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Ibrahim T, Argiz L, Infante S, Arasi S, Nurmatov U, Vazquez-Ortiz M. Oral Food Challenge Protocols in Food Protein-Induced Enterocolitis Syndrome: A Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2025; 13:814-832. [PMID: 39746512 DOI: 10.1016/j.jaip.2024.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 12/20/2024] [Accepted: 12/24/2024] [Indexed: 01/04/2025]
Abstract
BACKGROUND Oral food challenges (OFCs) are essential for the diagnosis and follow-up of acute food protein-induced enterocolitis syndrome (FPIES) because no diagnostic or prognostic biomarkers are available. However, the optimal OFC procedure remains unclear. OBJECTIVE This systematic review aimed to assess OFC procedures' design and clinical outcomes in patients with FPIES. METHODS We searched 10 databases for studies published in English between 1978 and February 2024 involving children or adults undergoing OFC for FPIES. Critical appraisal followed Effective Public Health Practice Project parameters. RESULTS In total, 52 studies met inclusion criteria, all observational studies. Of these, 35 were judged to have strong methodological quality. There was great heterogeneity in OFC procedures, particularly in cumulative dose, number, size, and timing between doses. Oral food challenge outcome reporting was often inadequate, especially regarding reaction symptoms and severity grading. In single-dose OFC protocols, most children reacted after at least 2 hours. Four small studies showed that a single dose of 25% of an age-appropriate portion was sufficient to trigger reactions in 80% to 100% of cases, and this was associated with less severe reactions. Owing to methodological heterogeneity and insufficient outcome reporting, further assessment of the OFC protocol characteristics associated with safer outcomes was not possible. CONCLUSIONS There is significant heterogeneity in FPIES OFC practices. Current recommendations for OFC procedures and outcome assessments have limitations and should be revisited, because this may affect patient safety and diagnostic accuracy. Future studies should focus on standardizing clinical outcomes and generating evidence to support safer, more accurate OFC protocols in FPIES.
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Affiliation(s)
- Tayseer Ibrahim
- Allergy and Immunology Division, Department of Medicine, Hamad Medical Corporation, Doha, Qatar.
| | - Laura Argiz
- Department of Allergy, Clínica Universidad de Navarra, Pamplona, Spain; RICORS Red De Enfermedades Inflamatorias (REI)- RD21/0002/0028, Madrid, Spain
| | - Sonsoles Infante
- Pediatric Allergy Unit, Hospital General Universitario Gregorio Marañón, Gregorio Marañón Health Research Institute, IiSGM, Madrid, Spain
| | - Stefania Arasi
- Allergy Unit, Department of Pediatric Medicine, Bambino Gesù Children's Research Hospital, IRCCS, Rome, Italy
| | - Ulugbek Nurmatov
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Marta Vazquez-Ortiz
- Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Gelsomino M, Barni S, Mastellone F, Bersani G, Barbato M, Condemi C, Mori F, Vazquez-Ortiz M, Indirli GC, Miceli Sopo B, Simeone G, Miceli Sopo S. Severity Trend of Recurrence in Pediatric Food Protein-Induced Enterocolitis Syndrome. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2025; 13:842-850. [PMID: 39828136 DOI: 10.1016/j.jaip.2025.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 12/26/2024] [Accepted: 01/08/2025] [Indexed: 01/22/2025]
Abstract
BACKGROUND Reintroduction of the offending food in pediatric patients affected by food protein-induced enterocolitis syndrome (FPIES) is carried out in hospitals with an oral food challenge (OFC), which leads to a long waiting time and increases the societal burden of medical cost and human resources. OBJECTIVE To assess the severity trend of acute FPIES adverse reactions over time in the same patient for possible outpatient or home reintroduction of the offending food. METHODS All children (aged <18 years) with a diagnosis of acute FPIES referred to two Italian pediatric allergy clinics were retrospectively enrolled. To determine whether home or outpatient clinic reintroduction of trigger food was possible, a risk of severe reactions of 5% or less was arbitrarily considered acceptable. RESULTS Of202 patients enrolled, 23 (11.4%) had increasing severity from mild to moderate up to severe episodes. No variables analyzed in these patients (sex, age at onset, and the interval between the first and severe episodes) had a statistically significant influence on the risk of more severe reactions. Of all patients who initially presented with mild or moderate episodes, 15.2% and 13.9% later manifested severe episodes over time, respectively. Of patients with cow's milk FPIES that started with a mild episode, 5.5% later experienced a severe episode. CONCLUSIONS Performing OFC for acute FPIES is not safe enough at home because the probability of severe adverse reaction is greater than 5%. However, it could be considered to perform OFC in an outpatient clinic in patients with cow's milk FPIES who started with a mild episode and if a rapid transfer plan to emergency department is available.
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Affiliation(s)
- Mariannita Gelsomino
- Pediatric Allergy Unit, Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Simona Barni
- Allergy Unit, Anna Meyer Children's Hospital IRCCS, Florence, Italy
| | - Francesco Mastellone
- Pediatric Allergy Unit, Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Giulia Bersani
- Pediatric Allergy Unit, Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Marta Barbato
- Pediatric Allergy Unit, Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Chiara Condemi
- Pediatric Allergy Unit, Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesca Mori
- Allergy Unit, Anna Meyer Children's Hospital IRCCS, Florence, Italy
| | - Marta Vazquez-Ortiz
- Section of Inflammation, Repair, and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | - Bruno Miceli Sopo
- Faculty of Medicine, Catholic University of the Sacred Heart, Largo Agostino Gemelli 8, Rome, Italy
| | | | - Stefano Miceli Sopo
- Pediatric Allergy Unit, Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy.
