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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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2
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Akashi M, Kaburagi S, Kajita N, Morita H. Heterogeneity of food protein-induced enterocolitis syndrome (FPIES). Allergol Int 2024; 73:196-205. [PMID: 38553113 DOI: 10.1016/j.alit.2024.02.001] [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: 02/06/2024] [Accepted: 02/13/2024] [Indexed: 04/02/2024] Open
Abstract
Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food allergy with gastrointestinal symptoms such as vomiting and diarrhea. The development of international consensus guidelines for the diagnosis and management of FPIES in 2017 enabled us to compare patients worldwide, regardless of geographic variation in disease features. As a result, it has become clear that there is heterogeneity among patients with FPIES or that there are cases that partly fit the diagnostic criteria for FPIES but have different characteristics. This review highlights the heterogeneity in FPIES characteristics in terms of trigger foods, the age of onset, differences in geographic regions, and symptoms; it further proposes four disease entities, including acute FPIES in children, acute FPIES in adults, chronic FPIES, and early-onset neonatal FPIES, depending on the age of onset and presumed pathophysiology. The major symptoms at onset and trigger foods differ in acute FPIES in children, acute FPIES in adults, and chronic FPIES, whereas the disease entities may share a similar pathophysiology. Early-onset neonatal FPIES may have a different pathophysiology than acute or chronic FPIES, and may not necessarily fulfil the full diagnostic criteria for acute or chronic FPIES described in the international consensus guidelines. Due to the similarity in symptoms, early-onset neonatal FPIES may sometimes be misdiagnosed as necrotizing enterocolitis. We aim to increase awareness of FPIES among medical staff in pediatrics, neonatology, and internal medicine and promote research, to gain a better understanding of the heterogeneity and pathophysiology of FPIES.
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Affiliation(s)
- Masayuki Akashi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Sachiko Kaburagi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Kajita
- Department of Allergy, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hideaki Morita
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, Tokyo, Japan; Allergy Center, National Center for Child Health and Development, Tokyo, Japan.
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3
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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: 0] [Impact Index Per Article: 0] [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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4
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Ye L, Wong T, Lavine E, Cook VE, Erdle SC. Using the canadian egg ladder in children with food protein-induced enterocolitis syndrome: a case series. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2023; 19:87. [PMID: 37803461 PMCID: PMC10557249 DOI: 10.1186/s13223-023-00843-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/15/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Current management of food protein-induced enterocolitis syndrome (FPIES) involves strict avoidance of the offending food for 12-18 months, followed by oral food challenge (OFC) under physician supervision. OFCs are resource-intensive and there is a lack of a universal standardized protocol for FPIES. Prolonged avoidance may increase the risk of IgE-mediated allergy, particularly in atopic patients. Food ladders have shown success in promoting accelerated tolerance in patients with IgE-mediated allergy. Our case series evaluated the safety of use of the Canadian Egg Ladder in patients with mild-to-moderate FPIES to egg. METHODS From May 2020 to November 2021, patients with mild-to-moderate FPIES to egg, defined as no history of lethargy or intravenous fluid administration, were started on the Canadian Egg Ladder. Instructions for advancing up the ladder were identical to using the Canadian Egg Ladder in patients with IgE-mediated allergy. Patients were followed every 3-6 months, at which time information was collected regarding progression up the ladder, symptoms while on treatment and interventions required. Treating allergists completed a survey to capture baseline demographic characteristics and prior tolerance to egg. Descriptive statistics were analyzed using MS Excel. RESULTS Twenty-one patients with mild-to-moderate FPIES were started on the Canadian Egg Ladder. Median age at initiation of the ladder was 10 months (IQR, 9-11). Nineteen (90.5%) patients completed the ladder, tolerating a serving size amount of cooked egg, over a median duration of 7 month (IQR, 4-9 months). Four patients (19.0%) had mild symptoms including vomiting (9.5%), pallor (9.5%), belching (4.8%), irritability (4.8%) and small spit up (4.8%). In three of the four patients, symptoms were the result of accidental exposure to a higher step of the ladder. There were no reports of lethargy. No patients required health care presentation or intravenous fluid administration. No patients discontinued the ladder. CONCLUSIONS The Canadian Egg Ladder can safely guide the dietary advancement of egg-containing foods in patients with mild-to-moderate FPIES to egg, without the need for prolonged avoidance and resource-intensive OFCs.
