Effect of different protein diet on the prognosis of children with Henoch-Schönlein Purpura

Abstract

Introduction
The aim of this study was to explore the association of different protein diet with the recurrence/recurrent rash of Henoch-Schönlein purpura (HSP) and to analyze the potential risk factors for recurrence of HSP.

Methods
A total of 72 children with HSP treated in Beijing Children's Hospital from January to June 2021 were collected retrospectively. According to the different protein diets, the children were divided into an animal protein group with 32 children and a plant protein group with 40 children. The clinical data of the children were collected, including general data, times of skin rash recurrence, the incidence of HSP recurrence, and the incidence of renal lesions. The daily protein intake of the children was recorded by questionnaire and followed up for 8 weeks after discharge.

Results
There were no statistical difference between animal protein group and plant protein group in times of skin rash recurrence, the incidence of HSP recurrence, and the incidence of renal lesions of children (p > 0.05). However, the protein intake of animal protein group was significantly higher than that of plant protein group (p < 0.05), which did not affect the recurrence of HSP (p > 0.05). In addition, respiratory infection at the beginning of the disease was potential risk factors for the recurrence of HSP in children (p < 0.05).

Conclusions
There is no significant association between animal or plant protein diet and the recurrence of HSP or skin rash. Timely avoidance of infection after cure may help to reduce the recurrence rate of HSP in children.

Full text

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Effect of different protein diet on the prognosis of
children with Henoch-Schönlein Purpura
HUI LI
Beijing Children's Hospital Capital Medical University
KAI FENG (  20170941087@bucm.edu.cn )
Beijing Children's Hospital Capital Medical University https://orcid.org/0000-0003-2063-9760
Research Article
Keywords: Henoch-Schönlein Purpura, children, animal protein, plant protein, diet, recurrence
Posted Date: October 28th, 2022
DOI: https://doi.org/10.21203/rs.3.rs-2197720/v1
License:   This work is licensed under a Creative Commons Attribution 4.0 International License. 
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Abstract
Introduction
The aim of this study was to explore the association of different protein diet with the recurrence/recurrent
rash of Henoch-Schönlein purpura (HSP) and to analyze the potential risk factors for recurrence of HSP.
Methods
A total of 72 children with HSP treated in Beijing Children's Hospital from January to June 2021 were
collected retrospectively. According to the different protein diets, the children were divided into an animal
protein group with 32 children and a plant protein group with 40 children. The clinical data of the children
were collected, including general data, times of skin rash recurrence, the incidence of HSP recurrence, and
the incidence of renal lesions. The daily protein intake of the children was recorded by questionnaire and
followed up for 8 weeks after discharge.
Results
There were no statistical difference between animal protein group and plant protein group in times of skin
rash recurrence, the incidence of HSP recurrence, and the incidence of renal lesions of children (p > 0.05).
However, the protein intake of animal protein group was signicantly higher than that of plant protein
group (p < 0.05), which did not affect the recurrence of HSP (p > 0.05). In addition, respiratory infection at
the beginning of the disease was potential risk factors for the recurrence of HSP in children (p < 0.05).
Conclusions
There is no signicant association between animal or plant protein diet and the recurrence of HSP or skin
rash. Timely avoidance of infection after cure may help to reduce the recurrence rate of HSP in children.
Background
Henoch-Schönlein purpura (HSP), also known as Anaphylactoid purpura, is a vasculitis syndrome
characterized by systemic vasculitis. Clinical features include non-thrombocytopenic skin rash,
accompanied by joint swelling and pain, abdominal pain, hematochezia, and kidney injury, which are
prone to recurrent attack.1 Recently, with the change of diet structure and environment, the incidence of
HSP in childhood is on the rise.2 Some studies have pointed out that children with HSP need to prohibit
protein diet intake for a long time during their illness to reduce the recurrence.3 However, HSP is mainly
found in school age children, long-term fasting of animal protein will seriously affect children's health,
reduce immunity, increase the chance of infection, and lead to the recurrence of HSP.4 At present, there is

