Food Protein Induced Enterocolitis Syndrome (FPIES)

Food Protein Enterocolitis Syndrome or FPIES is a severe reaction to a food that typically occurs within the first 6 months of life.  These babies can be sick, sick, sick.  They usually have repeated vomiting that can be accompanied by diarrhea that can contain blood and mucus.  As a result, they can appear pale and lethargic, with all of this developing a short time (a few minutes or even up to 6 hours) after eating or drinking the food that triggered these symptoms.  The more severe form occurs in 5% of these infants, requiring emergency hospital treatment with IV fluids because they quickly develop a shocky state with low blood pressure.  They may become very pale or even turn blue.  If so, emergency care is needed (Epipens won't work).

Unfortunately there are no lab tests to identify trigger foods.  The only way to tell is to make sure there is no infection or other problem present and to recognize that it could have been caused by a food that was eaten just before the symptoms developed.  If there is any doubt, a supervised food challenge can be performed.

Common triggers of FPIES:
  • The most common triggers are milk (67%) and soy (41%) followed by grains (19% rice, 16% oat, 10% wheat, 8% corn) and egg (11%).
  • 80% react to either milk or soy.
  • 43% of patients with FPIES to milk also react to soy.
  • 42% of patients with a grain trigger react to 2 or more grains.
  • 24% with milk and soy react to one or more grains.
  • Reactions to meat, fruits and vegetables occur but that is less common. Chicken, turkey, bananas, sweet potato and peas are the most common triggers from these groups.
  • 70% of patients react to 1 or 2 foods.
  • 30% react to 3 or more foods.
  • 5% react to 6 or more foods.
  • 20% also have classical (IgE) sensitivity based on positive skin tests More on this here.
Breastfeeding or Formula in FPIES infants?
  • Breastfeeding moms need to eliminate possible trigger foods from their diet (a portion of the food protein may have crossed their breast milk, and it can again)
  • Because of possible milk and soy reactions, a fully hydrolysed formula is often needed
  • 10- 36% need a super expensive amino acid-based formula (but it's worth it)
Introduction of foods for FPIES infants:
  • Any food already tolerated can be continued
  • Yellow fruits and vegetables should be started first instead of cereal at 6 months
  • If tolerated, grains, legumes, and poultry can continue
  • If grains, legumes and poultry haven't been started, it may be best to avoid them until 1 year of age
  • Tolerance to one food from a “high-risk” group may mean tolerance of another food in that group. (For example: tolerating chicken may mean they can eat turkey, if they are doing well on soy, they should be able to eat other legumes, etc.)
When do infants outgrow FPIES?
  • Milk and soy triggered FPIES is typically outgrown by 18 months
  • Fish and egg triggered FPIES is typically outgrown by 53 months
  • Wait 18 months after the last reaction to try any trigger food again.  But reintroducing trigger foods should be supervised or at least directed by an experienced physician
Age of complete FPIES resolution:
  • 35% of children are FPIES-free by 2 years old
  • 70% of children are FPIES-free by 3 years old
  • 80% of children are FPIES-free by 4 years old
  • 85% of children are FPIES-free by 5 years old

Bailey Koch, RD, CSP, LD 19 May 2015

Bailey Koch is the President of Atlanta Pediatric Nutrition, Inc., which provides nutrition services to pediatric physicians’ practices and provides consulting services to food companies and researchers. Bailey serves on our Read More

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