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Affiliation(s)
- Linlei Ye
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.
| | - Tiffany Wong
- Division of Allergy, BC Children's Hospital, Vancouver, BC, Canada
| | - Elana Lavine
- Department of Pediatrics, University of Toronto, Humber River Hospital, Toronto, ON, Canada
| | - Victoria E Cook
- Division of Allergy, BC Children's Hospital, Vancouver, BC, Canada
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5
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McIntyre A, Baker MG, Singh AM. Reply to "Recurrences in food protein-induced enterocolitis syndrome: Let's get the label right". THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3283-3284. [PMID: 37805229 DOI: 10.1016/j.jaip.2023.06.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 06/20/2023] [Indexed: 10/09/2023]
Affiliation(s)
- Amanda McIntyre
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Mary Grace Baker
- Elliot and Roslyn Jaffe Food Allergy Institute, Division of Pediatric Allergy & Immunology, Kravis Children's Hospital, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Anne Marie Singh
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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Vazquez-Ortiz M, Argiz L, Infante S, Barni S, Boyle RJ. Recurrences in food protein-induced enterocolitis syndrome: Let's get the label right. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3282. [PMID: 37805228 DOI: 10.1016/j.jaip.2023.05.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/08/2023] [Accepted: 05/11/2023] [Indexed: 10/09/2023]
Affiliation(s)
- Marta Vazquez-Ortiz
- Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom.
| | - Laura Argiz
- Allergy Section, Clinica Universidad de Navarra, Madrid, Spain
| | - Sonsoles Infante
- Paediatric Allergy Unit, Hospital General Universitario Gregorio Marañón, Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
| | - Simona Barni
- Paediatric Allergy Department, Anna Meyer Children's Hospital, Florence, Italy
| | - Robert J Boyle
- Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Patel N, Shreffler WG, Custovic A, Santos AF. Will Oral Food Challenges Still Be Part of Allergy Care in 10 Years' Time? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:988-996. [PMID: 36822320 PMCID: PMC10698627 DOI: 10.1016/j.jaip.2023.02.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/05/2023] [Accepted: 02/05/2023] [Indexed: 02/24/2023]
Abstract
Oral food challenges (OFCs) are currently the definitive diagnostic procedure in food allergy. Their design has evolved over the decades to maximize safety, optimize convenience, and address several specific clinical questions. However, they are a resource-intensive investigation that carry a risk for severe allergic reaction in which fatal outcomes, although rare, have been reported. In this review, we explore the many roles that OFC fulfil in the clinical and research settings. We also discuss progress that has been made in developing alternative diagnostic tools and how far these have reached in offering a viable replacement to OFC in clinical practice. Finally, we discuss the ongoing importance of research OFC to improve the future diagnostic capabilities of novel diagnostic tools.
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Affiliation(s)
- Nandinee Patel
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Wayne G Shreffler
- Food Allergy Center and Center for Immunology and Inflammatory Disease, Massachusetts General Hospital/Harvard Medical School, Boston, Mass
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Alexandra F Santos
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom; Children's Allergy Service, Evelina London, Guy's and St Thomas' Hospital, London, United Kingdom.
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8
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Jacobs S, Trogen B, Nowak-Wegrzyn A. Recurrence of Food Protein-Induced Enterocolitis Syndrome (FPIES) Following a Food Challenge. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:326-328. [PMID: 36610758 DOI: 10.1016/j.jaip.2022.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 01/06/2023]
Affiliation(s)
- Samantha Jacobs
- Department of Pediatrics, NYU Grossman School of Medicine, New York, NY
| | - Brit Trogen
- Allergy and Immunology, Department of Medicine, Icahn School of Medicine, New York, NY
| | - Anna Nowak-Wegrzyn
- Allergy and Immunology, Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, NY; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland.
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9
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Baker MG, Sampson HA. Recent trends in food protein-induced enterocolitis syndrome (FPIES). J Allergy Clin Immunol 2023; 151:43-46. [PMID: 36608982 DOI: 10.1016/j.jaci.2022.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/27/2022] [Accepted: 11/08/2022] [Indexed: 01/05/2023]
Abstract
Food protein-induced enterocolitis syndrome (FPIES) was first described in detail in the late 20th century as a non-IgE-mediated food allergy characterized by delayed gastrointestinal symptoms after ingestion of a trigger food. Although the initial case series reported infants reacting to cow's milk- and soy-based formulas, we now recognize that FPIES affects patients across the age spectrum. This brief review highlights our evolving understanding of FPIES with a discussion of triggers, epidemiology, food challenges, and pathophysiology.
