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Hamada M, Sakurai Y, Tanaka I. Effectiveness of continuous allergenic food intake for acute food protein-induced enterocolitis syndrome. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100232. [PMID: 38510796 PMCID: PMC10951517 DOI: 10.1016/j.jacig.2024.100232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/09/2024] [Accepted: 01/21/2024] [Indexed: 03/22/2024]
Abstract
Continuous intake of allergenic food is a safe and efficient treatment strategy for patients with a prolonged course of acute food protein-induced enterocolitis syndrome. The initial dose, dose escalation rate, and starting age for continuous allergenic food intake need further clarification.
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Affiliation(s)
- Masaaki Hamada
- Department of Pediatrics, Yao Municipal Hospital, Osaka, Japan
| | - Yoshihiko Sakurai
- Department of Legal Medicine, Nara Medical University School of Medicine, Kashihara, Japan
| | - Ichiro Tanaka
- Department of Pediatrics, Yao Municipal Hospital, Osaka, Japan
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Ocak M, Akarsu A, Sahiner UM, Soyer O, Sekerel BE. Food protein-induced enterocolitis syndrome: Current practices in oral food challenge. Allergy Asthma Proc 2021; 42:343-349. [PMID: 34187626 DOI: 10.2500/aap.2021.42.210042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: Oral food challenges (OFC) in food protein-induced enterocolitis syndrome (FPIES) are performed to confirm a diagnosis, test for development of tolerance, and find safe alternatives. Objective: We aimed to define OFC outcomes and identify safer test strategies. Methods: OFCs performed in children with FPIES over a 5-year period were reviewed. Results: A total of 160 OFCs were performed in 59 children (median age, 2.3 years). The most commonly tested foods were hen's egg, fish, and cow's milk. Sixty-six OFC results (41.3%) were positive. Twelve (18.2%) reactions were mild, 18 (27.3%) were moderate, and 36 (54.5%) were severe. Intravenous fluid, ondansetron, and corticosteroids were administered in 83.3, 72.7, and 66.7% of the patients, respectively; one patient required hospitalization. A reaction was most likely with fish (odds ratio [OR] 2.878 [95% confidence interval {CI}, 1.279-6.473]; p = 0.011), and least likely with cow's milk (OR 0.268 [95% CI, 0.082-0.872]; p = 0.029). Of the 36 OFCs with egg yolk, 23 patients had a failed OFC, and of the 17 OFCs with egg white (all tolerant to egg yolk), only 2 patients had a failed result. Interestingly, two patients tolerated baked whole egg but not egg yolk. In cow's milk FPIES, two patients could consume fermented milk but not fresh milk. Of the 11 patients with anchovy-triggered FPIES, 6 tolerated sea bass, and 5 tolerated trout, whereas 4 patients with sea bass FPIES tolerated trout. Conclusion: The search for alternative food species, processing, or subdivision of a trigger food is common practice in FPIES, which reflects the expectations of children and their families. The experience gained can be put into practice and will contribute to the understanding of the disease mechanism.
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Nowak-Wegrzyn A, Berin MC, Mehr S. Food Protein-Induced Enterocolitis Syndrome. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:24-35. [PMID: 31950904 DOI: 10.1016/j.jaip.2019.08.020] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/14/2019] [Accepted: 08/21/2019] [Indexed: 01/01/2023]
Abstract
Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food allergy that manifests with projectile, repetitive emesis that can be followed by diarrhea and may be accompanied by lethargy, hypotonia, hypothermia, hypotension, and metabolic derangements. FPIES usually starts in infancy although onset at older ages is being increasingly recognized. FPIES is not rare, with the cumulative incidence of FPIES in infants estimated to be 0.015% to 0.7%, whereas the population prevalence in the US infants was 0.51%. FPIES diagnosis is challenging and might be missed because of later (1-4 hours) onset of symptoms after food ingestion, lack of typical allergic skin and respiratory symptoms, and food triggers that are perceived to be hypoallergenic. Diagnosis is based on the recognition of symptoms because there are no biomarkers of FPIES. The pathophysiology remains obscure although activation of the innate immune compartment has been detected. Management relies of avoidance of food triggers, treatment of accidental exposures, and periodic re-evaluations with supervised oral food challenges to monitor for resolution. There are no strategies to accelerate development of tolerance in FPIES. Here we review the most important current concepts in epidemiology, pathophysiology, diagnosis, and management of FPIES.
