Food protein induced enterocolitis to banana
Question:
5/28/2021
I am evaluating a 10-month-old female who I believe has FPIES in association with bananas. After two episodes of severe vomiting, lethargy and numerous hours after banana intake she went to ER due to severity. In addition to banana avoidance, is it recommended she avoid similar foods i.e., avocado? Obviously, she will continue eating all foods she currently tolerated well. She is still breast fed. Does mom need to pull banana out of her own diet? I don’t believe that is recommended in FPIES but unsure. Since she is breastfed are there concerns for this child when starting cow’s milk, soy products etc. in light of possibility of numerous foods and FPIES?
Answer:
According to the 2017 international consensus guidelines, avocado is considered a lower-risk food as compared to banana. It is advised to start with the lowest-risk foods and then to advance to moderate-risk foods before attempting high-risk foods. Generally, it is recommended to wait at least four days before introducing the next new food. Introduction of foods should be prioritized by texture and nutritional value.
Interestingly, a 2019 report by Blackman et al in which a retrospective review of the EMR was performed found that banana and avocado were the most commonly reported fruits (24% and 16% respectively) to cause FPIES. Regarding avocado, you could consider whether there is a nutritional or cultural need for its introduction. If not, then you might delay its introduction until after you have introduced lower- and moderate-risk foods. The tables in the consensus guidelines are very helpful in this regard. Among babies with solid food FPIES, the rate of reaction to another solid food is less than 44% while the risk of reacting to cow milk or soy is less than 25%.
It is rare for children to react to a food passed through breast milk. If the infant is showing no signs of reaction after breastfeeding, then mother does not need to restrict her own diet.
While it is possible that your patient may react to cow milk or soy, the risk of this is lower than the risk to react to other solid foods. I suggest that you encourage mother to continue breastfeeding through the first year of life, after which you could introduce cow milk and soy products one at a time.
References
Nowak-Wegrzyn A et al. J Allergy Clin Immunol 2017
Blackman AC et al. Ann Allergy Asthma Immunol. 2019
Maciag MC et al. J Allergy Clin Immuunol Pract 2020
I hope this helps you with your patient.
Jacqueline A. Pongracic, MD, FAAAAI