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Affiliation(s)
- Mary Grace Baker
- Elliot and Roslyn Jaffe Food Allergy Institute, Division of Pediatric Allergy & Immunology, Kravis Children's Hospital, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Hugh A Sampson
- Elliot and Roslyn Jaffe Food Allergy Institute, Division of Pediatric Allergy & Immunology, Kravis Children's Hospital, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
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Mathew M, Leeds S, Nowak-Węgrzyn A. Recent Update in Food Protein-Induced Enterocolitis Syndrome: Pathophysiology, Diagnosis, and Management. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2022; 14:587-603. [PMID: 36426394 PMCID: PMC9709682 DOI: 10.4168/aair.2022.14.6.587] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/29/2022] [Accepted: 10/07/2022] [Indexed: 11/26/2022]
Abstract
Food protein-induced enterocolitis syndrome (FPIES), though first reported in the 1970s, remains poorly understood and likely underdiagnosed. It is a non-immunoglobulin E (IgE)-mediated food allergy syndrome, most commonly identified in infancy and childhood. It can manifest as a constellation of symptoms following food ingestion, including repetitive and projectile emesis (1-4 hours), accompanied by pallor, lethargy, muscular hypotonia, and diarrhea (5-10 hours). In more severe reactions, significant leukocytosis with neutrophilia, thrombocytosis, metabolic derangements, methemoglobinemia, anemia, low albumin, and total protein may be present. Hypotension and ultimately hypovolemic distributive shock may occur in up to 15%-20% of cases. The diagnosis of FPIES is challenging and providers continue to face difficulties in management. This review article aims to highlight the most recent updates in epidemiology, natural history, pathophysiology, potential diagnostic markers, and guidelines for the management of FPIES.
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Affiliation(s)
- Mehr Mathew
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Stephanie Leeds
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Anna Nowak-Węgrzyn
- Department of Pediatrics, Hassenfeld Children's Hospital, NYU Grossman School of Medicine, New York, NY, USA
- Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland.
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Hayano S, Natsume O, Yasuoka R, Katoh Y, Koda M. Predictors of initial oral food challenge outcome in food protein-induced enterocolitis syndrome. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2022; 1:122-127. [PMID: 37781265 PMCID: PMC10509941 DOI: 10.1016/j.jacig.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 04/12/2022] [Accepted: 05/09/2022] [Indexed: 10/03/2023]
Abstract
Background There is a paucity of data on predictors of clinical history in oral food challenge (OFC) outcome for the initial diagnosis of food protein-induced enterocolitis syndrome (FPIES). Objective This study aimed to identify predictors for the diagnosis of FPIES. Methods The study included patients who underwent OFC to diagnose FPIES from 2010 to 2021. Patients with a positive OFC result were classified as belonging to the FPIES group, and those with negative OFC result within 120 days from the last symptomatic episode were classified as belonging to the no-allergy (NA) group. Background factors were analyzed in the groups. Results A total of 50 OFCs to 12 different foods were conducted in 50 patients. Of those 50 patients, 30 were classified as belonging to the FPIES group. No significant difference was observed between the FPIES and NA groups with respect to background factors, including the features of symptomatic episodes and examinations of immediate-type allergy. A history of asymptomatic ingestion was observed in 23 of 24 and 13 of 19 patients in the FPIES and NA groups, respectively; thus, it was significantly more common in patients with FPIES. The diagnostic rate of patients with fewer than 3 symptomatic episodes was 52%, and that of patients with 3 episodes or more was 75%, not considering a patient without available data. Conclusions A definite diagnosis of FPIES should be based on OFC, as there are no predictors for OFC positivity other than a history of asymptomatic ingestion. The absence of asymptomatic ingestion history was a negative predictor for the diagnosis of FPIES.
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Affiliation(s)
- Satoshi Hayano
- Allergic Disease Research Center, Chutoen General Medical Center, Kakegawa, Japan
- Department of Pediatrics, Chutoen General Medical Center, Kakegawa, Japan
| | - Osamu Natsume
- Department of Pediatrics, Chutoen General Medical Center, Kakegawa, Japan
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu City, Japan
- Department of Pediatrics, Public Morimachi Hospital, Morimachi, Japan
| | - Ryuhei Yasuoka
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu City, Japan
| | - Yukiko Katoh
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu City, Japan
| | - Masaki Koda
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu City, Japan
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12
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Baker MG, Cecilia Berin M, Sicherer S. Update on Food Protein-Induced Enterocolitis Syndrome (FPIES). Curr Allergy Asthma Rep 2022; 22:113-122. [PMID: 35522370 DOI: 10.1007/s11882-022-01037-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food allergy characterized by delayed, and potentially severe, gastrointestinal symptoms. Since the advent of a specific diagnostic code and establishment of diagnostic guidelines, our understanding of this condition has grown. RECENT FINDINGS FPIES affects patients from early infancy into adulthood. Any food can be a trigger, and common culprit foods vary geographically and by age. An understanding of the complex underlying immune mechanisms remains elusive, although studies show pan-leukocyte activation, cytokine release, and increased gastrointestinal permeability. Management involves trigger avoidance, and patients may benefit from the support of a dietitian to ensure adequate nutrient intake. Tolerance develops over time for most children, but due to the risk of severe symptoms, re-introduction of a suspected FPIES trigger is recommended only under supervision at an oral food challenge. Studies continue to evaluate the optimal challenge protocol. Caregivers of children with FPIES report high levels of anxiety and stress, which is attributed to the dramatic symptomatology, dietary restrictions, nutritional concerns, lack of confirmatory diagnostic tests, and limited tools for management of reactions. Our understanding of the FPIES diagnosis has improved over the last few decades, but there remain opportunities, particularly regarding discerning the pathophysiology and best management practices.
