Comparison Table

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Note
  • 10% with FPIES may also develop an IgE-mediated allergy to that food
  • There are only 2 case reports of an exclusively breast-fed infant with acute FPIES
    • It has been hypothesized that in breast-fed infants proctocolitis might represent an attenuated form of FPIES because in both conditions, an intense inflammatory response can occur in the rectum

FPIES Differential Diagnosis

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  • For infants presenting with bloody stools (gross or occult), the differential diagnosis includes:
    • Common conditions: anal fissures, infectious colitis, and lymphonodular hyperplasia.
    • Less common conditions: necrotizing enterocolitis, intussusception, Henoch-Schonlein purpura, familial Mediterranean fever, Meckel diverticulum, pancreatitis, Hirschsprung enterocolitis, amoebic colitis, and inflammatory bowel diseases
    • Severe: necrotizing enterocolitis, sepsis, Hirschprung's, intussusception, volvulus, FPIES
    • Mild/moderate: anal fissue, perianal dermatitis/excoriations, GI infection (e.g. Salmonella, Shigella, Camylobacter, Yersinia, parasites), coagulation disorders, vitamin K deficiency, food protein-induced proctocolitis (aka allergic proctocolitis)



FPIES Triggers

  • Most common triggers ("classic FPIES") are cow's milk and soy; co-sensitization to cow's milk/soy occurs in >50%
  • Most common solid food trigger is rice
  • Other reported solid foods include:
    • Grains (rice, oats, barley, corn)
    • Meat and poultry (beef, chicken, turkey)
    • Eggs (rare)
    • Vegetables and fruit (white potato, sweet potato, squash, string beans, banana, tomato)
    • Legumes (peanut, green peas, lentils)
    • Seafood (fish, crustaceans, molluscs)
      • Most common solid food trigger in Italy is finned fish, which can be specific to one type of fish only
    • Probiotic Saccharomyces boulardii
  • In patients with both classic and solid-food FPIES, sensitization to multiple solid foods is frequent (e.g. FPIES to different grains)
  • FPIES in exclusively breast-fed infants seems to be extremely rare


FPIES Management

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  • Consider repeating SPT/sIgE every year to monitor for development of IgE-mediated allergy to the FPIES food
  • In case of reaction with accidental ingestion, seek immediate medical care. Patient should carry a letter describing FPIES:
  • Ondansetron (IV > PO) may be helpful in treating FPIES reactions (in addition to fluid resuscitation and corticosteroids)


FPIES Oral Food Challenge (Nowak-Wegrzyn)

  • Consider challenges every 18-24 months in patients without recent reactions
  • If patient develops positive SPT or sIgE to the food in question, then a more gradual dosing schedule should be considered
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  • Ondansetron (IV > PO) may be helpful in treating FPIES reactions (in addition to fluid resuscitation and corticosteroids)
  • Criteria for a positive challenge in patients with FPIES: (1) emesis, diarrhea, or both; (2) fecal blood; (3) fecal leukocytes; (4) fecal eosinophils; and (5) increase in peripheral polymorphonuclear leukocyte count of greater than 3500 cells/mm3.
    • Positive: 3 or more criteria are met
    • Equivocal: 2 are met
    • Negative: 0-1 are met

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Food Protein-Induced Proctocolitis Management (Nowak-Wegrzyn)

  • Dietary elimination of causative food in maternal diet (if breastfeeding), or substitution of current formula with hypoallergenic (e.g. casein hydrolysate) formula, until 1 year old
    • Most commonly identified foods are cow's milk (65%), egg (19%), corn (6%), soy (3%), 2 of these (5%), none identified (12%), improvement with elemental amino-acid formula only (4%)
  • Introduce solids at 4-6 months (as usual, except for causative food)
  • Check SPT/sIgE to the causative food at 1 year old, with gradual home introduction if negative (consider starting with baked goods)



References