D1.63 - Suspected Hypersensitivity to Non-Nutritive Sweeteners With Recurrent Respiratory Manifestations in a Pediatric Patient

Background

The consumption of non-nutritive sweeteners has increased markedly with the growing popularity of sugar-free and low-calorie foods. However, hypersensitivity reactions to sweeteners used as food additives remain poorly characterized, particularly in children. Diagnostic evaluation is challenging due to mixed exposures, lack of standardized testing, and limited clinical awareness. We report a pediatric case highlighting recurrent respiratory manifestations associated with ingestion of products containing non-nutritive sweeteners.

Methods

A pediatric patient with recurrent food-related respiratory symptoms underwent systematic clinical evaluation. This included a detailed dietary history focusing on exposure to sugar-free products, skin prick testing using selected candidate non-nutritive sweeteners including allulose and stevia, serum total IgE and tryptase measurement, pulmonary function testing, fractional exhaled nitric oxide assessment, and longitudinal clinical follow-up with avoidance counseling and documentation of accidental re-exposure.

Results

A 9-year-old girl with a history of atopic dermatitis experienced recurrent episodes of cough, wheezing, and occasional stridor temporally associated with ingestion of sugar-free foods and beverages. Some episodes were accompanied by cutaneous symptoms, whereas others presented exclusively with respiratory manifestations, occasionally requiring emergency department visits and bronchodilator treatment. She had no prior diagnosis of asthma.

Serum-specific IgE testing for common food allergens was unremarkable, except for sensitization to house dust mites, and serum tryptase levels were within the normal range. Pulmonary function testing demonstrated normal baseline lung function without a significant bronchodilator response, although fractional exhaled nitric oxide was elevated. Skin prick testing revealed a positive wheal response to allulose, while testing for stevia at multiple dilutions was negative. Evaluation for other suspected sweeteners, including monk fruit extract and erythritol, could not be performed. During a two-year follow-up period, strict avoidance was advised; however, accidental re-exposure to products containing non-nutritive sweeteners reproducibly triggered respiratory symptoms, sometimes in the absence of skin involvement.

Conclusion

This case illustrates suspected hypersensitivity to non-nutritive sweeteners in a child, presenting predominantly with recurrent respiratory symptoms and variable cutaneous findings. As exposure to sugar-free food additives continues to increase, clinicians should consider non-traditional food components as potential triggers when standard allergy evaluations are inconclusive. Increased awareness and further studies are needed to establish diagnostic and management strategies for sweetener-related hypersensitivity in pediatric patients.