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Affiliation(s)
- Mary Grace Baker
- Icahn School of Medicine at Mount Sinai, Department of Pediatrics, Division of Allergy and Immunology, Kravis Children's Hospital, The Elliot and Roslyn Jaffe Food Allergy Institute, One Gustave L. Levy Place, Box 1198, New York, NY, 10029, USA.
| | - M Cecilia Berin
- Icahn School of Medicine at Mount Sinai, Department of Pediatrics, Division of Allergy and Immunology, Kravis Children's Hospital, The Elliot and Roslyn Jaffe Food Allergy Institute, One Gustave L. Levy Place, Box 1198, New York, NY, 10029, USA
| | - Scott Sicherer
- Icahn School of Medicine at Mount Sinai, Department of Pediatrics, Division of Allergy and Immunology, Kravis Children's Hospital, The Elliot and Roslyn Jaffe Food Allergy Institute, One Gustave L. Levy Place, Box 1198, New York, NY, 10029, USA
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13
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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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14
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Nicolaides R, Bird JA, Cianferoni A, Brown-Whitehorn T, Nowak-Wegrzyn A. Oral Food Challenge for FPIES in Practice-A Survey: Report from the Work Group on FPIES Within the Adverse Reactions to Foods Committee, FAED IS, AAAAI. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3608-3614.e1. [PMID: 34483087 DOI: 10.1016/j.jaip.2021.06.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/11/2021] [Accepted: 06/25/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food allergy diagnosed via history and/or an oral food challenge (OFC). OBJECTIVE To determine allergists' approach to FPIES OFCs. METHODS A web-based survey was e-mailed to 1100 randomly selected American Academy of Allergy, Asthma and Immunology members. RESULTS A total of 132 individuals responded (12% response rate). A total of 95.5% (n = 105) of respondents perform OFCs in their practice, but only 58.7% (n = 71) perform FPIES OFCs. The median number of FPIES OFCs in children was reported as 3 per year (range, 0-76); all but 1 respondent (2.5%) had not performed any FPIES OFCs in adults. The most common FPIES OFC foods were cow's milk, rice, lightly cooked egg, oat, soy, baked milk, and baked egg. The decision to offer FPIES OFCs was based on the severity of past reactions, the patient and family's desire, and the patient's age. FPIES OFCs were most commonly performed in an outpatient setting, with placement of peripheral intravenous access depending on the severity of past reactions and with a serving appropriate for age divided into 3 equal portions administered over 30 minutes. There was significant variability in the approach to conducting FPIES OFCs. Most respondents (87.4%, n = 127) indicated that specific guidelines for performing FPIES OFCs would be helpful. CONCLUSIONS Our study highlights the discordance in allergists' practices performing OFCs for IgE-mediated food allergy compared with FPIES. The lack of universal agreement on the optimal way to perform OFCs in FPIES demonstrates the need for future studies to develop a standardized protocol for FPIES OFCs.
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Affiliation(s)
- Rory Nicolaides
- Department of Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - J Andrew Bird
- Department of Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - Antonella Cianferoni
- Children's Hospital of Philadelphia, University of Pennsylvania Medical School, Philadelphia, Pa
| | - Terri Brown-Whitehorn
- Children's Hospital of Philadelphia, University of Pennsylvania Medical School, Philadelphia, Pa
| | - Anna Nowak-Wegrzyn
- Allergy and Immunology, Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, NY; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland.