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Affiliation(s)
- Anna Nowak-Wegrzyn
- Department of Pediatrics, New York University Langone Health, New York, NY; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland.
| | - M Cecilia Berin
- Precision Immunology Institute, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sam Mehr
- Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, VIC, Australia
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Food protein-induced enterocolitis syndrome oral food challenge: Time for a change? Ann Allergy Asthma Immunol 2021; 126:506-515. [PMID: 33662509 DOI: 10.1016/j.anai.2021.02.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/11/2021] [Accepted: 02/22/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Food protein-induced enterocolitis syndrome (FPIES) is typically diagnosed based on a characteristic clinical history; however, an oral food challenge (OFC) may be necessary to confirm the diagnosis or evaluate for the development of tolerance. FPIES OFC methods vary globally, and there is no universally agreed upon protocol. The objective of this review is to summarize reported FPIES OFC approaches and consider unmet needs in diagnosing and managing FPIES. DATA SOURCES PubMed database was searched using the keywords food protein-induced enterocolitis syndrome, oral food challenge, cow milk allergy, food allergy, non-immunoglobulin E-mediated food allergy and FPIES. STUDY SELECTIONS Primary and review articles were selected based on relevance to the diagnosis of FPIES and the FPIES OFC. RESULTS We reviewed the history of FPIES and the evolution and variations in the FPIES OFC. A summary of current literature suggests that most patients with FPIES will react with 25% to 33% of a standard serving of the challenged food, there is little benefit to offering a divided dose challenge unless there is suspicion of specific immunoglobulin E to the food being challenged, reactions typically appear within 1 to 4 hours of ingestion, and reactions during OFC rarely result in emergency department or intensive care unit admission. CONCLUSION International standardization in the FPIES OFC approach is necessary with particular attention to specific dose administration across challenged foods, timing between the patient's reaction and offered OFC to verify tolerance, patient safety considerations before the OFC, and identification of characteristics that would indicate home reintroduction is appropriate.
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Bartnikas LM, Nowak-Wegrzyn A, Schultz F, Phipatanakul W, Bingemann TA. The evolution of food protein-induced enterocolitis syndrome: From a diagnosis that did not exist to a condition in need of answers. Ann Allergy Asthma Immunol 2021; 126:489-497. [PMID: 33444729 DOI: 10.1016/j.anai.2021.01.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/24/2020] [Accepted: 01/04/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Although food protein-induced enterocolitis syndrome (FPIES) was first described approximately 50 years ago and research is increasing, there are still considerable unmet needs in FPIES. This article catalogs the areas of progress and areas for further research. DATA SOURCES Through our personal experiences in caring for patients with FPIES, our personal research, and a review of the existing FPIES literature as indexed in PubMed, we explored what is known and what is needed in FPIES. STUDY SELECTIONS The studies that have improved the knowledge of FPIES, defined phenotypes, allowed for better-informed management of FPIES, and laid the groundwork for further research. RESULTS Further research is needed in the areas of prevalence, natural history, trigger foods, threshold doses, how and when to perform oral food challenges, and immunopathogenesis of this disorder. Development of a biomarker and determination of the best method to treat reactions is also needed. Furthermore, FPIES has a substantial psychosocial and economic impact on families, and more research is needed in developing and implementing ameliorating strategies. CONCLUSION By partnering together, health care providers, advocacy organizations, and families can continue to advance our understanding and improve the care of patients and families living with FPIES.
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Affiliation(s)
- Lisa M Bartnikas
- Division of Allergy and Immunology, Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, New York University Langone Health, New York, New York; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Fallon Schultz
- International Food Protein-Induced Enterocolitis Syndrome Association (I-FPIES), Point Pleasant Beach, New Jersey
| | - Wanda Phipatanakul
- Division of Allergy and Immunology, Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Theresa A Bingemann
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York.