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Hwang JB, Jang HJ. Saccharomyces boulardii as a single trigger of food protein-induced enterocolitis syndrome: Seven case reports. World J Clin Cases 2025; 13:98111. [PMID: 40012823 PMCID: PMC11612675 DOI: 10.12998/wjcc.v13.i6.98111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 09/12/2024] [Accepted: 11/12/2024] [Indexed: 11/25/2024] Open
Abstract
BACKGROUND Food protein-induced enterocolitis syndrome (FPIES) is the most serious type of non-immunoglobulin E (IgE)-mediated food allergic reaction manifesting as sepsis-like symptom, which can lead to shock. Saccharomyces boulardii (S. boulardii), a probiotic prescribed frequently in clinical settings, has been reported to trigger FPIES in an infant with soy-triggered FPIES. In this report, we describe a new clinical FPIES in which S. boulardii was the sole triggering factor of acute FPIES adverse reaction in seven healthy infants. CASE SUMMARY Seven FPIES cases triggered by only S. boulardii were gathered from 2011 to the present. None of the patients had previously experienced any allergic reaction to cow's milk, soy, or complementary food. The age of the patients was 4-10-months old, and the symptoms of FPIES developed after ingestion of S. boulardii, which is mostly prescribed for the treatment of gastroenteritis or antibiotic-associated diarrhea. All patients experienced severe repetitive vomiting 1-3 hours after S. boulardii ingestion. Extreme lethargy, marked pallor, and cyanosis were also observed. No IgE-mediated hypersensitivity developed in any patient. Diarrhea was followed by initial intense vomiting in approximately 5-10 hours after S. boulardii ingestion, and only one case showed bloody, purulent, and foul-smelling diarrhea. The patients stabilized quickly, mostly within 6 hours. Symptoms got all improved within 24 hours after discontinuation of S. boulardii. CONCLUSION S. boulardii can be the sole trigger of acute FPIES and be prescribed cautiously even in healthy children without FPIES.
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Affiliation(s)
- Jin-Bok Hwang
- Department of Pediatrics, Keimyung University School of Medicine, Dongsan Medical Center, Daegu 42601, South Korea
| | - Hyo-Jeong Jang
- Department of Pediatrics, Keimyung University School of Medicine, Dongsan Medical Center, Daegu 42601, South Korea
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Perriere A, Garcette K, Kalach N, Tounian P, Lemoine A. Food protein induced enterocolitis syndrome: French practices assessment in children. Arch Pediatr 2025; 32:114-119. [PMID: 39875216 DOI: 10.1016/j.arcped.2024.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 09/23/2024] [Accepted: 12/08/2024] [Indexed: 01/30/2025]
Abstract
BACKGROUND Food protein-induced enterocolitis syndrome (FPIES) is a specific non IgE-mediated food allergy. The international consensus guidelines defined diagnosis criteria and management plan in 2017. OBJECTIVES To assess practices regarding FPIES in France and in French-speaking countries, according to those guidelines. METHODS AND SETTING We carried out a 22-question online survey to assess practices of specialised physicians (paediatricians, allergists, gastroenterologists, members of 2 French-speaking learning societies and/or working at hospitals in paediatric allergy units) following patients with FPIES between August 2019 and February 2022. RESULTS We received 92 replies to our survey, mostly from hospital practitioners following less than 10 patients with FPIES. Oral rehydration solution and/or Ondansetron were largely prescribed in the emergency kit (61/72, 84.7 % and 47/72, 65.3 % respectively). 20 practitioners declared never prescribing an emergency kit. There was some confusion when distinguishing between FPIES and an IgE-mediated food allergy, as suggested by the unnecessary prescription of an antihistamine (18/72, 25.0 %) and/or epinephrine (11/72, 15.3 %) in the emergency kit. An explanatory FPIES emergency management letter to physicians in case of allergic reactions was provided in 83.7 % (77/92) of patients. Oral food challenge (OFC) practices varied greatly concerning doses: most respondents used several doses (52/92, 56.5 %) during the same day (33/52, 63.4 %). Eleven responders (12.0 %) used the same protocol as for an IgE-mediated food allergy. CONCLUSION Our survey showed that practices of FPIES management in France are generally aligned with the international consensus guidelines. There are still pending issues to be standardised, such as the emergency kit prescription and its contents, as well as OFC management strategies. This work confirms the need for continuous training of physicians regarding FPIES management. Further guidelines are needed to improve standardisation of FPIES management.
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Affiliation(s)
- Amélie Perriere
- Sorbonne Université, Paediatric Nutrition and Gastroenterology Department, APHP-Trousseau Hospital, 26 avenue du Dr Arnold Netter, 75012 Paris, France.
| | - Karine Garcette
- Sorbonne Université, Paediatric Nutrition and Gastroenterology Department, APHP-Trousseau Hospital, 26 avenue du Dr Arnold Netter, 75012 Paris, France; CMSEA, 11 rue Froment, 75011 Paris, France.
| | - Nicolas Kalach
- Paediatric Department, Saint Antoine Paediatric Clinic, Saint Vincent de Paul Hospital, Catholic University of Lille, boulevard de Belfort, BP 387, 59020 Lille Cedex, France.
| | - Patrick Tounian
- Sorbonne Université, Paediatric Nutrition and Gastroenterology Department, APHP-Trousseau Hospital, 26 avenue du Dr Arnold Netter, 75012 Paris, France.
| | - Anaïs Lemoine
- Sorbonne Université, Paediatric Nutrition and Gastroenterology Department, APHP-Trousseau Hospital, 26 avenue du Dr Arnold Netter, 75012 Paris, France.