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15
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Miceli Sopo S, Sinatti D, Gelsomino M. Retrospective analysis of 222 oral food challenges with a single dose in acute food protein-induced enterocolitis syndrome. Pediatr Allergy Immunol 2021; 32:1066-1072. [PMID: 33621373 DOI: 10.1111/pai.13489] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/16/2021] [Accepted: 02/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The method of performing oral food challenge (OFC) in acute food protein-induced enterocolitis syndrome (FPIES) has not been systematically studied. Therefore, there is a certain variability in the choice of the various centers. METHODS Since 2011, we have been performing OFC for acute FPIES with a single dose of culprit food, a full serving size for age. In case of atypical FPIES (skin prick test, SPT, positive), we applied this protocol only if the description of previous adverse reactions was compatible with that of a classic acute FPIES, if other IgE-mediated food allergies were absent, and if the mean diameter of the wheal evoked by the SPT with the challenged food was ≤5 mm. We have retrospectively analyzed 222 OFCs from 2011 to 2020. The grading of reactions was carried out according to the International Consensus Guidelines on FPIES of 2017. RESULTS Forty-eight of 222 OFC (21.6%) failed. The mild reactions were 22 of 48 (45.8%), the moderate ones 22 of 48 (45.8%), and the severe ones 4 of 48 (8.4%) failed OFCs. The tested food processing (in the case of cow milk and chicken egg) did affect neither probability nor severity of the reaction. Patients with positive SPT for the tested food presented four times more severe reactions (2 of 9 failed OFC, 22.2%) than patients with negative SPT (2 of 39 failed OFC, 5.1%) (P = .316). CONCLUSIONS The administration of a single dose in a full serving size for age appears to be a sufficiently safe method for OFC for acute FPIES, with the benefit of saving time. In patients with positive SPT for the tested food, it may be prudent to start with a smaller dose carrying on, in the absence of adverse reactions, with the administration of the full dose after a 4-hour observation.
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Affiliation(s)
- Stefano Miceli Sopo
- Pediatric Allergy Unit, Pediatrics Section, Department of Life Sciences and Public Health, Policlinico Gemelli University Foundation IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Dario Sinatti
- Pediatrics Section, Department of Life Sciences and Public Health, Policlinico Gemelli University Foundation IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Mariannita Gelsomino
- Pediatrics Section, Department of Life Sciences and Public Health, Policlinico Gemelli University Foundation IRCCS, Catholic University of Sacred Heart, Rome, Italy
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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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Ruffner MA, Spergel JM, Brown-Whitehorn TF. CON: Peripheral intravenous access should always be secured before initiating food protein-induced enterocolitis syndrome oral food challenge. Ann Allergy Asthma Immunol 2021; 126:462-463. [PMID: 33941318 DOI: 10.1016/j.anai.2020.12.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/19/2020] [Accepted: 12/28/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Melanie A Ruffner
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Terri F Brown-Whitehorn
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Ford LS, Konstantinou GN, Caubet JC. PRO: Peripheral intravenous access should always be secured before initiating food protein-induced enterocolitis syndrome oral food challenge. Ann Allergy Asthma Immunol 2021; 126:460-461. [PMID: 33941317 DOI: 10.1016/j.anai.2021.01.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/06/2021] [Accepted: 01/19/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Lara S Ford
- Department of Allergy and Immunology, The Children's Hospital at Westmead, Sydney, New South Wales, Australia; Discipline of Child and Adolescent Health, University of Sydney School of Medicine, Sydney, New South Wales, Australia
| | - George N Konstantinou
- Department of Allergy and Clinical Immunology, 424 General Military Training Hospital, Thessaloniki, Greece
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland.
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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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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: 12] [Impact Index Per Article: 4.0] [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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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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Cianferoni A. Food protein-induced enterocolitis syndrome epidemiology. Ann Allergy Asthma Immunol 2021; 126:469-477. [PMID: 33607250 DOI: 10.1016/j.anai.2021.02.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/05/2021] [Accepted: 02/10/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Food protein-induced enterocolitis syndrome (FPIES) is a condition with heterogeneous features (ie, age at presentation, severity, food triggers, comorbidities) and is not as rare as initially believed. In the last few years, the first population-based epidemiologic study, few prospective birth cohort evaluating FPIES prevalence, and several larger (>100 patients) studies have been published, making epidemiologic estimation more reliable. In this review, we report on the available data on the epidemiology of FPIES. DATA SOURCES PubMed review using the following words: FPIES, epidemiology, and prevalence. STUDY SELECTIONS The review focused on the population-based epidemiologic study, few prospective birth cohort evaluating FPIES prevalence, and several larger (>100 patients) studies. RESULTS We identified 8 population or cohort studies. CONCLUSION FPIES is not rare in both children and adults and may affect as many as 900,000 people in the United States alone. Most children and adult with FPIES seem to react to 1 to 2 foods; however, they may need further diet restriction owing to high level of comorbidity with immunoglobulin E-mediated food allergies and eosinophilic esophagitis. Globally, cow's milk, rice/oat, and seafood seem to be the most common triggers.
