2025 – PAGE 103 – ALLERGY & IMMUNOLOGY

(DOUBLE TAKE) FOOD PROTEIN INDUCED ENTEROPATHY

Food Protein Induced Enteropathy is NOT IgE mediated. It can cause problems from birth, but often presents as FAILURE TO THRIVE (FTT) after months of already being on cow’s milk formula, or less commonly from exposure to other allergenic foods. Celiac disease is a member of this group. SYMPTOMS include diarrhea ± emesis, malabsorption, anemia and failure to thrive while on formula, but not on clears or non-whole-protein-containing formulas. This CAN occur in breastfed babies, but only if enough whole protein from the mom’s diet enters the breast milk. It usually presents after switching from breastfeeding to formula. Forty percent of children are also sensitive to soy.

• DIAGNOSIS: Usually made by history, however for if you suspect celiac disease then get an upper endoscopy and duodenal biopsy to look for villous atrophy. Don’t get an allergy skin test.
• TREATMENT: If the mom is breastfeeding, try asking mom to stop drinking milk products. If that doesn’t work, change to HYDROLYSATE formula (formula containing HYDROLYZED cow’s milk proteins) or to an AMINO ACID DERIVED FORMULA. Typically resolves once the GI tract matures, although some food sensitivities may remain.
• MNEMONIC: It’s so much easier if you just call it “FORMULA INDUCED Enteropathy.” SYMPTOMS include diarrhea ± emesis and possibly BLOODY stool or flecks while on formula, but not on clears or non-whole-protein-containing formulas.
• PEARL: Think of “enter” as it’s entering the bowel cells. The wall is location of the problem. The dysfunctional bowel wall interferes with normal absorption, so this can present as failure to thrive.
• PEARL: Less severe than Food Protein Induced Enterocolitis (FPIES). Children with Food Protein Enteropathy usually have less vomiting, no bloody diarrhea and less severe reactions to the problem foods.

(DOUBLE TAKE) FOOD PROTEIN INDUCED PROCTITIS/COLITIS

Food Protein Induced Proctitis/Colitis is another disorder that is NOT IgE mediated so does not need allergy testing. It occurs in the lower GI tract and the main sign is blood in the stools.

• • More common in breastfed infants due to cow’s milk protein in the mother’s diet
  • Babies are usually well other than having blood in the stools
• TREATMENT: Same as for food protein induced enteropathy. Even small amounts of milk protein in mom’s diet can cause problems, so have her check the contents of everything she eats. If eliminating milk doesn’t work, try eliminating eggs, soy, then consult a gastroenterologist. Typically resolves once the GI tract matures, although some food sensitivities may remain.
• PEARL: “This is an “-ITIS” of lower GI tract. These kids appear generally well, but usually present with blood and/or mucus in the stool. It’s due to an intolerance of a protein in their diet. Can be seen in breastfed infants who have a cow milk intolerance. Moms must remove milk from their diet. Kids generally do well later in life when cow’s milk is brought back into their diet.

(DOUBLE TAKE) FOOD PROTEIN INDUCED ENTEROCOLITIS SYNDROME (FPIES)

Food Protein Induced Enterocolitis Syndrome (FPIES) is the other non-IgE mediated food intolerance in infants. Its chronic form is similar to food protein induced enteropathy, with vomiting, diarrhea, and malabsorption. The acute form, however, is more dramatic, with severe vomiting ± diarrhea, often leading to lethargy and a shock-like state. Occurs 1–3 hours after ingestion of offending food. Cow’s milk and soy are the most common triggers but solids, especially RICE, are also frequent. Typically resolves once the GI tract matures, although some food sensitivities may remain.

• PEARL: The exact mechanism is still not known. Seems to be an allergic type of sensitization. Kids have a delayed reaction at 1-3 hours after exposure which results in tons of vomiting, diarrhea and more. Can even look listless and septic. Cow’s milk and soy are the biggest culprits. For older kids, rice and some other solids can be the culprits. They usually to outgrow this condition.