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Beaudoin M, Mehra A, Wong LSY, Vazquez-Ortiz M, González-Delgado P, Nowak-Wegrzyn A. An Algorithm for the Diagnosis and Treatment of Food Protein-Induced Enterocolitis Syndrome (FPIES), 2024 Update. Allergy 2025; 80:362-365. [PMID: 39655844 DOI: 10.1111/all.16432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 10/28/2024] [Accepted: 12/01/2024] [Indexed: 01/12/2025]
Affiliation(s)
- Michele Beaudoin
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, New York, USA
| | - Ashna Mehra
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, New York, USA
| | - Lydia Su Yin Wong
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, New York, USA
- Department of Pediatrics, National University of Singapore, Singapore, Singapore
| | | | - Purificación González-Delgado
- Allergy Service, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
- Clinical Medicine Department, University Miguel Hernández, Alicante, Spain
- Allergy Section, Alicante General University Hospital Dr. Balmis, Alicante, Spain
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, New York, USA
- Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
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Sampson HA, Arasi S, Bahnson HT, Ballmer-Weber B, Beyer K, Bindslev-Jensen C, Bird JA, Blumchen K, Davis C, Ebisawa M, Nowak-Wegrzyn A, Patel N, Peters RL, Sicherer S, Spergel J, Turner PJ, Yanagida N, Eigenmann PA. AAAAI-EAACI PRACTALL: Standardizing oral food challenges-2024 Update. Pediatr Allergy Immunol 2024; 35:e14276. [PMID: 39560049 DOI: 10.1111/pai.14276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2024] [Accepted: 10/28/2024] [Indexed: 11/20/2024]
Abstract
This common statement of the American Academy of Allergy, Asthma and Immunology (AAAAI) and The European Academy of Allergy and Clinical Immunology (EAACI) provides an update of the 2012 published guidelines on food challenges. The guidelines equally address food challenges in the research and the clinical settings. They first address the diagnostic tests which can guide the decision to conduct a challenge. Safety of food challenges is prime, and the various procedures and safety issues as well as medications potentially involved in challenges are extensively discussed. Challenges are suggested to be conducted with semi-logarithmic incremental doses based on the protein content, typically for IgE-mediated food allergy with intervals of 20-30 min between doses. Specific protocols for other types of reactions such atopic dermatitis or gastrointestinal food allergy are detailed separately. Proper stopping criteria are essential in order to reduce the risk of false-positive diagnoses, but also severe reactions. The guidelines recommend criteria based on "go on," "stop," or "observation." These revised guidelines will clearly provide much needed guidance for food challenges in the research and clinical settings. They will continue to evolve with new diagnostic tests or new needs in the field of food allergy.
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Affiliation(s)
- Hugh A Sampson
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stefania Arasi
- Translational Research in Pediatric Specialties Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Henry T Bahnson
- The Immune Tolerance Network, Seattle & Benaroya Research Institute at Virginia Mason, Seattle, Washington, USA
| | - Barbara Ballmer-Weber
- Allergy Unit, Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
- Clinic for Dermatology and Allergology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Kirsten Beyer
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Carsten Bindslev-Jensen
- Department of Dermatology and Allergy Centre, Odense Research Centre for Anaphylaxis (ORCA), Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - J Andrew Bird
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Katarina Blumchen
- Division of Pneumology, Allergology and Cystic Fibrosis, Department of Paediatric and Adolescent Medicine, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Carla Davis
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Motohiro Ebisawa
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, NHO Sagamihara National Hospital, Kanagawa, Japan
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, Hassenfeld Children's Hospital, NYU Grossman School of Medicine, New York, New York, USA
- Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Nandinee Patel
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Rachel L Peters
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Scott Sicherer
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Paul J Turner
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Noriyuki Yanagida
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, NHO Sagamihara National Hospital, Kanagawa, Japan
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Gonzalez-Delgado P, Anvari S, Entrala A, Infante S. Medical algorithm: Diagnosis and management of adult food protein-induced enterocolitis syndrome. Allergy 2024; 79:2881-2884. [PMID: 38686652 DOI: 10.1111/all.16142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 04/11/2024] [Accepted: 04/18/2024] [Indexed: 05/02/2024]
Affiliation(s)
- Purificación Gonzalez-Delgado
- Allergy Service, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
- Departamento de Medicina Clínica, Universidad Miguel Hernández, Alicante, Spain
| | - Sara Anvari
- Division of Immunology, Allergy and Retrovirology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
- Texas Children's Hospital, William T. Shearer Center for Human Immunobiology, Houston, Texas, USA
| | - Ana Entrala
- Allergy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Sonsoles Infante
- Allergy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
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Argiz L, Valsami-Fokianos M, Arasi S, Barni S, Boscia S, Bracaglia G, Bracamonte T, Carballeira I, Dinardo G, Echeverria L, Garcia E, Garcia-Magan C, Gomez-Rial J, Gonzalez-Delgado P, Fiocchi A, Garriga T, Ibrahim T, Infante S, Machinena A, Mangone G, Mori F, Moure JD, O'Valle V, Pascal M, Pecora V, Prieto A, Quevedo S, Salas A, Vazquez-Cortes S, Vila L, Martinon-Torres F, Gomez-Carballa A, Boyle RJ, Vazquez-Ortiz M. Clinical-Hematological Changes and Predictors of Severity in Acute Food Protein-Induced Enterocolitis Syndrome Reactions at Oral Food Challenge: A Multicenter Observational Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:2454-2467.e8. [PMID: 38796100 DOI: 10.1016/j.jaip.2024.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 04/26/2024] [Accepted: 05/14/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Oral food challenge (OFC) is the criterion standard for diagnosis of acute food protein-induced enterocolitis syndrome (FPIES). No diagnostic/prognostic biomarkers are available, and OFC assessment criteria are not validated. OBJECTIVE To assess clinical-hematological changes and predictors of severity of FPIES reactions at OFC. METHODS This was an observational multicenter prospective study. Children aged 0 to 18 years diagnosed with acute FPIES were recruited at follow-up OFC in 12 tertiary centers in Spain and Italy. OFC outcomes (as positive/negative/inconclusive and mild/moderate/severe) were assessed on the basis of published "2017 FPIES Consensus" criteria. Clinical characteristics were recorded, and full blood cell count was done at baseline, reaction onset, and 4 hours later. Regression analysis was performed to assess predictors of severe reactions at OFC. RESULTS A total of 81 children had positive OFC (mild in 11% [9 of 81], moderate in 61% [49 of 81], and severe in 28% [23 of 81]). Increase in neutrophils and reduction in eosinophils, basophils, and lymphocytes were observed (P < .05). OFC was inconclusive in 19 cases despite objective signs or neutrophilia. Regression analysis showed that a 2-day OFC protocol where only 25% of an age-appropriate portion is given on day 1 (not sex, age, culprit food, cumulative dose, and previous reaction severity) was associated with reduced odds of severe reaction compared with giving multiple doses in a single day. CONCLUSIONS Distinct hematological changes may help support FPIES diagnosis. Current OFC assessment criteria may not capture the broad spectrum of acute FPIES presentations. This 2-day protocol may be associated with a reduced risk of severe reactions. Future work should aim to develop safer OFC and non-OFC diagnostics for FPIES.
