Food Protein–Induced Enterocolitis Syndrome Food Challenges: Experience From a Large Referral Center

Abstract

To describe experience with oral food challenges (OFCs) for food protein-induced enterocolitis syndrome (FPIES), using a protocol that includes ingestion of one-third of the goal food serving size with 4 hours of observation, followed by home titration to goal dose.A total of 119 subjects underwent 169 OFCs at Children’s Hospital of Philadelphia to 19 different foods between 2014 and 2017. Patients with food protein-induced allergic proctocolitis were excluded. Patients with intermittent food exposures and delayed emesis within 1 to 4 hours and/or diarrhea within 5 to 10 hours were classified as having acute FPIES. Patients with daily ingestion of the food with intermittent emesis, chronic diarrhea, poor weight gain, or malnutrition were classified as having chronic FPIES.This was a retrospective chart review. Data regarding age, sex, implicated foods, age of onset, and symptoms prompting food challenge were collected. OFC data were also collected, including age at the time of challenge, cumulative dose of food, outcome of challenge, timing to reaction, treatment of positive challenge results, disposition, and presence of a late reaction.Thirty OFCs (18%) resulted positive, with 17 (10%) resulting positive during the initial challenge and 13 (7.7%) during home dosing. Most reactions during initial OFC required intravenous fluids (IVFs). Two patients developed hypotension. In 139 OFCs (82%), patients tolerated both initial OFC and home dose titration. One hundred twenty six OFCs (75%) were performed in patients with a previous history of FPIES reaction to the index food, and 43 OFCs (25%) were performed to foods avoided as a precaution. In all positive OFC results, symptoms of acute FPIES reaction occurred at least 85 minutes after dosing. Of all OFCs performed, IVF was administered to 14 patients (7.1%), and ondansetron was administered to 12 patients (6.1%). The mean age of passing an OFC to milk, soy, and grain was lower than that of other solid foods. The mean age of passing an OFC to milk was 35 months, soy was 38.4 months, and grains were 35.7 months.This FPIES OFC protocol is safe. Early administration of IVFs may prevent the development of hypotension. It is difficult to stratify the risk of a severe or delayed reaction on the basis of patient characteristics. More data are needed to identify patients appropriate for home food introduction.Risk stratification based on patient histories is challenging. In the studied population, there was overlap of clinical features between patients who required IVFs and those who were able to orally rehydrate in the context of a positive OFC result. Data from this single-center referral center for FPIES are encouraging and suggest potential for home food reintroduction in older patients. Data regarding the mean age of successful reintroduction for various foods in this study may help to inform future studies.