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Mastrorilli C, Santoro A, Procaccianti M, Pagliaro G, Caffarelli C. New insights into food protein-induced enterocolitis in children. Minerva Pediatr 2020; 72:416-423. [PMID: 32686925 DOI: 10.23736/s0026-4946.20.05976-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Food protein-induced enterocolitis syndrome (FPIES) represents a non-IgE-mediated food allergic disorder with delayed gastrointestinal symptoms that may evolve in a medical emergency. Clinically, FPIES can be distinguished into acute and chronic phenotypes. FPIES is mainly diagnosed in infancy however the onset at older ages is being progressively described. The pathogenetic mechanism underlying FPIES remains mainly unexplained, but an alteration of food-specific T-cell response has been proposed. The diagnosis of FPIES is primarily clinical, since there are not available specific biomarkers. Oral food challenge (OFC) is the gold standard for diagnosing FPIES or excluding the onset of tolerance to the triggering food. Management of FPIES includes an acute phase treatment and a maintenance therapy with the strict food avoidance until challenge, in order to prevent new attacks and avoid nutritional alterations. Acute management requires hydration that can be performed orally or intravenously according to clinical status. Long-term management of FPIES is based on the avoidance of the culprit food(s) and supervised introduction of other high-risk foods if never taken before among infants before 12 months of age. There is a compelling need of future achievements in FPIES research for the definition of underlying disease pathogenesis and potential therapeutic point of care.
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Affiliation(s)
- Carla Mastrorilli
- Unit of Pediatric Allergy and Pulmonology, Department of Pediatrics and Emergency, Consorziale-Policlinico University Hospital, Pediatric Hospital Giovanni XXIII, Bari, Italy -
| | - Angelica Santoro
- Department of Medicine and Surgery, Pediatric Clinic, University of Parma, Parma, Italy
| | - Michela Procaccianti
- Department of Medicine and Surgery, Pediatric Clinic, University of Parma, Parma, Italy
| | - Giuseppe Pagliaro
- Pediatric Unit, Department of Obstetrics, Gynecology and Pediatrics, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Carlo Caffarelli
- Department of Medicine and Surgery, Pediatric Clinic, University of Parma, Parma, Italy
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Labrosse R, Graham F, Caubet JC. Non-IgE-Mediated Gastrointestinal Food Allergies in Children: An Update. Nutrients 2020; 12:nu12072086. [PMID: 32674427 PMCID: PMC7400851 DOI: 10.3390/nu12072086] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 06/26/2020] [Accepted: 07/02/2020] [Indexed: 02/07/2023] Open
Abstract
Non-immunoglobulin E-mediated gastrointestinal food allergic disorders (non-IgE-GI-FA) include food protein-induced enterocolitis syndrome (FPIES), food protein-induced enteropathy (FPE) and food protein-induced allergic proctocolitis (FPIAP), which present with symptoms of variable severity, affecting the gastrointestinal tract in response to specific dietary antigens. The diagnosis of non-IgE-GI-FA is made clinically, and relies on a constellation of typical symptoms that improve upon removal of the culprit food. When possible, food reintroduction should be attempted, with the documentation of symptoms relapse to establish a conclusive diagnosis. Management includes dietary avoidance, nutritional counselling, and supportive measures in the case of accidental exposure. The prognosis is generally favorable, with the majority of cases resolved before school age. Serial follow-up to establish whether the acquisition of tolerance has occurred is therefore essential in order to avoid unnecessary food restriction and potential consequent nutritional deficiencies. The purpose of this review is to delineate the distinctive clinical features of non-IgE-mediated food allergies presenting with gastrointestinal symptomatology, to summarize our current understanding of the pathogenesis driving these diseases, to discuss recent findings, and to address currents gaps in the knowledge, to guide future management opportunities.