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Affiliation(s)
- L Argiz
- Department of Allergy, Clínica Universidad de Navarra, Pamplona, Spain; RICORS Red De Enfermedades Inflamatorias (REI) - RD21/0002/0028, Madrid, Spain
| | - M Valsami-Fokianos
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - S Arasi
- Allergy Unit, Department of Pediatric Medicine, Bambino Gesù Children's Research Hospital, IRCCS, Rome, Italy
| | - S Barni
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - S Boscia
- Division of Immunology, Meyer Children's Hospital IRCCS, Florence, Italy; Department of Health Sciences, University of Florence, Florence, Italy
| | - G Bracaglia
- Laboratory Medicine, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - T Bracamonte
- Paediatric Allergy Section, Severo Ochoa University Hospital, Madrid, Spain
| | - I Carballeira
- Paediatric Allergy Section, Arquitecto Marcide Hospital, Coruña, Spain
| | - G Dinardo
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - L Echeverria
- Paediatric Allergy Section, Severo Ochoa University Hospital, Madrid, Spain
| | - E Garcia
- Paediatric Allergy Section, Arquitecto Marcide Hospital, Coruña, Spain
| | - C Garcia-Magan
- Paediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Coruña, Spain
| | - J Gomez-Rial
- Genetics, Vaccines and Infections Research Group (GENVIP), Instituto de Investigación Sanitaria de Santiago (IDIS), University of Santiago de Compostela, Santiago de Compostela, Spain
| | | | - A Fiocchi
- Allergy Unit, Department of Pediatric Medicine, Bambino Gesù Children's Research Hospital, IRCCS, Rome, Italy
| | - T Garriga
- Paediatric Allergy Section, Vall D'Hebron University Hospital, Growth and Development Research Group, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - T Ibrahim
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Allergy and Immunology Division, Hamad Medical Corporation, Doha, Qatar
| | - S Infante
- Pediatric Allergy Unit, Hospital General Universitario Gregorio Marañón, Gregorio Marañón Health Research Institute, IiSGM, Madrid, Spain
| | - A Machinena
- Pediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - G Mangone
- Division of Immunology, Meyer Children's Hospital IRCCS, Florence, Italy
| | - F Mori
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - J D Moure
- Paediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Coruña, Spain
| | - V O'Valle
- Paediatric Allergy Section, Severo Ochoa University Hospital, Madrid, Spain
| | - M Pascal
- Immunology Department, CDB, Hospital Clínic de Barcelona, Barcelona, Spain; IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - V Pecora
- Allergy Unit, Department of Pediatric Medicine, Bambino Gesù Children's Research Hospital, IRCCS, Rome, Italy
| | - A Prieto
- Paediatric Allergy Section, General University Hospital, Malaga, Spain
| | - S Quevedo
- Paediatric Allergy Section, Severo Ochoa University Hospital, Madrid, Spain
| | - A Salas
- Genetics, Vaccines and Infections Research Group (GENVIP), Instituto de Investigación Sanitaria de Santiago (IDIS), University of Santiago de Compostela, Santiago de Compostela, Spain; Unidade de Xenética, Instituto de Ciencias Forenses, Facultade de Medicina, Universidade de Santiago de Compostela, and GenPoB Research Group, Instituto de Investigación Sanitaria (IDIS), Hospital Clínico Universitario de Santiago de Compostela (SERGAS), Galicia, Spain
| | | | - L Vila
- Paediatric Allergy Section, Teresa Herrera Hospital, Coruña, Spain
| | - F Martinon-Torres
- Paediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Coruña, Spain; Genetics, Vaccines and Infections Research Group (GENVIP), Instituto de Investigación Sanitaria de Santiago (IDIS), University of Santiago de Compostela, Santiago de Compostela, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - A Gomez-Carballa
- Genetics, Vaccines and Infections Research Group (GENVIP), Instituto de Investigación Sanitaria de Santiago (IDIS), University of Santiago de Compostela, Santiago de Compostela, Spain; Unidade de Xenética, Instituto de Ciencias Forenses, Facultade de Medicina, Universidade de Santiago de Compostela, and GenPoB Research Group, Instituto de Investigación Sanitaria (IDIS), Hospital Clínico Universitario de Santiago de Compostela (SERGAS), Galicia, Spain
| | - R J Boyle
- Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Marta Vazquez-Ortiz
- Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom.
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Haddad C, Banerjee A, Eubanks J, Rana R, Rider NL, Pompeii L, Anvari S. A Second Slice of FPIES: A Single-Center Reappraisal of Pediatric FPIES. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:2118-2126. [PMID: 38685476 DOI: 10.1016/j.jaip.2024.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 04/18/2024] [Accepted: 04/20/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Food protein-induced enterocolitis syndrome (FPIES) is being increasingly recognized as a non-IgE-mediated food allergy; however, it remains unclear if and how the presentation, diagnosis, and management of this disease has changed in recent years. OBJECTIVE To reappraise the FPIES cohort at a large US pediatric tertiary referral center. METHODS We performed a retrospective chart review of pediatric patients with FPIES (International Classification of Diseases, Tenth Revision code K52.21) diagnosed in our allergy/immunology clinics between 2018 and 2022. RESULTS There were 210 children diagnosed with FPIES. Most were White (73.8%), non-Hispanic (71.4%), and male (54.3%) with private insurance (77.6%). Cow's milk was the most common food trigger (35.2%), with the earliest median age of onset of 5 months. The atypical FPIES rate was 13.8%. FPIES was accurately diagnosed in 54.3% at the first medical contact. The oral food challenge pass rate was 73.5%. The rate of trigger resolution at 36 months was 77%. CONCLUSIONS By comparing trends from a previous and current FPIES cohort, we were able to assess the potential impact of various guidelines and practice changes on the diagnosis and management of FPIES at our center. Milk and oat surpassed rice as the most common FPIES triggers; peanut and egg emerged as new FPIES triggers; there was a shorter time to diagnosis and an increased rate of atypical FPIES. Our findings reflect earlier recognition of FPIES and prompt allergy/immunology referral from community physicians, implementation of recent medical society guidelines for infant feeding practices, and growing clinical expertise of allergists at our center.