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no unied and standardized diet management for HSP. Therefore, our paper through the retrospective
research method to collect the intake of plant protein and animal protein in children with HSP on
conventional diet restriction scheme, and provides clinical basis for the diet management of children with
HSP.
Methods
Subjects
From January to June 2021, 72 children with HSP hospitalized in the department of Traditional Chinese
Medicine, Beijing Children's Hospital were enrolled. All children were diagnosed according to the HSP
diagnostic criteria formulated by the European anti rheumatism alliance and the European Society of
pediatric rheumatology in 2006.5
These patients were divided into the following two groups by whether take animal protein diet: animal
protein group (32 patients received animal protein diet programs) and plant protein group (40 patients
received plant protein diet programs). Vitamin C were used for intravenous drip injection, and sodium
hydrocortisone succinate (2 mg/kg/day, 2 times/day) were given according to whether the patients had
abdominal pain and the amount was gradually reduced after the symptoms disappeared. The drug was
stopped after 7–10 days, and the symptoms were treated. At the same time, diet was restricted or guide
dietary was followed. Children of the two groups were followed up and dietary survey by telephone every
3 days was performed at 8 weeks after discharge.
Conventional restricted diet programs
All patients in two groups received the following conventional diet restriction scheme in this study:
1. It was forbidden to eat raw, cold, hard and other stimulating food or drinks. Three meals a day included
porridge, noodles, steamed bread, rice and some salt and oil. Patients were advised to drink warm boiled
water.
2. A small amount of one kind of vegetable was added rst after discharge, and no new rash appeared 3
days later, then another vegetable was added. Generally, the vegetables were added in the following
orders, such as green vegetable, cabbage, tomato, potato, cucumber, and reduce the consumption of
vegetables that are dicult to chew, such as broccoli and cauliower.
3. A small amount of fruits can also be added in the following order such as banana, apple, watermelon,
peach, and reduce the consumption of mango, peach and other allergic fruits. The interval between the
two kinds of fruits must be > 3 days.
4. In the process of adding food, when skin rash, abdominal pain and other repeated symptoms occurred,
it was necessary to stop eating the added food and restart after the situation was considered to be stable.
Plant protein group

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1. Bean products were added rst after discharge, such as soy-bean milk, tofu, gluten, etc. And no new
rash appeared 3 days later, another bean product was added.
2. Animal protein is prohibited during follow-up observation, like sh, shrimp, meat, eggs, milk, etc.
Animal protein group
1. The meats were added rst after discharge in the following orders, and no new rash appeared 5 days
later, then another meat was added. Generally, the meats were added in the following orders: lean pork,
chicken, ducks, and reduce the consumption of sh, shrimp, beef and mutton.
2. After adding meats without new rash for 2 weeks, a small amount of eggs could be added. After
adding eggs without repeated rash for 1 week, a small amount of milk could be added in the food. 3.
Bean products rich in plant protein is prohibited during follow-up observation.
Record clinical data
The clinical data of the children were collected, including general data, times of skin rash recurrence, the
incidence of HSP recurrence, and the incidence of renal lesions.6 The daily protein intake of the children
was recorded by questionnaireand followed up for 8 weeks after discharge.
1. Repeated rashes: purpura-like rashes appeared again in batches after the previous rashes were
eliminated and cleared.
2. Recurrence of HSP: the children diagnosed as HSP with purpura-like rashes again at least 1 month
after the disappearance of the rash; hematuria and/or proteinuria occurred during follow-up. 3. No clinical
symptoms of HSP after cure to the end of the follow-up period were determined as non-recurrence.
Statistical analysis
SPSS 26.0 was used for data statistical analysis in this study. The measurement data conforming to
normal distribution were expressed as mean ± SD, the comparison between the two groups adopts two
sample t-test. The measurement data that do not conform to the normal distribution are represented by
the median (interquartile interval) [M (P25, p75)] and Mann Whitney U test is used for the comparison
between the two groups. Counting data were expressed as n (%), and the comparison between the two
groups were examined by χ2 test.
P
value < 0.05 was considered to be statistical signicant.
Results
Comparison of general clinical information of children
There were no signicant differences in age, gender and medical history among the two groups (
p
> 0.05)
(Table 1).