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Affiliation(s)
- Roxane Labrosse
- Division of Hematology-Oncology, Department of Pediatrics, Boston Children’s Hospital, Boston, MA 02115, USA;
- Division of Allergy and Immunology, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, QC H3T 1C5, Canada;
| | - François Graham
- Division of Allergy and Immunology, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, QC H3T 1C5, Canada;
- Division of Allergy and Immunology, Department of Medicine, Centre Hospitalier de l’Universite de Montreal (CHUM), University of Montreal, Montreal, QC H2X 3E4, Canada
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Woman, Child and Adolescent, University Hospitals of Geneva, 1205 Geneva, Switzerland
- Correspondence:
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Meyer R, Fox AT, Chebar Lozinsky A, Michaelis LJ, Shah N. Non-IgE-mediated gastrointestinal allergies-Do they have a place in a new model of the Allergic March. Pediatr Allergy Immunol 2019; 30:149-158. [PMID: 30403301 DOI: 10.1111/pai.13000] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 10/08/2018] [Accepted: 10/23/2018] [Indexed: 12/18/2022]
Abstract
The rise in food allergy has been described as the "second wave" of the allergy epidemic, with some developed countries reporting a prevalence of 10% of challenge-proven food allergies. Recognition of the Allergic March has played a crucial role in identifying causality in allergic conditions, linking atopic dermatitis to food allergy and food allergy to other atopic disorders, thereby highlighting opportunities in prevention and the importance of early intervention. This publication will establish the value of weaving the less well-understood, non-IgE-mediated food allergy into the Allergic March and mapping its progression through childhood and its associated co-morbidities. The proposed non-IgE-mediated Allergic March highlights the concomitant presentation of gastrointestinal symptoms and atopic dermatitis as early presenting symptoms in confirmed non-IgE-mediated allergies and the later development of atopic co-morbidities, including asthma and allergic rhinitis, similar to the IgE-mediated Allergic March. This publication highlights recent observations of a link between non-IgE-mediated food allergy in early childhood and functional gastrointestinal disorders in later life and also the reported occurrence of extra-intestinal manifestations at later ages. Although significant limitations exist in regard to the proposed evolution of the Allergic March model, the authors hope that this publication will influence the management of non-IgE-mediated gastrointestinal allergies and inform future research and interventions.
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Affiliation(s)
- Rosan Meyer
- Department Paediatrics, Imperial College, London, UK
| | - Adam T Fox
- Department of Paediatric Allergy, Evelina London Children's Hospital, London, UK
| | | | - Louise J Michaelis
- Department of Allergy and Immunology, Great North Children's Hospital, Newcastle Upon Tyne, UK
| | - Neil Shah
- Department Gastroenterology, Great Ormond Street Hospital, London, UK
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10
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Miceli Sopo S, Fantacci C, Bersani G, Romano A, Liotti L, Monaco S. Is food protein induced enterocolitis syndrome only a non IgE-mediated food allergy? Allergol Immunopathol (Madr) 2018; 46:499-502. [PMID: 29472022 DOI: 10.1016/j.aller.2017.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022]
Abstract
Food protein induced enterocolitis syndrome (FPIES) is classified as non-IgE-mediated or cell-mediated food allergy, although there is an atypical phenotype so defined for the presence of specific IgEs. All diagnostic criteria for FPIES include the absence of skin or respiratory symptoms of IgE-mediated type. We present four cases that suggest that specific IgEs may have a pathogenic role, resulting in the existence of different FPIES phenotypes. This could be important from a diagnostic and therapeutic point of view.
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11
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Bingemann TA, Sood P, Järvinen KM. Food Protein-Induced Enterocolitis Syndrome. Immunol Allergy Clin North Am 2018; 38:141-152. [DOI: 10.1016/j.iac.2017.09.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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12
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Venter C, Groetch M, Netting M, Meyer R. A patient-specific approach to develop an exclusion diet to manage food allergy in infants and children. Clin Exp Allergy 2018; 48:121-137. [DOI: 10.1111/cea.13087] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 11/07/2017] [Accepted: 11/08/2017] [Indexed: 12/19/2022]
Affiliation(s)
- C. Venter
- Children's Hospital Colorado; University of Colorado; Aurora CO USA
| | - M. Groetch
- Icahn School of Medicine at Mount Sinai; Jaffe Food Allergy Institute; New York NY USA
| | - M. Netting
- Healthy Mothers Babies and Children's Theme; South Australian Health & Medical Research Institute; Adelaide SA Australia
- Discipline of Paediatrics; School of Medicine; University of Adelaide; Adelaide SA Australia
- Nutrition Department; Women's and Children's Health Network; Adelaide SA Australia
| | - R. Meyer
- Department Paediatrics; Imperial College; London UK
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Weinberger T, Feuille E, Thompson C, Nowak-Węgrzyn A. Chronic food protein-induced enterocolitis syndrome: Characterization of clinical phenotype and literature review. Ann Allergy Asthma Immunol 2017; 117:227-33. [PMID: 27613454 DOI: 10.1016/j.anai.2016.03.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 03/02/2016] [Accepted: 03/07/2016] [Indexed: 12/29/2022]
Affiliation(s)
- Tamar Weinberger
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Elizabeth Feuille
- Jaffe Food Allergy Institute, Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Cecilia Thompson
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anna Nowak-Węgrzyn
- Jaffe Food Allergy Institute, Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York.
