Q:

3/11/2014
In looking for alternatives to milk and soy in a 1 year-old patient with FPIES. Our nutritionist suggested Hemp milk; however, brown rice syrup is an ingredient, and the patient is avoiding grains. Is there any knowledge if rice syrup contains rice protein (or is it like corn syrup which does not contain corn protein)? The family is currently using Neocate but the expense is an issue.

A:

Thank you for your inquiry.

I am forwarding your inquiry to Dr. David Fleischer, who is an expert in food allergy. As soon as we receive his response, we will forward it to you.

Thank you again for your inquiry.

Sincerely,
Phil Lieberman, M.D.

As you know, Dr. Fleischer sent an initial response along with some additional questions and information. His questions and your responses are noted below:

Questions:
1. What food(s) did the child actually react to in an FPIES manner?
2. What foods is the child avoiding? Assume all the common foods to cause FPIES.

If the child only reacted to milk OR soy, then I usually start OFCs with the other foods that the child has not reacted to previously and leave the ones he/she did until the child is older. The chance that the child is allergic to all the FPIES foods is unlikely, and to have to avoid these until age 3 is not really necessary. I usually start challenging these FPIES kids to the foods without a history of reaction at age one, usually with an IV in place.

Therefore, she may be able to challenge soy if the child only reacted to milk. Soy milk has much more protein than hemp or coconut milk. Main concern is to make sure there are sufficient fat and protein (and of course Vit D and Calcium) sources since whole milk may not be able to be used.

As far as I know, rice syrup does not contain protein as with corn syrup. If the child reacted to rice only, then milk and soy could be challenged at this age. If child didn't react to rice, then could challenge it - again rice milk doesn't contain much protein or fat.

Challenge protocols are in the attached review by Ania, as they are different than traditional graded OFCs.

David M. Fleischer, M.D.


Your answers to his two questions are copied below:
1. Sweet potato-he was scheduled for a milk challenge but were looking for alternatives in the meantime.

2. Yes, all the common foods-milk, soy, grains (eating quinoa); he has been eating legumes and is a vegetarian so not concerned about poultry (I wasn't sure if tolerating legumes clears him for soy?).  His skin testing for other highly allergenic foods-egg, nuts-was negative and he is eating these.

And this is the final response from Dr. Fleischer:

I would still do a challenge to soy to be safe, even though has tolerated other legumes. Soy or cow's milk with get you the "milk" you need, so would start with a challenge to one of those two.

David M. Fleischer, M.D.
Associate Professor of Pediatrics
Director, Food Challenge Unit
Children's Hospital Colorado
Dept. of Pediatrics, Section of Allergy

AAAAI - American Academy of Allergy Asthma & Immunology