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Affiliation(s)
- Antonella Cianferoni
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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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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Barni S, Vazquez-Ortiz M, Giovannini M, Liccioli G, Sarti L, Cianferoni A, Mori F. 'Diagnosing food protein-induced enterocolitis syndrome'. Clin Exp Allergy 2021; 51:14-28. [PMID: 33089888 DOI: 10.1111/cea.13767] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/03/2020] [Accepted: 10/17/2020] [Indexed: 12/13/2022]
Abstract
Food protein-induced enterocolitis syndrome is still a mysterious disease, pathogenically poorly characterized, although the first FPIES case has been described in 1967. Mainly, food protein-induced enterocolitis syndrome diagnosis is based on clinical history. The oral food challenge remains the gold standard to confirm the diagnosis, especially in particular situations. Although there are no diagnostic laboratory or imaging tests which are specific for diagnosis, they could, however, sometimes be helpful to rule out clinical conditions which are similar to food protein-induced enterocolitis syndrome reactions. The purpose of this review is to define the clinical features of FPIES and to summarize the current available tools for the diagnosis of FPIES. This review is intended to be a practical guide for the clinician facing a patient with food protein-induced enterocolitis syndrome avoiding delayed diagnosis with unnecessary laboratory tests and detrimental treatments. Moreover, it highlights the unmet needs in diagnosis that require urgent attention from the scientific community to improve the management of patients with FPIES.
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Affiliation(s)
- Simona Barni
- Allergy Unit, Meyer Children's University Hospital, Florence, Italy
| | - Marta Vazquez-Ortiz
- Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Giulia Liccioli
- Allergy Unit, Meyer Children's University Hospital, Florence, Italy
| | - Lucrezia Sarti
- Allergy Unit, Meyer Children's University Hospital, Florence, Italy
| | - Antonella Cianferoni
- Children's Hospital of Philadelphia, University of Pennsylvania Medical School, Philadelphia, PA, USA
| | - Francesca Mori
- Allergy Unit, Meyer Children's University Hospital, Florence, Italy
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Argiz L, Infante S, Machinena A, Pascal M, Echeverria L, Barni S, Garriga-Baraut T, Arasi S, Moure JD, Gomez-Carballa A, Martinon-Torres F, Boyle RJ, Vazquez-Ortiz M. Reactions on re-exposure following negative and inconclusive follow-up food challenges in children with acute FPIES. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3228-3231.e3. [DOI: 10.1016/j.jaip.2020.05.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 10/24/2022]
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Barni S, Sarti L, Liccioli G, Giovannini M, Liotti L, Novembre E, Mori F. Oral food challenge protocol for food protein-induced enterocolitis syndrome: time for a change? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2020; 8:2842-2843. [PMID: 32888540 DOI: 10.1016/j.jaip.2020.06.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/11/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Simona Barni
- Allergy Unit, Department of Pediatrics, Meyer Children's Hospital, Florence, Italy.
| | - Lucrezia Sarti
- Allergy Unit, Department of Pediatrics, Meyer Children's Hospital, Florence, Italy
| | - Giulia Liccioli
- Allergy Unit, Department of Pediatrics, Meyer Children's Hospital, Florence, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children's Hospital, Florence, Italy
| | - Lucia Liotti
- Pediatric Unit, Hospital of Senigallia, Senigallia, Italy
| | - Elio Novembre
- Allergy Unit, Department of Pediatrics, Meyer Children's Hospital, Florence, Italy
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, Meyer Children's Hospital, Florence, Italy
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Ruffner M, Spergel J, Cianferoni A, Brown-Whitehorn TF. Reply to "Oral food challenge protocol for food protein-induced enterocolitis syndrome: time for a change?". THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2020; 8:2843-2844. [PMID: 32888542 DOI: 10.1016/j.jaip.2020.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/11/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Melanie Ruffner
- Department of Pediatrics, Perelman School of Medicine and Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Jonathan Spergel
- Department of Pediatrics, Perelman School of Medicine and Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Antonella Cianferoni
- Department of Pediatrics, Perelman School of Medicine and Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Terri Faye Brown-Whitehorn
- Department of Pediatrics, Perelman School of Medicine and Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa.
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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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Guenther MW, Crain M, Parrish CP, Bird JA. An observed serving dose may not be necessary following a standard divided-dose FPIES oral food challenge. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1462-1464. [DOI: 10.1016/j.jaip.2019.10.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 10/08/2019] [Accepted: 10/21/2019] [Indexed: 11/30/2022]
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Oral food challenges: Special considerations. Ann Allergy Asthma Immunol 2020; 124:451-458. [PMID: 32088320 DOI: 10.1016/j.anai.2020.02.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 02/08/2020] [Accepted: 02/11/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To reinforce special considerations when offering and conducting oral food challenges (OFCs). DATA SOURCES Published studies and reviews. STUDY SELECTIONS Studies concerning OFCs and their conduct. RESULTS Multiple OFC protocols for various clinical situations and foods were reviewed. CONCLUSION OFCs are used for the definitive diagnosis of food allergy. Risk and benefit assessment guide the OFC procedure. The conduct of OFCs is influenced by multiple factors, including age, food, and goal of the challenge.