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Affiliation(s)
- Cynthia Haddad
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas
| | - Ankona Banerjee
- Baylor College of Medicine, Department of Pediatrics, Division of Epidemiology, Houston, Texas
| | - Joshua Eubanks
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas; Baylor College of Medicine, Texas Children's Hospital, Division of Immunology, Allergy and Retrovirology, Houston, Texas
| | - Ruchit Rana
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas; Baylor College of Medicine, Texas Children's Hospital, Division of Immunology, Allergy and Retrovirology, Houston, Texas
| | - Nicholas L Rider
- Liberty University College of Osteopathic Medicine, Department of Pediatrics, Division of Clinical Informatics, Lynchburg, Va
| | - Lisa Pompeii
- Division of Patient Services Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sara Anvari
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas; Baylor College of Medicine, Texas Children's Hospital, Division of Immunology, Allergy and Retrovirology, Houston, Texas; Texas Children's Hospital, William T. Shearer Center for Human Immunobiology, Houston, Texas.
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10
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Ullberg J, Ullberg D, Fech-Bormann M, Fagerberg UL. Resolution of Food Protein-Induced Enterocolitis Syndrome-A Long-Term Follow-Up Study of 113 Swedish Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:2127-2134.e1. [PMID: 38685480 DOI: 10.1016/j.jaip.2024.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 04/17/2024] [Accepted: 04/20/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Food protein-induced enterocolitis syndrome (FPIES), a non-IgE-mediated allergy, primarily affects infants and young children. Whether and when tolerance develops seems to vary among populations and trigger foods. OBJECTIVE This study aimed to evaluate tolerance development and its assessment in a Swedish cohort. METHODS This was a prospective follow-up study of a Swedish cohort of 113 children, followed at 25 pediatric departments, with acute FPIES. Data on oral food challenges and FPIES resolution were collected through chart reviews and, if incomplete, supplemental caregiver interviews. RESULTS The median age at last follow-up was 5.6 years (range: 8.7 months to 16.5 years). Eighty-three children (73%) developed tolerance to 96 of 137 (70%) foods: 93% for cow's milk, 92% for oat, and 46% for fish. The median age when tolerance was developed was 36.0 months (interquartile range: 23.7-48.2 months): 24.4 months for cow's milk, 30.1 months for oat, and 49.4 months for fish. Tolerance was determined in hospital in 45% of cases. Five percent demonstrated allergic sensitization to their FPIES trigger food. Age at tolerance development did not differ between sensitized and nonsensitized patients. CONCLUSIONS Most of the children in this Swedish cohort with FPIES achieved tolerance before age 4 years. Cow's milk- and oat-induced FPIES had similar remission patterns, with early resolution. Development of tolerance to fish occurred significantly later compared with all other FPIES-inducing foods.
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Affiliation(s)
- Josefin Ullberg
- Department of Pediatrics, Västmanland Hospital Västerås, Västerås, Sweden.
| | | | | | - Ulrika L Fagerberg
- Department of Pediatrics, Västmanland Hospital Västerås, Västerås, Sweden; Center for Clinical Research, Västmanland Hospital Västerås, Region Västmanland-Uppsala University, Västerås, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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11
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Gonzalez-Delgado P, Anvari S, Barrachina J, Portillo ALJ, Jimenez T, Marco de la Calle FM, Fernandez J. Egg-induced adult food protein-induced enterocolitis syndrome: Clinical phenotypes, natural history and immunological characteristics. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1657-1659. [PMID: 38462070 DOI: 10.1016/j.jaip.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/03/2024] [Accepted: 03/01/2024] [Indexed: 03/12/2024]
Affiliation(s)
- Purificación Gonzalez-Delgado
- Allergy Service, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain; Clinical Medicine Department, University Miguel Hernández, San Juan, Alicante, Spain.
| | - Sara Anvari
- Department of Pediatrics, Division of Immunology, Allergy and Retrovirology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas; William T. Shearer Center for Human Immunobiology, Texas Children's Hospital, Houston, Texas
| | - Jordi Barrachina
- Clinical Medicine Department, University Miguel Hernández, San Juan, Alicante, Spain
| | - Ana L Jimenez Portillo
- Immunology Service. Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Teodorikez Jimenez
- Allergy Service, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Francisco M Marco de la Calle
- Immunology Service. Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Javier Fernandez
- Allergy Service, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain; Clinical Medicine Department, University Miguel Hernández, San Juan, Alicante, Spain
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12
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Anvari S, Ruffner MA, Nowak-Wegrzyn A. Current and future perspectives on the consensus guideline for food protein-induced enterocolitis syndrome (FPIES). Allergol Int 2024; 73:188-195. [PMID: 38326194 DOI: 10.1016/j.alit.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 01/06/2024] [Indexed: 02/09/2024] Open
Abstract
Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE mediated food allergy presenting with delayed onset of projectile vomiting in the absence of cutaneous and respiratory symptoms. The pathophysiology of FPIES remains poorly characterized. The first international consensus guidelines for FPIES were published in 2017 and provided clinicians with parameters on the diagnosis and treatment of FPIES. The guidelines have served as a resource in the recognition and management of FPIES, contributing to an increased awareness of FPIES. Since then, new evidence has emerged, shedding light on adult-onset FPIES, the different phenotypes of FPIES, the recognition of new food triggers, center-specific food challenge protocols and management of acute FPIES. Emerging evidence indicates that FPIES impacts both pediatric and adult population. As a result, there is growing need to tailor the consensus guidelines to capture diagnoses in both patient groups. Furthermore, it is crucial to provide food challenge protocols that meet the needs of both pediatric and adult FPIES patients, as well as the subset of patients with atypical FPIES. This review highlights the evolving clinical evidence relating to FPIES diagnosis and management published since the 2017 International FPIES Guidelines. We will focus on areas where recent published evidence may support evolution or revision of the guidelines.
