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Nutritional management of food protein-induced enterocolitis syndrome
To summarize the latest information on the nutritional management of food protein-induced enterocolitis syndrome FPIES , focusing on the foods implicated and how to avoid these whilst maintaining a nutritionally sound diet. The number of foods implicated in FPIES per individual differs, but the majority of reported cases have two or fewer food triggers involved. Dietary management is complicated as both common food allergens as well as atypical food allergens can trigger FPIES.
Sound nutritional advice is required to ensure appropriate food avoidance, adequate consumption of other foods and sufficient nutritional intake to maintain and ensure growth and development. Usual symptoms include vomiting, diarrhoea, lethargy and, in some cases, hypovolemic shock and metabolic acidosis. It is often caused by cow's milk or soy proteins, but may also be triggered by the ingestion of other solid foods, particularly grains.
The diagnosis is made on the basis of a clinical history, reported symptoms and a food challenge when appropriate. During the acute phase, fluids and intravenous steroids are used as required and discussed by Miceli Sopo et al. During the maintenance phase, the treatment and management strategy is avoidance of the culprit food s.
Dietary management of food protein enterocolitis also requires advice on the intake of suitable foods to ensure sufficient nutritional intake, growth and development. Development of tolerance should be considered as discussed by Katz  in this edition to prevent unnecessary avoidance of foods. Finally, FPIES presents a number of unique and complex dietary issues, which in most cases will require the input of a dietitian.
Appropriate food avoidance includes knowledge of the allergens involved and the information required for appropriate allergen avoidance. The European Union considers cereals containing wheat and gluten, shellfish, eggs, fish, peanuts and tree nuts, cow's milk, celery, mustard, sesame seeds Sesamumindicum , mollusks, soy, lupine Lupinus spp.
Only one case study has been published by Fernandes et al. Healthcare professionals should give patients and carers clear guidance about food avoidance to prevent both unnecessary restrictions and accidental exposure to allergens. Information about which foods to avoid can be obtained from qualified dietitians and credible patient groups such as UK-based www.
Table 2  contains information about foods commonly implicated in FPIES and the nutrients they contain. Food allergen avoidance advice should ideally be provided by a dietitian  and include a discussion on understanding food labels and prevention of cross-contamination, and lifestyle issues such as time taken to shop and eating away from home .
The effect of any avoidance diet on nutritional intake will be influenced by the frequency of consumption of the food, dependency on commercially available food, parental resources and cooking skills. Of particular importance for FPIES is the number of foods involved, the role of breastfeeding, suitable formula choice, level or degree of food avoidance and appropriate weaning advice. Globally, there are slight differences in the number of foods that are causing FPIES in an individual child.
A number of other studies, however, indicated that more than one food is implicated in FPIES in an individual child [5,9,12]. In a multicentre trial conducted by Sopo et al. In contrast, Nowak-Wegrzyn et al.
The more foods that need to be avoided, the more the nutritional quality of the diet is affected. Forty-five children were classified as having IgE-mediated, 29 had non-IgE-mediated and 23 had mixed-type allergy.
Sixty-six children excluded two or fewer foods and 31 excluded at least three foods from their diet. In this study, children with food allergies were more underweight and stunted than the general population as published by others [38,39] , which appears to be linked to the number of foods excluded.
In addition, avoidance of a large number of foods increases the likelihood of food refusal and aversions, which may have an additional impact on food intake, particularly in children . Most breastfed infants with FPIES appear to tolerate breast milk from an unrestricted maternal diet . Of these 34 mothers, 21 lactating mothers were instructed to continue to eat the implicated food, in 7 cases it was unclear what advice was given, in 3 cases the infants were not being breastfed and in only 3 cases the mother was told to exclude the food trigger from her diet.
Although they could not determine how many of the 21 mothers continued to eat the trigger food, no infant re-presented to their clinic with a history of breast-milk-induced FPIES. Recent reports, however, question this observation. Previous maternal consumption of smaller amounts of soy in foods did not, however, lead to FPIES in the infant.
Very interestingly, Monti et al. This questions the use of milk-containing foods in a small minority of breastfed infants with FPIES triggered by cow's milk.
For now, however, routine avoidance of the allergenic food by the breastfeeding mother is not recommended for most infants with FPIES. This is in particular of relevance in those infants who did not present with FPIES whilst being breastfed, although the mother was consuming the allergenic food.
If maternal avoidance of any food is, however, required, it should ideally be instructed with the help of a dietitian. The choice of formula when dealing with cow's milk allergy has been touched on by the food allergy guidelines published over the last few years as summarized by Venter et al.
In brief, the United States U. Although the choice of formula is a clinical decision, it is worth noting the use of extensively hydrolysed formula eHF is not suitable for the treatment of FPIES in all infants [48—50]. There is some limited evidence as well that some children may catch up on their growth sooner when placed on an amino acid formula [51,52].
On a more practical note, infants, particularly those who are breastfed, may initially refuse hypoallergenic formulas because of taste issues. Dietitians are ideally suited to give advice regarding this problem. Some suggestions may be to mix breast milk with the formula, gradually increasing the amount of formula whilst reducing the breast milk, adding flavouring to the formula e.
Another option is to use the formula in baking and cooking, and a dietitian can provide mothers with suitable recipes.
There is very little published data, but some anecdotal evidence that children with FPIES may tolerate baked forms e.
It is, however, also known that if the allergenic food is part of the regular diet, infants and children may present with chronic symptoms and although these chronic symptoms are usually less dramatic, they can develop to be more severe .
