ReviewThe practical dietary management of food protein-induced enterocolitis syndrome
Introduction
Food allergies present nutritional challenges and risks in the pediatric population. The term food allergy covers a wide spectrum of clinical diseases, each with its own nutritional implications. Children with cow's milk allergy, early onset food allergy, and non–immunoglobulin (IgE)-mediated disease and mixed IgE-/non–IgE-mediated disease are at greatest nutritional risk.1,2 Food protein-induced enterocolitis syndrome (FPIES) meets the criteria for increased nutritional risk, as it is a non–IgE-mediated food allergy disorder with early onset of disease, frequently triggered by cow's milk, possible involvement of multiple food triggers, and may result in persistent gut inflammation when the food triggers remain in the diet.1,3 A recent retrospective study of 203 patients with FPIES found that compared with FPIES cases with 2 or fewer triggers, patients with multiple triggers were more likely to develop food aversion (43.2% vs 16.9%; P < .001) and to have poor weight gain (21.6% vs 6.6%; P = .005).4 To compound the risk, a 2017 survey found that approximately one-third of pediatricians surveyed had never heard of FPIES and another one-third were not familiar with diagnostic criteria or appropriate management.5
Appropriate dietary management entails the following 3 essential components: supporting normal growth and development, avoidance of allergens, and advancement of complementary foods. Education to avoid the trigger food and assisting caregivers in creating an individualized, well-designed complementary feeding (CF) plan to meet the infant's nutritional needs for optimal growth and development are essential management strategies. This publication is aimed at providing an evidence-based, practical approach for health care professionals working with patients with FPIES.
Section snippets
Overview of Food Protein-Induced Enterocolitis Syndrome
FPIES is characterized by delayed, often dramatic, gastrointestinal symptoms.6 FPIES classically presents in infancy or early childhood, with most children developing tolerance by school age, although reports of adults with suspected FPIES are increasing.7,8 Although much remains to be learned on the pathophysiology of FPIES, it is thought to be cell mediated with cytokine release contributing to increased intestinal permeability and inflammation.6 Of note, 2 phenotypes of FPIES have been
Dietary Avoidance Education
ICG summary statement on avoidance states the following: “Do not routinely recommend avoidance of products with precautionary allergen labeling in patients with FPIES,” though the guidelines group acknowledges the limited data set on which this recommendation is based.6 Currently, no studies have been performed to set reliable thresholds in children or adults with FPIES. Katz et al24 reported that 82% of children tolerated 50 mL of milk before a reaction developed. Sopo et al21 reported that
Conclusion
Food protein-induced enterocolitis syndrome (FPIES) is a non–IgE-mediated food allergy with onset in early infancy and risk of multiple food triggers, which presents nutritional challenges that are best addressed preemptively by the health care provider. Dietary and nutritional management of FPIES entails appropriate avoidance of the trigger food(s) without excessive avoidance, guidance on early introduction of safe and nutritious complementary foods, and progressive advancement of
References (82)
- et al.
Elimination diet in cow's milk allergy: risk for impaired growth in young children
J Pediatr
(1998) - et al.
Expression of transforming growth factor beta1, transforming growth factor type I and II receptors, and TNF-alpha in the mucosa of the small intestine in infants with food protein-induced enterocolitis syndrome
J Allergy Clin Immunol
(2002) - et al.
FPIES in adults
Ann Allergy Asthma Immunol
(2018) - et al.
Food protein-induced enterocolitis-like syndrome in a population of adolescents and adults caused by seafood
J Allergy Clin Immunol Pract
(2019) - et al.
Clinical features of food protein-induced enterocolitis syndrome
J Pediatr
(1998) - et al.
Chronic food protein-induced enterocolitis syndrome: characterization of clinical phenotype and literature review
Ann Allergy Asthma Immunol
(2016) Enterocolitis in low-birth-weight infants associated with milk and soy protein intolerance
J Pediatr
(1976)Milk- and soy-induced enterocolitis of infancy. Clinical features and standardization of challenge
J Pediatr
(1978)- et al.
Dietary protein intolerance in infants with transient methemoglobinemia and diarrhea
J Pediatr
(1993) - et al.
Food protein-induced enterocolitis syndrome: increased prevalence of this great unknown-results of the PREVALE study
J Allergy Clin Immunol
(2019)
Clinical presentation and referral characteristics of food protein-induced enterocolitis syndrome in the United Kingdom
Ann Allergy Asthma Immunol
Food protein-induced enterocolitis syndrome in Australia: a population-based study, 2012-2014
J Allergy Clin Immunol
Elevated atopic comorbidity in patients with food protein-induced enterocolitis
J Allergy Clin Immunol Pract
Food protein-induced enterocolitis syndrome oral food challenge: Time for a change?