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Affiliation(s)
- Sara Anvari
- Division of Immunology, Allergy and Retrovirology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA; William T. Shearer Center for Human Immunobiology, Texas Children's Hospital, Houston, TX, USA
| | - Melanie A Ruffner
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Anna Nowak-Wegrzyn
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, NYU Grossman School of Medicine, New York City, NY, USA; Department of Pediatrics Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland.
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13
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Spergel JM. Rise of gastrointestinal-based food allergy. Ann Allergy Asthma Immunol 2023; 131:692-693. [PMID: 38044019 DOI: 10.1016/j.anai.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 12/05/2023]
Affiliation(s)
- Jonathan M Spergel
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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14
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Patel G, Crain M, Bird JA, Parrish CP. Intravenous access is rarely necessary in food protein-induced enterocolitis syndrome oral food challenges. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3792-3794.e1. [PMID: 37579876 DOI: 10.1016/j.jaip.2023.07.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Gaytri Patel
- Department of Pediatrics, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Maria Crain
- Department of Pediatrics, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Texas; Children's Medical Center Food Allergy Center, Dallas, Texas
| | - J Andrew Bird
- Department of Pediatrics, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Texas; Children's Medical Center Food Allergy Center, Dallas, Texas
| | - Christopher P Parrish
- Department of Pediatrics, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Texas; Children's Medical Center Food Allergy Center, Dallas, Texas.
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15
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Shah S, Grohman R, Nowak-Wegrzyn A. Food protein-induced enterocolitis syndrome (FPIES): Beyond the guidelines. JOURNAL OF FOOD ALLERGY 2023; 5:55-64. [PMID: 39022754 PMCID: PMC11250192 DOI: 10.2500/jfa.2023.5.230014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
Background Food protein-induced enterocolitis syndrome (FPIES) is a non-immunoglobulin E (IgE) cell mediated food allergy that can cause severe symptoms and is considered an allergic emergency. Objective To describe FPIES epidemiology and appraise the approach to diagnosis and management. Methods A review of the relevant articles published in the peer-reviewed journals since the publication of the First International FPIES Consensus Guidelines in 2017. Results FPIES is estimated to affect 0.51-0.9% of children and 0.22% of adults in the United States. It typically presents with protracted, projectile vomiting, which occurs within 1-4 hours of ingesting culprit foods, sometimes followed by diarrhea within 24 hours of ingestion. In ∼15-20% of severe cases, patients go into hypovolemic or distributive shock. In chronic FPIES, infants may have failure to thrive and weight loss. The most common triggers include cow's milk, oat, rice, and avocado, with egg and peanut being more frequently reported. Examples of other common fruit and vegetable triggers include banana, apple, and sweet potato. FPIES can be classified into acute, chronic, adult-onset, or atypical subtypes. FPIES is associated with comorbid atopic conditions of IgE-mediated food allergy, atopic dermatitis, asthma, allergic rhinitis, and eosinophilic esophagitis. The natural history of infantile FPIES is generally favorable, with the exception of fish FPIES. Seafood FPIES in adults has low rates of resolution over 3-5 years. Correctly identifying FPIES can be challenging because there are no specific biomarkers for diagnosis and the constellation of symptoms may mimic those of infectious enteritis or sepsis. Management relies on dietary food avoidance, periodic re-evaluations for tolerance with oral food challenges, and management of acute reactions with rehydration and antiemetic ondansetron. Although the pathophysiology of FPIES remains poorly understood, underlying mechanisms such as cytokine release, leukocyte activation, and impaired gastrointestinal mucosal barrier function may act as cornerstones for further research. Conclusion Prevention, laboratory diagnostic testing, and strategies to accelerate tolerance development are urgent unmet needs in FPIES.
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Affiliation(s)
- Sohini Shah
- Department of Pediatrics, Hassenfield Children’s Hospital, Children’s Hospital at Montefiore/Montefiore Medical Center, Bronx, New York
| | - Rebecca Grohman
- Department of Pediatrics, Hassenfield Children’s Hospital, Children’s Hospital at Montefiore/Montefiore Medical Center, Bronx, New York
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, NYU Grossman School of Medicine, New York, New York, and
- Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
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16
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Mulé A, Prattico C, Al Ali A, Mulé P, Ben-Shoshan M. Diagnostic and Management Strategies of Food Protein-Induced Enterocolitis Syndrome: Current Perspectives. Pediatric Health Med Ther 2023; 14:337-345. [PMID: 37901587 PMCID: PMC10612481 DOI: 10.2147/phmt.s404779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/13/2023] [Indexed: 10/31/2023] Open
Abstract
Food protein-induced enterocolitis syndrome (FPIES) is a form of non-IgE mediated food allergy that presents with delayed gastrointestinal symptoms after ingestion of the trigger food. The data regarding FPIES are sparse, despite being recognized as a distinct clinical entity. This narrative review presents the characteristics of this disorder in the pediatric population, as well-standard diagnostic and management protocols. FPIES can be classified into acute and chronic subtypes, and some cases may develop into an IgE-mediated allergy. Given that skin prick tests and specific IgE levels are negative in the majority of cases, diagnosis relies on clinical history and oral food challenges. Management involves elimination diets, assessment of tolerance through oral food challenges, and rehydration in the event of a reaction. Future research should focus on improving diagnostic methods, illustrating underlying pathogenesis and biomarkers, and assessing long-term natural history. Increased knowledge and awareness for FPIES are required.
