Review
The practical dietary management of food protein-induced enterocolitis syndrome

https://doi.org/10.1016/j.anai.2021.03.007Get rights and content

Abstract

Objective

Food protein-induced enterocolitis syndrome (FPIES) is a non–immunoglobulin E-mediated food allergy with potential risk of malnutrition related to the early onset of disease, frequent avoidance of cow's milk, and the possibility of multiple food triggers. This publication is aimed at providing an evidence-based, practical approach to the dietary management of FPIES.

Data Sources

This is a narrative review summarizing information from national and international guidelines, retrospective studies, population studies, review articles, case reports, and case series to evaluate for nutritional risk and develop guidance for risk reduction in children with FPIES.

Study Selections

We have included retrospective clinical cohort studies, population-based studies, case reports, and case studies. We did not exclude any studies identified owing to the small number of studies addressing the nutritional management of individuals with FPIES.

Results

Children with FPIES are at risk of malnutrition owing to suboptimal oral intake, limited food choices, and knowledge deficits related to feeding. In particular, children with 3 or more FPIES triggers seem to be at increased risk for poor weight gain and developing food aversion. Caregivers of children with FPIES also report a high degree of psychosocial burden.

Conclusion

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 plan to meet the infant's nutritional needs for optimal growth and development are essential management strategies.

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

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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.

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