27. Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D, CARE Group.
The CARE guidelines: Consensus-based clinical case report guideline
development. J Clin Epidemiol. 2014;67(1):46-51.
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52 Integrative Medicine • Vol. 16, No. 4 • August 2017 O’Neil-Smith—Chronic Atopy and IBS