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Affiliation(s)
- Angela Mulé
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Catherine Prattico
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Adnan Al Ali
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Pasquale Mulé
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Moshe Ben-Shoshan
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, QC, Canada
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17
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Mediterranean Milk Ladder: Integrating a Healthy Eating Plan While Reintroducing Cow's Milk. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020234. [PMID: 36832362 PMCID: PMC9954599 DOI: 10.3390/children10020234] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/21/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023]
Abstract
The process of gradually reintroducing food allergens into an individual's diet is referred to as a food allergen "ladder", and the most recent edition of the original Milk Allergy in Primary (MAP) Care Guidelines, as well as the International Milk Allergy in Primary Care (IMAP), includes a shortened, improved, and international version with specific recipes, indicating the exact milk protein content, as well as the duration of heating and the temperature for each step of the ladder. Food allergen ladders are being used increasingly in clinical practice. The aim of this study was to develop a Mediterranean milk ladder based on the principles of the Mediterranean eating pattern. The protein content delivered in a portion of the final food product in each step of the ladder in the Mediterranean version corresponds to that provided in the IMAP ladder. Different recipes for the various steps were provided to increase acceptability and variety. Quantification of the total milk protein, casein content, and beta-lactoglobulin by Enzyme-linked immunosorbent assay (ELISA) could detect the gradual increase in concentrations, but the accuracy of the method was affected by the presence of the other ingredients in the mixtures. When developing the Mediterranean milk ladder, a key consideration was to reduce the amount of sugar by using limited amounts of brown sugar and substituting sugar with fresh fruit juice or honey for children aged older than one year. The proposed Mediterranean milk ladder includes principles of (a) healthy eating based on the Mediterranean diet and (b) the acceptability of foods across different age groups.
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18
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Crespo J, Pérez-Pallise ME, Skrabski F, Zambrano G, Rojas-Pérez-Ezquerra P, Noguerado-Mellado B, Zubeldia JM, Infante S. The Natural Course of Adult-Onset Food Protein-Induced Enterocolitis Syndrome. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2986-2992. [PMID: 35753669 DOI: 10.1016/j.jaip.2022.06.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 05/14/2022] [Accepted: 06/07/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Adult-onset food protein-induced enterocolitis syndrome (FPIES) has been increasingly recognized in recent years. Adult FPIES differs from pediatric FPIES in terms of dietary triggers and symptoms, thus further broadening the clinical phenotypes of the disease. The natural history of FPIES in adulthood is poorly characterized. OBJECTIVE To evaluate the natural course of FPIES in adults. METHODS We performed an ambispective study of adults diagnosed with acute FPIES during 2016-2021. Data on age, sex, symptoms, implicated food, and oral food challenge (OFC) outcomes at baseline and during follow-up were analyzed. RESULTS Forty-two adults were included (83.3% female; median age at diagnosis, 40 years). The predominant symptoms were diarrhea (92.9%) and abdominal cramps (71.4%); vomiting was reported by 59% of patients. The most common triggers were shellfish (n = 19, 45.2%) and fish (n = 19, 45.2%). The mean number of reactions before diagnosis was 6.3 (2-15). Twenty-one OFCs were carried out with the offending food in 15 patients. Six patients achieved tolerance (40%) after a mean of 17.8 months (range, 6-36 months). Twelve of all OFCs performed were positive (57.1%). The absolute leukocyte and neutrophil counts measured before and 1 to 2 hours after the positive challenge showed a mean increase of 3045 and 2736 cells/μL, respectively. Serum tryptase, C-reactive protein, and eosinophil and platelet values did not change significantly after the OFC. CONCLUSION Some patients may outgrow adult-onset FPIES.
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Affiliation(s)
- Jimena Crespo
- Allergy Department, Clínica Universidad de Navarra, Madrid, Spain; Universidad de Alcalá, Madrid, Spain
| | - María Esperanza Pérez-Pallise
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IiGSM), Madrid, Spain
| | - Filip Skrabski
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IiGSM), Madrid, Spain
| | - Gabriela Zambrano
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IiGSM), Madrid, Spain
| | - Patricia Rojas-Pérez-Ezquerra
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IiGSM), Madrid, Spain
| | - Blanca Noguerado-Mellado
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IiGSM), Madrid, Spain
| | - José Manuel Zubeldia
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IiGSM), Madrid, Spain; Biomedical Research Network on Rare Diseases (CIBERER)-U761, Madrid, Spain
| | - Sonsoles Infante
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IiGSM), Madrid, Spain.
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Feketea G, Vassilopoulou E, Geropanta F, Berghea EC, Bocsan IC. Alternative Fish Species for Nutritional Management of Children with Fish-FPIES—A Clinical Approach. Nutrients 2021; 14:nu14010019. [PMID: 35010894 PMCID: PMC8746553 DOI: 10.3390/nu14010019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 12/16/2021] [Accepted: 12/20/2021] [Indexed: 12/25/2022] Open
Abstract
In the Mediterranean region, fish is a common cause of food protein-induced enterocolitis syndrome (FPIES) in children. No laboratory tests specific to FPIES are available, and oral food challenge (OFC) is the gold standard for its diagnosis and testing for achievement of tolerance. Children with FPIES to fish are usually advised to avoid all fish, regardless of the species. Fish are typically classified into bony and cartilaginous, which are phylogenetically distant species and therefore contain less cross-reacting allergens. The protein β-parvalbumin, considered a pan-allergenic, is found in bony fish, while the non-allergenic α-parvalbumin is commonly found in cartilaginous fish. Based on this difference, as a first step in the therapeutic process of children with FPIES caused by a certain fish in the bony fish category (i.e., hake, cod, perch, sardine, gilthead sea bream, red mullet, sole, megrim, sea bass, anchovy, tuna, swordfish, trout, etc.), an OFC to an alternative from the category of cartilaginous fish is suggested (i.e., blue shark, tope shark, dogfish, monkfish, skate, and ray) and vice versa. Regarding the increased mercury content in some sharks and other large species, the maximum limit imposed by the European Food Safety Authority (EFSA) for weekly mercury intake must be considered. An algorithm for the management of fish-FPIES, including alternative fish species, is proposed.
