A New Form of Food Reactivity

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Food Protein Enterocolitis (FPIES) may be a new term to you, but as with a number of emerging subsets of food reactivity it appears to be a little over half as common as IgE food responses (0.34% by 1 year of age; immunoglobulin E-mediated cow’s milk allergy was 0.5%.). So whilst you may not see a case directly in practice, understanding its process and symptoms as well as treatments will prepare you for those cases that seem to fail to respond to normal approaches.

Food Protein Induced Enterocolitis Syndrome (FPIES) is an allergic reaction in the gastrointestinal system. The most common triggers are milk and soy, but any food (even those thought to be hypoallergenic e.g. rice, oat) can cause an FPIES reaction. FPIES typically starts within the first year of life.[1]

 

Unlike most food allergies, the FPIES reactions are delayed and usually begin about 2 hours after ingestion of the causative food. FPIES reactions are characterised by profuse vomiting and diarrhoea. In about 20% of cases the child will have such an extreme reaction to a food that they will go into shock and need to be taken quickly to the Emergency Room for immediate treatment. About 75% will have acute episodes on diagnosis. The other 25% children will have more chronic symptoms, which resolve within 1 week after avoiding the food.

Diagnosis

Unlike common food allergies, standard skin testing and blood testing for specific IgE are routinely negative in these patients. Therefore, a careful history and physical examination is the key for diagnosis.

During an acute episode, laboratory findings can include an elevated white blood count with increased neutrophils and eosinophils, elevated platelet count, anaemia (low red blood cell count) or low albumin may occur, particularly in chronic cases. In acute severe episodes, patients can develop methemoglobinaemia.

Natural History

FPIES typically presents before 6 months of age in formula-fed infants with repetitive emesis, diarrhoea, dehydration, and lethargy 1 to 5 hours after ingesting the offending food. The most common offending food is cow’s milk followed by soy, and rice. Other foods have been reported including oats, barley, chicken, turkey, egg white, green pea, peanut, sweet potato, white potato, fruit protein, fish, and molluscs. But, FPIES is possible with any food.

In 60-90% of affected children, FPIES is outgrown in the first 3 years of life. However, there are individual children that have FPIES continued into adulthood.

Treatment

For acute FPIES, treatment with intravenous hydration is often needed. There is no curative therapy at the current time. Strict avoidance of the offending food is the basic treatment. A hypoallergenic diet can be an amino acid elemental formula or an extensively hydrolysed casein or whey formula.

Welcome to IAFFPE

The International Association for Food Protein Enterocolitis (IAFFPE) is a recognised 501(c)3 non-profit corporation and organisation that provides education, support, and advocacy for individuals with Food Protein-Induced Enterocolitis Syndrome (FPIES) and their families.

Their web site will supply extensive resources. IAFFPE

Reference


[1] Leonard SA, Nowak-Węgrzyn A. Clinical diagnosis and management of food protein-induced enterocolitis syndrome. Curr Opin Pediatr. 2012 Dec;24(6):739-45. View Abstract

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