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Mehr S, Frith K, Barnes EH, Campbell DE, Allen K, Barnes E, Campbell DE, Frith K, Gold M, Joshi P, Kakakios A, Loh R, Mehr S, Peake J, Smart J, Smith P, Tang M, Wainstein B, Wong M, Zurynski Y. Food protein–induced enterocolitis syndrome in Australia: A population-based study, 2012-2014. J Allergy Clin Immunol 2017; 140:1323-1330. [DOI: 10.1016/j.jaci.2017.03.027] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 03/01/2017] [Accepted: 03/14/2017] [Indexed: 11/25/2022]
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Management of Food Protein-Induced Enterocolitis Syndrome (FPIES): Current Approach and Future Needs. CURRENT TREATMENT OPTIONS IN ALLERGY 2017. [DOI: 10.1007/s40521-017-0141-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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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; 139:1111-1126.e4. [PMID: 28167094 DOI: 10.1016/j.jaci.2016.12.966] [Citation(s) in RCA: 354] [Impact Index Per Article: 50.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 12/07/2016] [Accepted: 12/21/2016] [Indexed: 01/22/2023]
Abstract
Food protein-induced enterocolitis (FPIES) is a non-IgE cell- mediated food allergy that can be severe and lead to shock. Despite the potential seriousness of reactions, awareness of FPIES is low; high-quality studies providing insight into the pathophysiology, diagnosis, and management are lacking; and clinical outcomes are poorly established. This consensus document is the result of work done by an international workgroup convened through the Adverse Reactions to Foods Committee of the American Academy of Allergy, Asthma & Immunology and the International FPIES Association advocacy group. These are the first international evidence-based guidelines to improve the diagnosis and management of patients with FPIES. Research on prevalence, pathophysiology, diagnostic markers, and future treatments is necessary to improve the care of patients with FPIES. These guidelines will be updated periodically as more evidence becomes available.
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Michelet M, Schluckebier D, Petit LM, Caubet JC. Food protein-induced enterocolitis syndrome - a review of the literature with focus on clinical management. J Asthma Allergy 2017; 10:197-207. [PMID: 28721077 PMCID: PMC5499953 DOI: 10.2147/jaa.s100379] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Food protein-induced enterocolitis syndrome (FPIES) is a potentially severe presentation of non-IgE-mediated gastrointestinal food allergy (non-IgE-GI-FA) with heterogeneous clinical manifestations. Acute FPIES is typically characterized by profuse vomiting and lethargy, occurring classically 1-4 hours after ingestion of the offending food. When continuously exposed to the incriminated food, a chronic form has been described with persistent vomiting, diarrhea, and/or failure to thrive. Although affecting mainly infants, FPIES has also been described in adults. Although FPIES is actually one of the most actively studied non-IgE-GI-FAs, epidemiologic data are lacking, and estimation of the prevalence is based on a limited number of prospective studies. The exact pathomechanisms of FPIES remain not well defined, but recent data suggest involvement of neutrophils and mast cells, in addition to T cells. There is a wide range of food allergens that can cause FPIES with some geographical variations. The most frequently incriminated foods are cow milk, soy, and grains in Europe and USA. Furthermore, FPIES can be induced by foods usually considered as hypoallergenic, such as chicken, potatoes or rice. The diagnosis relies currently on typical clinical manifestations, resolving after the elimination of the offending food from the infant's/child's diet and/or an oral food challenge (OFC). The prognosis is usually favorable, with the vast majority of the case resolving before 5 years of age. Usually, assessment of tolerance acquisition by OFC is proposed every 12-18 months. Of note, a switch to an IgE-mediated FA is possible and has been suggested to be associated with a more severe phenotype. Avoiding the offending food requires education of the family of the affected child. A multidisciplinary approach including ideally allergists, gastroenterologists, dieticians, specialized nurses, and caregivers is often useful to optimize the management of these patients, that might be difficult.