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Schatz M, Sicherer SH, Khan DA, Zeiger RS. The Journal of Allergy and Clinical Immunology: In Practice 2019 Highlights. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:912-936. [PMID: 31980411 DOI: 10.1016/j.jaip.2020.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 01/03/2020] [Indexed: 10/25/2022]
Abstract
This article provides highlights of the clinically impactful original studies and reviews published in The Journal of Allergy and Clinical Immunology: In Practice in 2019 on the subjects of anaphylaxis, asthma, dermatitis, drug allergy, food allergy, immunodeficiency, immunotherapy, rhinitis/sinusitis, and urticaria/angioedema/mast cell disorders. Within each topic, practical aspects of diagnosis and management are emphasized. Treatments discussed include lifestyle modifications, allergen avoidance therapy, positive and negative effects of pharmacologic therapy, and various forms of immunologic and desensitization management. We designed this review to help readers consolidate and use this extensive and practical knowledge for the benefit of their patients.
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Affiliation(s)
- Michael Schatz
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif.
| | - Scott H Sicherer
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David A Khan
- Department of Internal Medicine, Division of Allergy & Immunology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Robert S Zeiger
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif; Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, Calif
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Abstract
Food allergies, defined as an immune response to food proteins, affect as many as 8% of young children and 2% of adults in western countries, and their prevalence appears to be rising like all allergic diseases. In addition to well-recognized urticaria and anaphylaxis triggered by IgE antibody- mediated immune responses, there is an increasing recognition of cell-mediated disorders, such as eosinophilic esophagitis and food protein-induced enterocolitis. Non-IgE-Mediated gastrointestinal food allergies are a heterogeneous group of food allergies in which there is an immune reaction against food but the primary pathogenesis is not a production of IgE and activation of mast cells and basophils. Those diseases tend to affect mainly the gastrointestinal tract and can present as acute (FPIES) or chronic reaction, such as Eosinophilic Esophagitis (EoE), Food Protein-Induced Allergic Proctocolitis (FPIAP). The role of food allergy in Non-EoE gastrointestinal Eosinophilic disorders (Non- EoE EGID) is poorly understood. In some diseases like EoE, T cell seems to play a major role in initiating the immunological reaction against food, however, in FPIES and FPIAP, the mechanism of sensitization is not clear. Diagnosis requires food challenges and/or endoscopies in most of the patients, as there are no validated biomarkers that can be used for monitoring or diagnosis of Non-IgE mediated food allergies. The treatment of Non-IgE food allergy is dependent on diet (FPIES, and EoE) and/or use of drugs (i.e. steroids, PPI) in EoE and Non-EoE EGID. Non-IgE mediated food allergies are being being investigated.
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Affiliation(s)
- Antonella Cianferoni
- Division of Allergy and Immunology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, United States
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Meyer R, Chebar Lozinsky A, Fleischer DM, Vieira MC, Du Toit G, Vandenplas Y, Dupont C, Knibb R, Uysal P, Cavkaytar O, Nowak‐Wegrzyn A, Shah N, Venter C. Diagnosis and management of Non-IgE gastrointestinal allergies in breastfed infants-An EAACI Position Paper. Allergy 2020; 75:14-32. [PMID: 31199517 DOI: 10.1111/all.13947] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 04/16/2019] [Accepted: 04/20/2019] [Indexed: 12/14/2022]
Abstract
It is well-established that food proteins, such as egg, soya, cow's milk and wheat, are detectable in breastmilk for many hours or days after ingestion. Exposure to these proteins is important to the process of developing tolerance but can also sometimes elicit IgE-mediated and non-IgE-mediated allergic symptoms in breastfed infants. Non-IgE-mediated allergy, outside of food protein-induced allergic proctocolitis and eosinophilic oesophagitis, is not well understood, leading to variations in the diagnosis and management thereof. A primary objective of the European Academy for Allergy and Clinical Immunology is to support breastfeeding in all infants, including those with food allergies. A Task Force was established, to explore the clinical spectrum of non-IgE-mediated allergies, and part of its objectives was to establish diagnosis and management of non-IgE-mediated allergies in breastfed infants. Eight questions were formulated using the Patient, Intervention, Comparison, Outcome (PICO) system and Scottish Intercollegiate Guideline Network (SIGN) criteria for data inclusion, and consensus was achieved on practice points through the Delphi method. This publication aims to provide a comprehensive overview on this topic with practice points for healthcare professionals.