Ann Asthma Allergy Immunol
Food protein-induced enterocolitis syndrome food challenges: experience from a large referral center
J Allergy Clin Immunol Pract
Food protein-induced enterocolitis syndrome by cow's milk proteins passed through breast milk
J Allergy Clin Immunol
Food protein-induced enterocolitis syndrome: insights from review of a large referral population
J Allergy Clin Immunol Pract
Colitis, persistent diarrhea, and soy protein intolerance
J Pediatr
A slice of food protein-induced enterocolitis syndrome (FPIES): insights from 441 children with FPIES as provided by caregivers in the international FPIES association
J Allergy Clin Immunol Pract
Emerging triggers of food protein-induced enterocolitis syndrome: lessons from a pediatric cohort of 74 children in the United States
Ann Allergy Asthma Immunol
Food allergen advisory labeling and product contamination with egg, milk, and peanut
J Allergy Clin Immunol
Food protein-induced enterocolitis syndrome
Pediatr Clin North Am
Food protein-induced enterocolitis syndrome in an exclusively breast-fed infant-an uncommon entity
J Allergy Clin Immunol
Guidelines for the diagnosis and management of food allergy in the United States: summary of the NIAID-Sponsored Expert Panel Report
Nutrition
When should infants with cow's milk protein allergy use an amino acid formula? A practical guide
J Allergy Clin Immunol Pract
Feeding difficulties in children with non-IgE-mediated food allergic gastrointestinal disorders
Ann Allergy Asthma Immunol
Establishing the prevalence of low vitamin D in non-immunoglobulin-E mediated gastrointestinal food allergic children in a tertiary centre
World Allergy Organ J
Complementary feeding and micronutrient status: a systematic review
Am J Clin Nutr
Mother-child touch patterns in infant feeding disorders: relation to maternal, child, and environmental factors
J Am Acad Child Adolesc Psychiatry
Managing food allergy and anaphylaxis: a new model for an integrated approach
Allergol Int
International survey on growth indices and impacting factors in children with food allergies
J Hum Nutr Diet
Food aversion and poor weight gain in food protein-induced enterocolitis syndrome: a retrospective study
J Allergy Clin Immunol
Knowledge of food protein-induced enterocolitis syndrome among general pediatricians
Ann Allergy Asthma Immunol
International consensus guidelines for the diagnosis and management of food protein-induced enterocolitis syndrome: executive summary-Workgroup Report of the Adverse Reactions to Foods Committee, American Academy of Allergy, Asthma & Immunology
J Allergy Clin Immunol
Clinical features and resolution of food protein-induced enterocolitis syndrome: 10-year experience
J Allergy Clin Immunol
Four distinct subtypes of non-IgE-mediated gastrointestinal food allergies in neonates and infants, distinguished by their initial symptoms
J Allergy Clin Immunol
Food protein-induced enterocolitis syndrome: 16-year experience
Pediatrics
Indexes of suspicion of typical cow's milk protein-induced enterocolitis
J Korean Med Sci
Food protein-induced enterocolitis syndrome: data from a multicenter retrospective study in Spain
J Pediatr Gastroenterol Nutr
A multicentre retrospective study of 66 Italian children with food protein-induced enterocolitis syndrome: different management for different phenotypes
Clin Exp Allergy
Remission patterns of food protein-induced enterocolitis syndrome in a Greek pediatric population
Int Arch Allergy Immunol
Cited by (11)
Identifying Children at Risk of Growth and Nutrient Deficiencies in the Food Allergy Clinic
2024, Journal of Allergy and Clinical Immunology: In PracticePersonalization of Complementary Feeding in Children With Acute Food Protein–Induced Enterocolitis Syndrome
2024, Journal of Allergy and Clinical Immunology: In PracticeCurrent and future perspectives on the consensus guideline for food protein-induced enterocolitis syndrome (FPIES)
2024, Allergology InternationalEvolution of Food Protein-Induced Enterocolitis Syndrome (FPIES) Index Trigger Foods and Subsequent Reactions After Initial Diagnosis
2023, Journal of Allergy and Clinical Immunology: In PracticeRecent trends in food protein–induced enterocolitis syndrome (FPIES)
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Disclosures: Ms Groetch receives royalties from UpToDate, FARE, and AND; serves on the Medical Advisory Board of IFPIES, as a Senior Advisor to FARE, and as a Health Sciences Advisor for APFED; and has no commercial interests to disclose. Ms Durban reports to have received honoraria for educational lectures from Abbott Nutrition, Mead Johnson Nutrition, and Nutricia North America and consultant fees from AstraZeneca and Mead Johnson Nutrition. Dr Meyer reports to have received honoraria for educational lectures from Nutricia/Danone, Mead Johnson, Abbott, and Nestlè and research support from Danone/Nutricia and reports to be on the CoMISS board from Nestlè. Dr Venter reports to have provided and reviewed educational material for Danone, Mead Johnson Nutrition, Abbott Laboratories, and Nestlè Nutrition Institute and to have received research support from Reckitt Benckiser, The National Peanut Board, and the INTENT group. Dr Muraro reports to have received honoraria for educational lectures from Aimmune, DVB Technologies, Nestlè Health Institute, Nestlè Purina, Nutricia, and Mylan. The remaining authors report no conflict of interest.
Funding: The authors have no funding sources to report.