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Affiliation(s)
- Marine Michelet
- Children Hospital, Pediatric Allergology Unit CHU Toulouse, Toulouse, France
| | | | | | - Jean-Christoph Caubet
- Geneva University Hospitals, Pediatric Allergology Unit, Geneva, Switzerland
- Correspondence: Jean-Christoph Caubet, Geneva University Hospitals, Pediatric Allergology Unit, 6 Rue Willy Donzé, 1205 Geneva, Switzerland, Email
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Lee E, Mehr S. What is New in the Diagnosis and Management of Food Protein-Induced Enterocolitis Syndrome? CURRENT PEDIATRICS REPORTS 2016. [DOI: 10.1007/s40124-016-0107-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Food protein-induced enterocolitis syndrome (FPIES) is a rare, non-immunoglobulin E-mediated gastrointestinal food allergy primarily diagnosed in infancy, but has also been reported in older children and adults. Acute FPIES reactions typically present with delayed, repetitive vomiting, lethargy, and pallor within 1 to 4 hours of food ingestion. Chronic FPIES typically presents with protracted vomiting and/or diarrhea, and weight loss or poor growth. Common foods triggering FPIES include cow's milk, soy, rice, oats, fish, and egg. More detailed diagnostic criteria may help in increasing awareness of FPIES and reducing delayed diagnoses or misdiagnoses.
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Affiliation(s)
- Stephanie A Leonard
- Division of Pediatric Allergy & Immunology, Rady Children's Hospital San Diego, University of California, San Diego, 3020 Children's Way, MC 5114, San Diego, CA 92123, USA
| | - Anna Nowak-Węgrzyn
- Division of Pediatric Allergy, Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, Box 1198, One Gustave L. Levy Place, New York, NY 10029, USA.
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Nowak-Węgrzyn A, Katz Y, Mehr SS, Koletzko S. Non-IgE-mediated gastrointestinal food allergy. J Allergy Clin Immunol 2015; 135:1114-24. [PMID: 25956013 DOI: 10.1016/j.jaci.2015.03.025] [Citation(s) in RCA: 181] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 03/25/2015] [Accepted: 03/25/2015] [Indexed: 01/07/2023]
Abstract
Non-IgE-mediated gastrointestinal food-induced allergic disorders (non-IgE-GI-FAs) account for an unknown proportion of food allergies and include food protein-induced enterocolitis syndrome (FPIES), food protein-induced allergic proctocolitis (FPIAP), and food protein-induced enteropathy (FPE). Non-IgE-GI-FAs are separate clinical entities but have many overlapping clinical and histologic features among themselves and with eosinophilic gastroenteropathies. Over the past decade, FPIES has emerged as the most actively studied non-IgE-GI-FA, potentially because of acute and distinct clinical features. FPIAP remains among the common causes of rectal bleeding in infants, while classic infantile FPE is rarely diagnosed. The overall most common allergens are cow's milk and soy; in patients with FPIES, rice and oat are also common. The most prominent clinical features of FPIES are repetitive emesis, pallor, and lethargy; chronic FPIES can lead to failure to thrive. FPIAP manifests with bloody stools in well-appearing young breast-fed or formula-fed infants. Features of FPE are nonbloody diarrhea, malabsorption, protein-losing enteropathy, hypoalbuminemia, and failure to thrive. Non-IgE-GI-FAs have a favorable prognosis; the majority resolve by 1 year in patients with FPIAP, 1 to 3 years in patients with FPE, and 1 to 5 years in patients with FPIES, with significant differences regarding specific foods. There is an urgent need to better define the natural history of FPIES and the pathophysiology of non-IgE-GI-FAs to develop biomarkers and novel therapies.
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Affiliation(s)
- Anna Nowak-Węgrzyn
- Jaffe Food Allergy Institute, Division of Pediatric Allergy, Mount Sinai School of Medicine, New York, NY.
