2/2/2012
I have a 7mo old male patient who I have diagnosed with FPIES, and would like some recommendations regarding introduction of other foods. I have reviewed the previous questions regarding FPIES and the helpful JACI article by Dr. Sicherer from several years ago.

This infant was breastfed exclusively until the age of 5 months. At that time, rice was added mixed with breast milk, and two hours later he developed profuse repeated vomiting to the point of limpness and lethargy. He developed diarrhea with mucous the next day. Rice was tried again about a week later, and he had an identical reaction. Since that time, however, he has also had similar episodes two hours after eating oat (on two occasions), chicken (on two occasions), and once each on separate feedings of squash, sweet potato, and peas. He is able to tolerate banana, prune, pear, and avocado, and is completely without symptoms in between ingestion of these particular foods. He has never received milk or soy protein in any form, nor has he ingested wheat.

Skin prick testing for the above foods, as well as for milk, egg, wheat, soy, and peanut, has been negative, as expected. I have reviewed an action plan with the mother to include ER care should there be further reactions, and am in the process of writing a letter to have on hand for ER physicians as suggested by Dr. Sicherer. He will continue to be breastfed, and I’ll recommend extensively-hydrolyzed formula, if needed for supplementation. I am aware that recommendations also include fully avoiding grains, legumes, and poultry, as well, for at least the first year. However, given that he has already reacted to so many foods (including those that are less commonly reported such as vegetables) I am unsure how to proceed in terms of adding other fruits and vegetables. In addition, when would addition of other grains (such as wheat) be reasonable to try? Which of these need to be done in a hospital setting? Thanks very much for your assistance.

Thank you for your inquiry.

I am forwarding your inquiry to Dr. Scott Sicherer, who, as you know, is an international expert in this topic. As soon as we receive his response, we will forward it to you.

Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

We have received a response from Dr. Scott Sicherer. Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

Response from Dr. Scott Sicherer:
We come across infants like this and I do not have a specific evidence-based protocol of feeding. We use trial and error with adjustments based upon the infant/child's progress and some knowledge of the epidemiology. I would agree that offering every new food as a supervised oral food challenge becomes tedious, but depending upon the pattern of reactions and severity of individual reactions, we do sometimes need to approach it that way, at least until there becomes more confidence in trying more and more low risk foods that create a pattern of non-reactivity. It is helpful to emphasize, for example, that for this child already a number of foods ARE tolerated. We usually wait a significant period of time before re-trying the foods that caused reactions, or ones that are epidemiologically more often causal. Thus, I would usually reserve milk and soy until after age 1 (perhaps leaning toward age 18 months) and do those as supervised challenges.

There is no current randomized study to suggest the best timing (perhaps earlier is better) but for practical reasons (easier IV access, some time to grow after the past reactions, etc) waiting is often more convenient and perhaps avoids some period of increased susceptibility. Additionally, the foods that are more often causal that already triggered a reaction would be held longer (rice, oat). Foods that are less often causal, or that caused less significant symptoms, might eventually be tried ahead of the more problematic foods. None of these suggestions is evidence-based, but, rather, practical since it is self-evident, for example, that some of the foods you mentioned already caused more than one reaction and some were less severe than others-most families understand the reasoning to try to use less risky foods first.    

It can be helpful to work with a dietitian (and also address family food preferences) to strategize new foods to try that would most improve the diet, add textures, etc. At some point you need to try new foods and may do a few under supervision and, once more confident, try more at home. There are many foods that are not on the list of common triggers and so after perhaps a rest of a few weeks these could be addressed, for example: apple, peach, broccoli, carrot, corn, cauliflower, spinach, etc. If reactions keep occurring, longer wait times between trials are a practical approach. If things are going well, a more rapid progression can be a practical approach. A bit later as appropriate beef, pork and wheat can be tried. Depending on how things are going, allergens such as egg can be tried. I usually monitor skin tests periodically since about 10% of the children develop IgE mediated allergies and it can be helpful at least to anticipate reaction types during feeding tests. After various fruits, grains, meats and vegetables are tolerated, I would usually circle back to legumes, squash and sweet potato ahead of the higher risk foods mentioned before (oat, rice, milk, soy), basically going with successes or slowing down if there are failures. I would usually start with legumes that were not the initial trigger (e.g., string bean instead of pea). However, family preferences also play a role so a milk trial might, for example, come earlier. Some people try to use food patch tests as a guide. We have not been very successful with that but you can check the reference:

Fogg MI, Brown-Whitehorn TA, Pawlowski NA, Spergel JM. Atopy patch test for the diagnosis of food protein-induced enterocolitis syndrome. Pediatr Allergy Immunol. 2006 Aug;17(5):351-5.

Sincerely,
Scott H. Sicherer, MD
Professor of Pediatrics
Jaffe Food Allergy Institute
Mount Sinai School of Medicine