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
Table 1
Comparison of general clinical features of children with HSP
Age
(years)
Gender
(male/female)
Medical history(months)
Plant protein group 8.05 ± 1.77 24/16 3.75 ± 0.87
Animal protein group 8.13 ± 1.91 18/14 3.78 ± 0.79
Different dietary guidance on protein intake level and major clinic features of children.
Eight weeks after admission, times of skin rash recurrence, the incidence of HSP recurrence, and the
incidence of renal lesions of children in the animal protein group were reaching the levels of the plant
protein group with no statistical difference (
p
> 0.05). Moreover, the protein intake of animal protein group
was signicantly higher than that of plant protein group (
p
< 0.05) (Table 2).
Table 2
Comparison of dietary guidance on protein intake level and major clinic features of children with HSP
n the number of repeat
[M(
P
25,
P
75)] recurrence
[n(%)] renal
lesions
[n(%)]
protein intake
level(g/d)
Plant protein
group 40 2.0(1.0,3.0) 12(30) 8(20) 12.80 ± 3.28
Animal protein
group 32 2.0(1.3,3.0) 8(25) 8(25) 18.38 ± 3.64
U/χ2/t  605.5 0.222 0.638 6.827
P
 0.686 0.257 0.612 < 0.01
The potential risk factors lead to recurrence of HSP.
According to whether the disease recurred, all children were divided into recurrence group and non-
recurrence group. Compared with non-recurrence group, the age, gender, repeated rashes, family history,
glucocorticoid and initial concomitant symptoms included gastrointestinal symptoms, joint swelling and
pain, hematuria or proteinuria and protein intake level (total, animal or plant) were no signicant
differences among two groups (
p
> 0.05). However, respiratory infection at the beginning of the disease in
the recurrence group was signicantly higher than that of children in another group (
p
< 0.05). In addition,

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we also found a fascinating phenomenon that the medical history of non-recurrence group was longer
than that of recurrence group (
p
< 0.05) (Table 3).
Table 3
The potential risk factors lead to recurrence of HSP
recurrence group(n =
20) non-recurrence group(n =
52) t/χ2
P
Age(years)
8 years
≤ 8 years
5
15
19
33
0.865 0.352
Gender
male
female
10
10
32
20
0.791 0.374
Medical history(months)
3 months
≤ 3 months
8
12
38
14
6.850 0.009
Initial concomitant
symptoms
gastrointestinal symptoms
joint swelling and pain
hematuria or proteinuria
respiratory infections
12
4
7
13
34
8
9
8
0.182
0.014
1.692
17.211
0.670
0.906
0.193
<
0.01
Repeated rashes ≥ 3 times 9 18 0.665 0.415
Family history 4 4 1.144 0.285
Glucocorticoid 7 17 0.3035 0.852
Protein intake level
Total protein intake level
Animal protein
Plant protein
8
12
24
28
0.086
-0.332
0.988
0.932
0.742
0.330
Discussion
HSP, now called immunoglobulin A vasculitis, is a systemic, immune complex-mediated, small-vessel
leukocytoclastic vasculitis characterized by nonthrombocytopenic palpable purpura, arthritis, and

