Food protein-induced enterocolitis syndrome: an update on natural history and review of management.

OBJECTIVES To review the clinical features, pathophysiology, and management of food protein-induced enterocolitis syndrome (FPIES) and to discuss new observations in epidemiology and natural history. DATA SOURCES PubMed searches were performed for articles published between 1978 and May 2011 using the keywords food-induced enterocolitis and FPIES. STUDY SELECTION Articles were selected based on their relevance to the topic of this review. The newest developments in FPIES were defined by articles published in the past 3 years. RESULTS FPIES is a non-IgE-mediated gastrointestinal food hypersensitivity thought to be cell-mediated, although the exact pathophysiologic mechanism requires further study. In a recent birth cohort, the incidence of cow's milk FPIES was 0.34% in the first year of life compared with 0.5% for IgE-mediated cow's milk allergy. FPIES typically presents before 6 months of age in formula-fed infants with repetitive emesis, diarrhea, dehydration, and lethargy 1 to 5 hours after ingesting the offending food. Four cases of FPIES in breastfed infants have recently been reported. The most common offending foods are cow's milk, soy, and rice. Diagnosis is based primarily on clinical history and, when unclear, physician-supervised oral food challenges. FPIES is usually outgrown by school age. Although management remains avoidance of the offending food, observations that natural history varies for different foods has redefined the timing of reintroduction. CONCLUSION Early recognition of FPIES and removal of the offending food are imperative to prevent misdiagnosis and mismanagement of symptoms that may mimic other causes. Close follow-up is required to determine when foods may be added back into the diet.