The International Food Protein Induced Enterocolitis Guidelines (FPIES) are out: what do they say?

Definition:

  • FPIES can present as acute and chronic FPIES.
  • Acute FPIES is characterized with delayed (4-6 hours or later) vomiting after consumption of the food, +/- diarrhea.
  • Chronic FPIES is not as well characterized as acute FPIES and tend to present in younger infants; often associated with chronic, intermittent vomiting, watery diarrhea and +/- failure to thrive/growth faltering.
  • FPIES represent a spectrum of syndromes rather than a uniform syndrome.

 

Diagnosis

  • The diagnosis of FPIES is often a clinical diagnosis based on the history (Table V provide a very useful summary of the minor and major criteria for diagnosis).
  • Chemistry or blood counts may help to rule our differential diagnosis, but is not useful to diagnose FPIES
  • Oral food challenges should ideally be conducted in a hospital setting were there is access to rapid fluid resuscitation
  • The challenge dose is different from those of a food challenges for IgE mediated food allergy (summary statement 8) – challenge doses are complex and many factors have to be taken into account; a dietitian can be particularly helpful with calculating doses and advising on age-appropriate serving sizes.
  • IgE testing is not helpful to identify foods relating to FPIES, but is useful to detect other co-existing food allergies.
  • IgE testing may be useful to detect  “converting” from FPIES to IgE mediated food allergy to the same food.
  • There is no need to perform endoscopies, radiology or stool testing, but do rule out other gastro-intestinal diseases.
  • Regular follow-up is required and foods known to cause FPIES should be reintroduced under doctor’s supervision after a period of avoidance.

 

Treatment

  • Treat acute FPIES according to severity. The use of resuscitation fluid and ondansetron is a clinical decision.
  • Use of epinephrine in the treatment of FPIES is not recommended or useful as FPIES is not IgE-mediated.

 

Foods involved

  • Milk and soy FPIES often present at a younger age than solid food FPIES.
  • The most often reported foods are cow’s milk, soy and grains (rice and oat) but a range of atypical allergenic foods are implicated.
  • Single of multiple foods can be involved in FPIE.
  • A few case studies/series have reported FPIES in adults to fish, seafood and egg.

 

Management

  • The offending foods should be avoided, ideally with the guidance of a registered dietitian.
  • Foods with any form of “may contain” need NOT be avoided.
  • It is not clear if baked milk and baked egg is tolerated in those with FPIES, but has been reported in a few cases.
  • In the case of cow’ milk induced FPIES, a hypoallergenic formula (amino acid or extensively hydrolyzed formula) should be prescribed.
  • Routine avoidance of the allergenic foods by the breastfeeding mother is not recommended.
  • Children with soy or milk FPIES are at higher risk of developing FPIES to either soy or milk and grains, particularly rice and oat.
  • During the weaning period: Food introduction should not be delayed – start with fruit (e.g. berries), vegetables (e.g. broccoli and cauliflower), meat (lamb) and then grains (particularly corn, quinoa and millet). (Table IX provide an excellent summary on the introduction of weaning foods)
  • Tolerance of a food from one food group is a positive indicator that other foods from that group may be tolerated.
  • In young infants with a history of severe reactions, some new weaning foods may be introduced under doctor’s supervision.
  • A dietitian is crucial to help this weaning process along to ensure intake of age-appropriate foods and nutrients that are of particular concern: essential fatty acids, vitamin D, iron and zinc.
  • Regular monitoring of growth is recommended.

 

Prevention of FPIES

  • There is currently no evidence for any dietary strategies to prevent FPIES