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abdominal pain and spontaneously resolves in 94% of children and 89% of adults.7 The exact etiology of
HSP is still largely unknown. At present, the known possible etiologies include infection, genetics,
vaccination, environmental pollution and so on.8 At present, there is no unied and standardized diet
management for HSP. Some studies have pointed out that food allergy, in particular allogeneic protein,
were the main etiological factors.9,10 However, fasting protein for a long time will seriously affect the
health of children, reduce immunity, increase the chance of infection, and lead to the recurrence of HSP.11
Compared with plant protein, animal protein is mainly composed of casein, with a complete range of
essential amino acids and can be better utilized and absorbed by human body.
The HSP children are mainly between the ages of 5 and 15 years and the mean age is 5 to 6 years.10,12 In
our investigation, the children ranged from 4 to 15 years, and the mean age was 8.08 ± 1.82 years, 88.9%
were < 10 years old. Children at this stage were in a critical period of growth and development. If the
protein supply of children with HSP were insucient for a long time, which can lead to anorexia, weight
loss and even malnutrition.13 Moreover, gastrointestinal tract, the largest gathering place of human
immune system, participates in human immune response.14 Fasting protein for a long time may break
the normal immune response of gastrointestinal tract and affect the prognosis of HSP. Our study shows
that the protein intake of animal protein group was signicantly higher than that of plant protein group (p
< 0.05), but times of skin rash recurrence, the incidence of HSP recurrence, and the incidence of renal
lesions of children between two group with no statistical difference in (p > 0.05). It suggests that there is
no signicant correlation between different protein intake and recurrent rash, recurrence and renal
damage. In addition, we also found that different kinds of protein intake were not associated with disease
recurrence (p > 0.05), but it is contrary to some research results.15,16
Our study also showed that the recurrence rate of HSP in children was 27.8% (20/72), suggesting that the
recurrence rate of HSP in children is high. Therefore, it is necessary to explore the risk factors of HSP
recurrence in children. Through the analysis of potential risk factors, it was found that the proportion of
respiratory infection in the recurrence group were higher than those in the non-recurrence group, which
was consistent with the previous research results.17,18 Other recent study showed that potential infections
occurred in 50.9%, in which streptococcus was the most common infectious agent (17.1%).19 It is
speculated that respiratory infection produce a variety of antigenic stimulus might cause the elevation of
circulating immunoglobulin A and complement activation, leading to inammation of small vessels in
different target-organs and cutaneous leukocytoclastic vasculitis. Symptomatic treatment plus adjunctive
anti-infectious agents could signicantly improve the remission rate of HSP in the infectious cases,
especially help relieve cutaneous rash. HSP is an immune complex-mediated vasculitis and
spontaneously resolves in 94% of children.7 Our research results, the medical history of non-recurrence
group was longer than that of recurrence group, further verify this point. We also found that the repeated
rashes ≥ 3 times rate of HSP in recurrence group was 45% (9/20), which is higher than non-recurrence
group [34.7%(18/52) ]. Although the common complications of HSP like repeated rashes, arthritis,
abdominal pain or renal damage effect the prognosis of the disease, but it is not a risk factor for the
recurrence of HSP.

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Conclusions
There was no signicant correlation between long-term fasting animal protein and repeated rash or
disease recurrence in children with HSP. It is suggested that children with HSP should have a balanced
diet, but should not limit their intake of animal protein for a long time. Strengthening the monitoring of
relevant indicators of respiratory infection in children and giving intervention as soon as possible will
reduce the recurrence of HSP. However, the medical community has not yet reached a consensus on the
dietary management of children's HSP, and the number of existing randomized controlled studies is small,
so it needs to be supported by multi center and large sample randomized controlled studies in the future.
List Of Abbreviations
HSP
Henoch-Schönlein purpura
Declarations
Ethics approval and consent to participate
Medical ethics committee of Beijing Children's Hospital [2021]-E-227-R.Written consent was obtained
from the parents of the participant.
Consent for publication
Written informed consent to publish this information was obtained from the patient’s parents.
Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated or analysed during the current
study.
Competing Interest
No conicts of interest have been declared.
Funding
This study was funded by the Key Disciplines of Traditional Chinese Medicine for Children with Spleen
and Stomach Diseases (No: JZZII8).
Author Contributions
LH: Conceptualization and methodology, formal analysis, investigation, writing (original draft, review and
editing), project administration.

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FK: Conceptualization and methodology, investigation, writing (original draft, review and editing),
supervision and project administration. All authors critically revised the manuscript, agree to be fully
accountable for ensuring the integrity and accuracy of the work, and read and approved the nal
manuscript.
Acknowledgments
The study is not applicable.
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