Being able to identify whether a particular food is causing these more chronic symptoms in the absence of severe or acute symptoms is one of the more challenging aspects of managing FPIES.
One empiric approach is that if a child is already tolerating baked milk or egg or small amounts of the offending food in their diet without any obvious symptoms and normal growth, these foods may be continued. However, in children with a history of severe reactions to small amounts of food, supervised food challenges are prudent to introduce the baked foods. This fact, and the fact that many of the foods causing FPIES are considered to be atypical allergenic foods and usually first weaning foods, can complicate the weaning process and highlights the need for a dietitian to be involved.
Traditionally, mothers start weaning with baby rice, oats, corn-based porridge, fruit and vegetables, followed shortly by fromage frais and yoghurt . Once finger foods are given, bread sticks or toast fingers with butter and soft cheese are also popular choices. First weaning foods do, however, differ across countries and cultures . Very importantly, the variety of tastes and textures and the timely introduction of these directly affect or prevent fussy eating behaviour [56,57].
Food refusal is commonly seen during infancy. It is thought that These figures are even higher in children with non-IgE-mediated food allergies [59,60]. The food refusal may be related to the symptoms experienced to liquids or foods in the past or maternal fear of introducing new foods .
This poses a particular challenge when managing children with food allergies, for example, making sure that the allergenic foods are avoided whilst providing sufficient variety in the diet to prevent long-term food aversions, restriction of food choices and nutritional deficiencies.
In the absence of clear guidance, it can be difficult to know which foods to introduce during weaning and in which order. A nutritional assessment can provide useful information that can be used as a baseline for monitoring the nutritional status and the impact of the avoidance diet.
For example, a young child with faltering growth related to multiple food allergies will require avoidance advice as well as advice on how to increase energy  , protein and vitamin and mineral intake.
Parents are often concerned about the growth of their children, particularly if they suffer from gastrointestinal disease. The simplest way of monitoring nutritional deficiencies in children is to assess their growth using the nationally recognized growth charts. Measuring the growth of infants, toddlers and children plays two important roles: Growth alone, however, does not indicate sufficient dietary intake and assessment of dietary intake is of great importance.
A variety of measures can be used to determine dietary intake and may include h recall, food frequency questionnaires and 3—7 day food diaries. All of these have their limitations and dietitians may use the most practical option or a variety of methods . The nutritional analysis, coupled with biochemical markers, can give useful information on any nutritional supplements required.
National guidance on nutritional supplementation differs and it is suggested to follow these guidelines and take into account the risk of developing nutritional deficiencies based on the food or foods being avoided see Table 2 for common foods implicated in FPIES and their main nutrients.
It is particularly important to consider iron and vitamin D intake in infants who are breastfed only i. Calcium may be a problem in some cases, but this will be highlighted during a dietary analysis. As many food allergies of early childhood resolve over time, regular assessment for the development of tolerance is required to avoid unnecessary dietary avoidance.
It is recommended to wait 12—18 months  before a food is reintroduced. It is known that FPIES can present severely after a period of avoidance, typically occurring hours after ingestion . Therefore, the rate and order and where foods will be reintroduced after a period of avoidance should be discussed and performed under the supervision of the physician. In summary, nutritional management of FPIES requires the identification of the offending allergen followed by appropriate avoidance and use of substitute food.
Of particular importance is advice to breastfeeding mothers, choice of formula and weaning guidance. The nutritional status and dietary intake should be monitored and advice on added protein, kcal and micronutrients should be provided when required. It is important to regularly consider the resolution of FPIES in order to reintroduce the food into the diet, but this decision should be made in discussion with the overseeing physician.
Papers of particular interest, published within the annual period of review, have been highlighted as:. National Center for Biotechnology Information , U. Current Opinion in Allergy and Clinical Immunology. Curr Opin Allergy Clin Immunol. Published online Apr Carina Venter a, b and Marion Groetch c. The work cannot be changed in any way or used commercially. This article has been cited by other articles in PMC.
Abstract Purpose of review To summarize the latest information on the nutritional management of food protein-induced enterocolitis syndrome FPIES , focusing on the foods implicated and how to avoid these whilst maintaining a nutritionally sound diet.
The food allergens involved The European Union considers cereals containing wheat and gluten, shellfish, eggs, fish, peanuts and tree nuts, cow's milk, celery, mustard, sesame seeds Sesamumindicum , mollusks, soy, lupine Lupinus spp. Open in a separate window.
Table 1 Foods most commonly implicated in food protein-induced enterocolitis syndrome. Information on food allergen avoidance Healthcare professionals should give patients and carers clear guidance about food avoidance to prevent both unnecessary restrictions and accidental exposure to allergens. Table 2 Foods commonly implicated in food protein-induced enteropathy and their nutrients. Sushi, paella, curries, gumbo and risotto Carbohydrate, calcium, iron, phosphorus, potassium, thiamine, riboflavin, niacin, folate and pantothenic acid Rice cereal Rice pudding Chicken, turkey, lamb Any meat containing dishes Protein, fat , selenium, phosphorus, potassium, zinc, iron Vitamin B6 and niacin Sweet potato Sweet potato and dishes containing sweet potato such as curries or vegetarian meals Beta-carotene vitamin A , pantothenic acid, thiamine, niacin, riboflavin, magnesium, manganese and potassium Peas Vegetarian meals Folic acid, pantothenic acid, niacin, thiamine, pyridoxine, ascorbic acid, vitamin K, vitamin A, calcium, iron, copper, zinc and manganese.
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