| | - Yitzhak Katz
- Allergy and Immunology Institute, Assaf Harofeh Medical Center, Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sam Soheil Mehr
- Department of Allergy and Immunology, Children's Hospital at Westmead, Westmead, Australia
| | - Sibylle Koletzko
- Division of Gastroenterology and Hepatology, Dr von Hauner Children's Hospital, Ludwig-Maximilians-Universität Munich, Munich, Germany
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Miceli Sopo S, Monaco S, Greco M, Scala G. Chronic food protein-induced enterocolitis syndrome caused by cow's milk proteins passed through breast milk. Int Arch Allergy Immunol 2015; 164:207-9. [PMID: 25034379 DOI: 10.1159/000365104] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 06/02/2014] [Indexed: 11/19/2022] Open
Abstract
We describe 2 cases of food protein-induced enterocolitis syndrome (FPIES) caused by cow's milk (CM) passed through breast milk. The onset in both cases was characterized by chronic symptoms (regurgitation, colic, diarrhea, failure to thrive); in one patient, two acute episodes due to the direct consumption of CM formula by the infant were also reported. The diagnosis of FPIES through breast milk can be easily overlooked, especially in milder cases. We also discuss some important issues concerning the general management of the disease. In conclusion, (1) the diagnosis of chronic FPIES should be taken into account even in exclusively breast-fed infants who present suggestive symptoms such as persistent regurgitation, small amounts of vomiting, lethargy, failure to thrive, dehydration, diarrhea (sometimes bloody) and abdominal distention. A 2-week maternal elimination diet should be considered even in apparently mild cases. (2) CM seems to be the most frequently reported culprit food. (3) In those cases in which acute FPIES is elicited by the direct consumption of the culprit food in breast-fed infants, maternal diet may be unrestricted.
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Affiliation(s)
- Stefano Miceli Sopo
- Department of Pediatrics, Agostino Gemelli Hospital, Catholic University of the Sacred Heart, Rome, Italy
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Abstract
PURPOSE OF REVIEW The article discusses the clinical management of patients affected by food protein-induced enterocolitis syndrome (FPIES), focusing on established therapeutic choices and future options. RECENT FINDINGS After FPIES has been diagnosed and avoidance of the culprit food prescribed, the most important management needs are as follows. First, recurrence of acute FPIES episodes due to accidental ingestion of culprit food. It may be useful to give patients' families an action plan. The principal suggested treatments are intravenous fluids and steroids, whereas the use of epinephrine and ondansetron requires further study. In mild-to-moderate cases, oral rehydration should be sufficient. Second, dietary introduction of at-risk foods. In children with FPIES, in addition to that/those identified as culprit(s), some foods may not be tolerated (typically cow's milk, legumes, cereals, poultry). It has been suggested to avoid introducing these foods during the baby's first year. Otherwise, they may be given for the first time in hospital, performing an oral food challenge. Third, acquisition of tolerance. Children affected by cow's milk-FPIES have a good chance of acquiring tolerance by the time they reach age 18-24 months. For other culprit foods, insufficient data are available to indicate the appropriate time, so that it is suggested that an oral food challenge be performed about 1 year after the last acute episode. SUMMARY Future clinical management of FPIES must take into account, among other factors, improved understanding of pathogenesis, possible detection of different phenotypes, and the introduction of more effective therapies for acute episodes. These factors will undoubtedly influence management decisions, which will become more diversified and effective.
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Miceli Sopo S, Battista A, Greco M, Monaco S. Ondansetron for food protein-induced enterocolitis syndrome. Int Arch Allergy Immunol 2014; 164:137-9. [PMID: 24993542 DOI: 10.1159/000363384] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 05/05/2014] [Indexed: 11/19/2022] Open
Abstract
Recently, a study on 5 patients [Holbrook et al.: J Allergy Clin Immunol 2013;132:1219-1220] documented the efficacy of the intravenous administration of ondansetron in children with acute symptoms due to food protein-induced enterocolitis syndrome (FPIES). We report on the experience at our institution using ondansetron during oral food challenge (OFC) in 5 children affected by FPIES. In all 5 cases, the use of intramuscular ondansetron led to a complete and rapid resolution of symptoms within 15 min. Intramuscular administration, without the need for intravenous access for an infusion or steroid administration, enables this therapy to be easily performed, even at home (i.e. out of a hospital setting). A home treatment with ondansetron cannot be considered as an alternative to a medical examination with eventual treatment in hospital, which is advised after any acute episode of FPIES. We consider ondansetron to be very useful in the management of acute FPIES. Further study is required to confirm its efficacy.
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Affiliation(s)
- Stefano Miceli Sopo
- Department of Pediatrics, Agostino Gemelli Hospital, Catholic University of the Sacred Heart, Rome, Italy
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Järvinen KM, Nowak-Węgrzyn A. Food Protein-Induced Enterocolitis Syndrome (FPIES): Current Management Strategies and Review of the Literature. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2013; 1:317-22. [DOI: 10.1016/j.jaip.2013.04.004] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 04/16/2013] [Accepted: 04/18/2013] [Indexed: 11/25/2022]
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