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Safety of food protein-induced enterocolitis syndrome food challenges

Published online: September 20, 2018

Food protein-induced enterocolitis syndrome (FPIES) is a food allergy that presents with delayed vomiting and diarrhea. FPIES remains a clinical diagnosis – there are currently no laboratory studies specific for FPIES. Oral food challenge (OFC) can be helpful for diagnosis in cases where the history or triggering food is unclear. In many cases, OFC are performed to assess for tolerance to common FPIES triggers that were not yet ingested and for the development of tolerance to the index food that triggered a reaction. The total dose and dosing regimen for performing FPIES OFC has not been systematically studied and protocols and practices vary. Many existing studies on FPIES OFC are limited in size.

In an article recently published in The Journal of Allergy and Clinical Immunology: In Practice, Wang and colleagues reviewed 169 FPIES oral food challenges and their outcomes, with a focus on their unique protocol: 1-dose, a third of a serving size for age, under medical supervision with subsequent home titration to age-appropriate serving size. The authors found that 139 challenges (72%) were negative and children were able to introduce food. Thirty challenges (18%) were positive, with 17 challenges positive (10%) during initial challenge and 13 (7.7%) during home dosing. Most reactions during initial challenge required intravenous fluids, but reactions at home were generally mild. There were overlapping clinical features of patients who had severe reactions compared to those who did not. In contrast to existing case series, ondansetron administration did not result in complete resolution of symptoms in all patients. Finally, wheat is commonly avoided in patients in grain FPIES, but all patients who were challenged to wheat as a precaution passed.

The results of this review highlight the advantage of a 1-dose protocol, which appears to be safe. Patients at risk of having a severe reaction could not be easily identified; therefore challenges should be performed under medical supervision and IV access established prior to challenge is strongly recommended. The utility of ondansetron as an adjunctive treatment is an ongoing question. IVF is the cornerstone of treatment of reactions. Finally, wheat avoidance may not be necessary in patients with oat or grain FPIES, and introduction may be performed at home in older children.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.