What is the relationship between FPIES (Food Protein-Induced Enterocolitis Syndrome) and milk allergy in pediatric patients?

From the Guidelines

Milk allergy is a common cause of Food Protein-Induced Enterocolitis Syndrome (FPIES) in pediatric patients.

Relationship between FPIES and Milk Allergy

• FPIES is a non-IgE-mediated disorder that typically occurs in young infants and manifests as chronic emesis, diarrhea, and failure to thrive 1.
• Milk and soy protein are the most common causes of FPIES, although some studies also report reactions to other foods, including rice, oat, or other cereal grains 1.
• The symptoms of FPIES depend on the frequency and dose of the trigger food, as well as the phenotype and age of an individual patient 1.
• Chronic FPIES is less well characterized compared with acute FPIES and only reported in infants younger than 4 months of age fed with cow’s milk (CM) or soy infant formula 1.
• Hypoalbuminemia and poor weight gain can predict chronic CM-induced FPIES in young infants with chronic gastrointestinal symptoms 1.

Diagnosis and Management

• The diagnosis of FPIES is based on a supportive medical history, resolution of symptoms with the elimination of the causative food, and, in many cases, provocation of symptoms following an open or single-blind oral food challenge 1.
• The treatment of FPIES involves the elimination of the causative food from the diet, and in some cases, the use of hypoallergenic formulas may be necessary 1.
• Maternal dietary allergen avoidance may be attempted to prevent or manage non-IgE-mediated food allergy, including FPIES, in breastfed infants 1.

From the Research

Relationship between FPIES and Milk Allergy

The relationship between Food Protein-Induced Enterocolitis Syndrome (FPIES) and milk allergy in pediatric patients is complex and has been studied in several research papers.

• FPIES is a non-IgE-mediated food allergy characterized by gastrointestinal symptoms, and cow's milk is one of the most common trigger foods 2, 3, 4, 5, 6.
• Some studies have reported that patients with FPIES may develop an IgE-mediated allergy to the same trigger food, including cow's milk 2, 3.
• A study found that among children with specific IgE to cow's milk, 41% changed from a milk FPIES to an IgE-mediated phenotype over time 3.
• Another study reported that FPIES typically resolves by age 5 years, but milk FPIES, especially with detectable food-specific IgE, can have a protracted course and eventually transition to acute reactions 3.
• The exact mechanisms of this transition are not fully understood and require further investigation 2.

Clinical Features and Resolution of FPIES

The clinical features and resolution of FPIES have been characterized in several studies.

• FPIES diagnosis is frequently delayed due to the absence of classic allergic symptoms and lack of biomarkers 3, 4, 6.
• The most common foods associated with FPIES are cow's milk, soy, rice, and oat 3, 4, 5, 6.
• FPIES is often misdiagnosed as sepsis or gastroenteritis, but a diagnosis of FPIES is favored if there is rapid resolution of symptoms within hours of presentation, an absence of fever, and a lack of a significant rise in C-reactive protein at presentation 6.
• FPIES is a self-limiting condition, with most cases resolving by age three to five years 4.

Management and Diagnosis of FPIES

The management and diagnosis of FPIES are crucial for pediatric patients.

• Diagnosis is often hampered by the lack of awareness of FPIES, absence of reliable biomarkers, the non-specific nature of the presenting symptoms, and the delay between allergen exposure and symptoms 6.
• Avoidance of the trigger food is the primary management strategy for FPIES 6.
• Ondansetron may be helpful in managing acute FPIES 4.