Paeds · gastroenterology-hepatology-and-nutrition
Food protein-induced enterocolitis and enteropathy
Also known as Food protein-induced enterocolitis syndrome · FPIES · Food protein-induced enterocolitis and enteropathy · Food protein-induced enteropathy · Non-IgE-mediated food allergy with delayed vomiting · Dietary protein enterocolitis
Fellowship guide to food protein-induced enterocolitis syndrome (FPIES): a non-IgE-mediated food allergy of infancy in which a trigger protein produces delayed, repetitive vomiting one to four hours after ingestion with lethargy, pallor and watery diarrhoea, the 2017 international consensus diagnostic criteria that separate acute from chronic FPIES, the distinction from sepsis and surgical abdomen, the absence of any validated diagnostic test and the central role of supervised oral food challenge, the resuscitation of the acute reaction with intravenous fluids and ondansetron, and the avoidance diet, the action plan and the natural history of tolerance that most children outgrow.
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- An infant who develops repetitive delayed vomiting one to four hours after eating a food, with marked pallor, lethargy, floppiness or watery diarrhoea, has food protein-induced enterocolitis syndrome until proven otherwise, and is at risk of dehydration, acidosis and hypovolaemic shock
- The same acute FPIES reaction is one of the commonest mimics of sepsis, viral gastroenteritis and surgical abdomen in infancy, so a recurrent pattern triggered by the same food, repeated negative septic screens and no alternative diagnosis are the clues that the child is not simply septic
- An exclusively formula-fed young infant with chronic intermittent vomiting, watery or bloody diarrhoea and poor weight gain has chronic FPIES to cow's milk or soy until proven otherwise and can become profoundly dehydrated and acidotic if the trigger is not removed
- Hypotension, methemoglobinaemia or profound metabolic acidosis during an acute reaction is a life-threatening presentation needing aggressive intravenous fluid resuscitation, and in the premature or young infant it is easily mistaken for necrotising enterocolitis
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- Food protein-induced enterocolitis syndrome (FPIES): recognition and management
- Non-IgE-mediated food allergy: FPIES diagnostic criteria, acute reaction resuscitation and oral food challenge
- The infant with delayed vomiting after food: recognising FPIES and separating it from sepsis
- Short case: the infant with recurrent pallor, lethargy and vomiting after feeds
- Long case: chronic FPIES with faltering growth and the pathway to diagnosis and tolerance
- Allergy: food protein-induced enterocolitis syndrome
- Non-IgE-mediated food allergy: FPIES criteria, triggers and management
- Allergy and gastroenterology: the infant with delayed vomiting and pallor
- Allergy/Immunology and Gastroenterology: food protein-induced enterocolitis syndrome
- Patient Care: non-IgE-mediated food allergy and FPIES in infants
- Medical Expert: food protein-induced enterocolitis syndrome
Overview & Definition
Food protein-induced enterocolitis syndrome is the non-IgE-mediated food allergy that every paediatric trainee must be able to pull out of the differential of a suddenly pale, vomiting infant. The child looks septic, the septic screen is negative, and the whole story unlocks the moment you realise the collapse is timed one to four hours after a specific food. That delayed, repetitive vomiting with lethargy, pallor and watery diarrhoea, in the absence of any hive, wheeze or swelling, is the signature, and recognising it changes the child from a case of recurrent sepsis into a case of a avoidable food trigger. [1]
The mechanism is cell-mediated rather than antibody-mediated, which is why skin-prick tests and specific immunoglobulin E are unhelpful and why the reaction is delayed rather than immediate. There is no validated laboratory test, so the diagnosis is clinical, built on the consensus criteria, and confirmed by resolution on elimination and recurrence on a medically supervised oral food challenge. The companion syndrome is food protein-induced enteropathy, a chronic, malabsorptive pattern with diarrhoea, vomiting and faltering growth from ongoing ingestion, which sits on the same non-IgE spectrum and resolves on removal of the trigger. [1] [2]
References12ShowHide
- [1]Nowak-Węgrzyn A; Chehade M; Groetch ME; Spergel JM; Wood RA; Allen K 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, 2017.PMID 28167094
- [2]Sicherer SH; Eigenmann PA; Sampson HA Clinical features of food protein-induced enterocolitis syndrome. J Pediatr, 1998.PMID 9709708
- [3]Sicherer SH Food protein-induced enterocolitis syndrome: case presentations and management lessons. J Allergy Clin Immunol, 2005.PMID 15637562
- [4]Caubet JC; Ford LS; Sickles L; Järvinen KM; Sicherer SH; Sampson HA; Nowak-Węgrzyn A Clinical features and resolution of food protein-induced enterocolitis syndrome: 10-year experience. J Allergy Clin Immunol, 2014.PMID 24880634
- [5]Mehr S; Kakakios A; Frith K; Kemp AS Food protein-induced enterocolitis syndrome: 16-year experience. Pediatrics, 2009.PMID 19188266
- [6]Leonard SA; Pecora V; Fiocchi AG; Nowak-Węgrzyn A Food protein-induced enterocolitis syndrome: a review of the new guidelines. World Allergy Organ J, 2018.PMID 29441147
- [7]Nowak-Wegrzyn A, Sampson HA, Wood RA, et al. Food protein-induced enterocolitis syndrome caused by solid food proteins. Pediatrics, 2003.PMID 12671120
- [8]Feuille E; Nowak-Węgrzyn A Medical Algorithms: Recognizing and treating food protein-induced enterocolitis syndrome. Allergy, 2019.PMID 31070799
- [9]Miceli Sopo S; Monaco S; Badina L; Barni S; Toscano A; Tripodi S; Meglio P Food protein-induced enterocolitis syndrome caused by fish and/or shellfish in Italy. Pediatr Allergy Immunol, 2015.PMID 26287446
- [10]Ludman S; Harmon M; Whiting D; du Toit G Clinical presentation and referral characteristics of food protein-induced enterocolitis syndrome in the United Kingdom. Ann Allergy Asthma Immunol, 2014.PMID 25065570
- [11]Feuille E; Menon NR; Huang F; Nowak-Węgrzyn A Knowledge of food protein-induced enterocolitis syndrome among general pediatricians. Ann Allergy Asthma Immunol, 2017.PMID 28890023
- [12]Shah S; Grohman R; Nowak-Węgrzyn A Food protein-induced enterocolitis syndrome (FPIES): Beyond the guidelines. J Food Allergy, 2023.PMID 39022754