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Affiliation(s)
- Rosan Meyer
- Department Paediatrics Imperial College London London UK
| | - Adriana Chebar Lozinsky
- Department of Allergy and Immune Disorders Murdoch Children's Research Institute Melbourne Victoria Australia
| | - David M. Fleischer
- Children’s Hospital Colorado University of Colorado Denver School of Medicine Aurora CO USA
| | - Mario C. Vieira
- Department of Paediatrics, Pontifical Catholic University of Paraná, Center for Pediatric Gastroenterology Hospital Pequeno Príncipe Curitiba Brazil
| | - George Du Toit
- Department of Pediatric Allergy, Division of Asthma, Allergy and Lung Biology King’s College London and Guy’s and St. Thomas’ National Health Service Foundation Trust London UK
| | - Yvan Vandenplas
- KidZ Health Castle, UZ Brussel Vrije Universiteit Brussel Brussels Belgium
| | - Christophe Dupont
- Department of Paediatric Gastroenterology Necker University Children Hospital Paris France
| | - Rebecca Knibb
- Department of Psychology Aston University Birmingham UK
| | - Piınar Uysal
- Department of Allergy and Clinical Immunology Adnan Menderes University Aydin Turkey
| | - Ozlem Cavkaytar
- Department of Pediatric Allergy and Immunology, Istanbul Medeniyet University, Medical Faculty Goztepe Training and Research Hospital Istanbul Turkey
| | - Anna Nowak‐Wegrzyn
- Icahn School of Medicine at Mount Sinai Jaffe Food Allergy Institute New York New York USA
| | - Neil Shah
- Department Gastroenterology Great Ormond Street Hospital London London UK
| | - Carina Venter
- Children’s Hospital Colorado University of Colorado Denver School of Medicine Aurora CO USA
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Barni S, Sarti L, Mori F, Liotti L, Pucci N, Novembre E. A modified oral food challenge in children with food protein-induced enterocolitis syndrome. Clin Exp Allergy 2019; 49:1633-1636. [PMID: 31386243 DOI: 10.1111/cea.13477] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 07/15/2019] [Accepted: 07/23/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Simona Barni
- Allergy Unit, A. Meyer Children's Hospital, Florence, Italy
| | - Lucrezia Sarti
- Allergy Unit, A. Meyer Children's Hospital, Florence, Italy
| | - Francesca Mori
- Allergy Unit, A. Meyer Children's Hospital, Florence, Italy
| | - Lucia Liotti
- Pediatric Unit, Hospital of Senigallia, Senigallia, Italy
| | - Neri Pucci
- Allergy Unit, A. Meyer Children's Hospital, Florence, Italy
| | - Elio Novembre
- Allergy Unit, A. Meyer Children's Hospital, Florence, Italy
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Feuille E, Nowak‐Wegrzyn A. Medical Algorithms: Recognizing and treating food protein-induced enterocolitis syndrome. Allergy 2019; 74:2019-2022. [PMID: 31070799 DOI: 10.1111/all.13857] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/04/2019] [Accepted: 04/22/2019] [Indexed: 11/28/2022]
Affiliation(s)
| | - Anna Nowak‐Wegrzyn
- Icahn School of Medicine at Mount Sinai Jaffe Food Allergy Institute New York New York
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Caubet J, Cianferoni A, Groetch M, Nowak‐Wegrzyn A. Food protein‐induced enterocolitis syndrome. Clin Exp Allergy 2019; 49:1178-1190. [DOI: 10.1111/cea.13415] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 05/03/2019] [Accepted: 05/03/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Jean‐Christoph Caubet
- Geneva University Hospital Geneva Switzerland
- Division of Allergy and Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai Kravis Children's Hospital New York New York
| | - Antonella Cianferoni
- Children's Hospital of Philadelphia University of Pennsylvania Medical School Philadelphia Pennsylvania
| | - Marion Groetch
- Division of Allergy and Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai Kravis Children's Hospital New York New York
| | - Anna Nowak‐Wegrzyn
- Division of Allergy and Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai Kravis Children's Hospital New York New York
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Mehr S, Brown-Whitehorn T. What do allergists in practice need to know about non-IgE-mediated food allergies. Ann Allergy Asthma Immunol 2019; 122:589-597. [PMID: 30935977 DOI: 10.1016/j.anai.2019.03.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/21/2019] [Accepted: 03/22/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Sam Mehr
- Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Allergy and Immunology, Children's Hospital at Westmead, Sydney, New South Wales, Australia.
| | - Terri Brown-Whitehorn
- Division of Allergy and Immunology, Department of Pediatric, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
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