Prospective Follow-up Oral Food Challenge in Food Protein-Induced Enterocolitis Syndrome

Abstract

Hwang JB, Sohn SM, Kim AS. Arch Dis Child. 2009;94(6):425–428PURPOSE OF THE STUDY. To determine tolerance rates to cow's milk and soy for infants affected by food protein-induced enterocolitis syndrome (FPIES).STUDY POPULATION. Twenty-three patients (7 female and 16 male) with infantile FPIES were prospectively followed.METHODS. Infants with a diagnosis of FPIES were diagnosed by positive oral food challenges for milk or soy formula at 36 days of age (SD: 14 days; range: 13–58 days). These infants were prospectively followed until >2 years of age. They underwent ≥2 follow-up oral challenges. The first follow-up oral challenges were performed at 6 months of age, and patients were randomly allocated to either milk (N = 11) or soy (N = 12). Second and third follow-up oral challenges were performed at 2-month intervals, in a crossed and switched-over manner. The challenge consisted of a single open oral feeding of 0.03 to 0.05 mg of cow's milk protein or soy protein per kg of body weight.RESULTS. Seventy-two oral food challenges with cow's milk or soy were performed in 23 patients with FPIES. There were 27 positive challenges (37.5%). For all positive challenges, projectile vomiting and lethargy were noted at ∼1 to 4.5 hours. Symptoms less commonly seen were cyanosis in 6 challenges (22.2%) and hypotension in 3 challenges (11.1%). No false-negative challenges were seen among the 45 negative challenges. Tolerance rates for milk at 6, 8, and 10 months of age were 27.3%, 41.7%, and 63.6%, respectively. Tolerance rates for soy at 6, 8, and 10 months of age were 75.0%, 90.9%, and 91.7%, respectively. Mean ages for outgrowing reactivity to cow's milk and soy among the 23 patients were 12.0 months (SD: 4.4 months; range: 6–20 months) and 7.8 months (SD: 2.1 months; range: 6–14 months), respectively. Solid-food FPIES was observed in 2 of the patients (rice, beef, and egg in 1 child >11 months of age and fish and shellfish in 1 child >12 months of age). These 2 children became tolerant to these foods after 2 years of age.CONCLUSIONS. The study reveals that infants with FPIES lose intolerance to soy protein at an earlier age, compared with cow's milk. The authors suggest that soy oral challenge should be performed at 6 to 8 months of age and that milk oral challenge should be conducted when the child is >1 year of age. Challenge should be conducted under close medical supervision. The authors also found that a smaller than previously published challenge dose (0.03 to 0.05 mg of cow's milk or soy protein per kg of body weight) was adequate in inducing symptoms.REVIEWER COMMENTS. Performing oral challenges in infants affected by FPIES is not a light undertaking, as evidenced by the number of children who had a positive oral challenge, cyanosis, and hypotension. This article gives insight to clinicians regarding when and how to perform oral challenges for infants affected by milk and/or soy protein-induced enterocolitis syndrome.