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Affiliation(s)
- Gavriela Feketea
- PhD School, Iuliu Hatieganu University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania;
- Department of Pediatrics, Amaliada Hospital, 27200 Amaliada, Greece
- Department of Pediatrics, Karamandaneio Children’s Hospital, 26331 Patras, Greece
| | - Emilia Vassilopoulou
- Department of Nutritional Sciences and Dietetics, International Hellenic University, 57400 Thessaloniki, Greece;
| | | | - Elena Camelia Berghea
- Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Pediatrics, “Marie S. Curie” Emergency Children’s Clinical Hospital, 041451 Bucharest, Romania
- Correspondence:
| | - Ioana Corina Bocsan
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Iuliu Haţieganu University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania;
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Zubeldia-Varela E, Barker-Tejeda TC, Blanco-Pérez F, Infante S, Zubeldia JM, Pérez-Gordo M. Non-IgE-Mediated Gastrointestinal Food Protein-Induced Allergic Disorders. Clinical Perspectives and Analytical Approaches. Foods 2021; 10:foods10112662. [PMID: 34828942 PMCID: PMC8623505 DOI: 10.3390/foods10112662] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 10/27/2021] [Indexed: 12/21/2022] Open
Abstract
Non-IgE-mediated gastrointestinal food allergy (non-IgE-GI-FA) is the name given to a series of pathologies whose main entities are food protein-induced allergic proctocolitis (FPIAP), food protein-induced enteropathy (FPE), and food protein-induced enterocolitis syndrome (FPIES). These are more uncommon than IgE-mediated food allergies, their mechanisms remain largely unknown, and their diagnosis is mainly done by clinical history, due to the lack of specific biomarkers. In this review, we present the latest advances found in the literature about clinical aspects, the current diagnosis, and treatment options of non-IgE-GI-FAs. We discuss the use of animal models, the analysis of gut microbiota, omics techniques, and fecal proteins with a focus on understanding the pathophysiological mechanisms of these pathologies and obtaining possible diagnostic and/or prognostic biomarkers. Finally, we discuss the unmet needs that researchers should tackle to advance in the knowledge of these barely explored pathologies.
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Affiliation(s)
- Elisa Zubeldia-Varela
- Department of Basic Medical Sciences, Facultad de Medicina, Institute of Applied Molecular Medicine (IMMA), Universidad San Pablo-CEU, CEU Universities, ARADyAL, 28660 Madrid, Spain; (E.Z.-V.); (T.C.B.-T.)
- Centre for Metabolomics and Bioanalysis (CEMBIO), Department of Chemistry and Biochemistry, Facultad de Farmacia, Universidad San Pablo-CEU, CEU Universities, Urbanización Montepríncipe, Boadilla del Monte, 28660 Madrid, Spain
| | - Tomás Clive Barker-Tejeda
- Department of Basic Medical Sciences, Facultad de Medicina, Institute of Applied Molecular Medicine (IMMA), Universidad San Pablo-CEU, CEU Universities, ARADyAL, 28660 Madrid, Spain; (E.Z.-V.); (T.C.B.-T.)
- Centre for Metabolomics and Bioanalysis (CEMBIO), Department of Chemistry and Biochemistry, Facultad de Farmacia, Universidad San Pablo-CEU, CEU Universities, Urbanización Montepríncipe, Boadilla del Monte, 28660 Madrid, Spain
| | - Frank Blanco-Pérez
- VPr1 Research Group “Molecular Allergology”, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany;
| | - Sonsoles Infante
- Allergy Paediatric Unit, Allergy Service, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (S.I.); (J.M.Z.)
- Gregorio Marañón Health Research Institute (IiSGM), 28007 Madrid, Spain
| | - José M. Zubeldia
- Allergy Paediatric Unit, Allergy Service, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (S.I.); (J.M.Z.)
- Gregorio Marañón Health Research Institute (IiSGM), 28007 Madrid, Spain
- Rare Diseases Networking Biomedical Research Centre (CIBERER, U-761), Carlos III Institute of Health, 28029 Madrid, Spain
| | - Marina Pérez-Gordo
- Department of Basic Medical Sciences, Facultad de Medicina, Institute of Applied Molecular Medicine (IMMA), Universidad San Pablo-CEU, CEU Universities, ARADyAL, 28660 Madrid, Spain; (E.Z.-V.); (T.C.B.-T.)
- Correspondence: ; Tel.: +34-91-372-4700 (ext. 14675)
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Barni S, Giovannini M, Liccioli G, Sarti L, Mori F. Comments on Miceli Sopo et al. Pediatr Allergy Immunol 2021; 32:1588-1589. [PMID: 34021918 DOI: 10.1111/pai.13563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 05/17/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Simona Barni
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Giulia Liccioli
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Lucrezia Sarti
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
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Trogen B, Nowak-Wegrzyn A. Food protein-induced enterocolitis syndrome: Up close and personal. Ann Allergy Asthma Immunol 2021; 126:447-448. [PMID: 33941314 DOI: 10.1016/j.anai.2021.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 03/18/2021] [Indexed: 12/14/2022]
Affiliation(s)
- Brit Trogen
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, New York
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, New York; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland.
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Groetch M, Baker MG, Durban R, Meyer R, Venter C, Muraro A. The practical dietary management of food protein-induced enterocolitis syndrome. Ann Allergy Asthma Immunol 2021; 127:28-35. [PMID: 33757808 DOI: 10.1016/j.anai.2021.03.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 03/03/2021] [Accepted: 03/16/2021] [Indexed: 12/13/2022]
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.
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Affiliation(s)
- Marion Groetch
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Mary Grace Baker
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Raquel Durban
- Asthma & Allergy Specialists, Charlotte, North Carolina
| | - Rosan Meyer
- Department of Paediatrics, Imperial College London, London, United Kingdom
| | - Carina Venter
- Section of Pediatric Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Antonella Muraro
- Food Allergy Referral Centre, Department of Woman and Child Health, Padua University Hospital, Padua, Italy
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