FURTHER CHARACTERIZATION OF MULTIPLE FOOD PROTEIN INTOLERANCES OF INFANCY, AN ENTITY DISTINCT FROM FPIES

Abstract

Introduction FPIES is a non-IgE-mediated food allergy presenting in the first year of life with vomiting and diarrhea, up to 80% reacting to more than one food. Among patients who have multiple intolerances are a group that have intolerances to protein hydrolysate-based formulas but do well on elemental formulas. First described in 1995 as “multiple food protein intolerance of infancy” with serious nutritional problems, McWilliams reported a similar case series of twenty-four infants in JACI: In Practice 2016. Case Description Thirteen patients, including two sibling pairs, were followed for multiple non-IgE-mediated food intolerances. Average age of onset was 2.3 months, ten patients developed symptoms by one month. Vomiting was the presenting symptom in 77% (69% with diarrhea, 46% with lethargy), 69% had sleep issues, and 85% had significant mucous in stool. Eight of thirteen had parental complaint of hematochezia. The most common intolerances were rice, squash, banana, and avocado. All patients had intolerances to at least 5 foods (maximum 31), resulting in 62% with suboptimal weight gain. 90% of formula fed patients required an elemental formula. None have had total resolution (69% followed ≥ 2 years old; longest for 8 years). Discussion Patients with multiple food intolerances and symptoms of vomiting, diarrhea, and lethargy are often treated as having FPIES. However, our patients have a different presentation, including hematochezia, mucous in stools and behavior changes. These are important to recognize as they follow different patterns of intolerances, require elemental formulas, develop suboptimal growth, and have slower resolution of symptoms.