Brief communication

Food protein-induced enterocolitis to casein hydrolysate formulas☆,☆☆

Cow's milk protein allergy (CMPA) is the most common food allergy in childhood and its prevalence ranges between 1.9% and 4.9%. Most children present with CMPA at age less than 1 year and therefore may require a hypoallergenic formula in the absence of breast milk. Hypoallergenic formulas include both extensively hydrolyzed formula (EHF) and amino acid formula (AAF). For most children with a CMPA, an EHF will be sufficient for symptom resolution, as reflected in current guidelines, but there is a subset of children with CMPA where an AAF may be indicated. The appropriate use of an AAF is a highly debated topic, because there is a significant fiscal burden to either the health care system or the parents. From the literature, the following themes were identified as possible reasons for choosing an AAF: (1) symptoms not fully resolved on EHF, (2) faltering growth/failure to thrive, (3) multiple food eliminations, (4) severe complex gastrointestinal food allergies, (5) eosinophilic esophagitis, (6) food protein–induced enterocolitis syndrome, (7) severe eczema, and (8) symptoms while breast-feeding. Each of these themes was critically reviewed using all available published data and found that using an AAF in height growth faltering may be indicated. In addition, patients who end up on an AAF often present with multisystem involvement, requiring multiple food eliminations and fall within the more severe spectrum of gastrointestinal allergies. In eosinophilic esophagitis, all current recommendations support the use of an AAF as first-line approach, and in children with anaphylaxis, despite limited evidence an AAF is recommended because of the potential risk for a severe reaction. The use of an AAF in children who are breast-fed remains a highly controversial topic and at all times breast-feeding should be supported in children with CMPA. This article provides a practical guide that is evidence based for health care professionals to the use of AAF.

Food protein–induced enterocolitis (FPIES) is a non-IgE cell- mediated food allergy that can be severe and lead to shock. Despite the potential seriousness of reactions, awareness of FPIES is low; high-quality studies providing insight into the pathophysiology, diagnosis, and management are lacking; and clinical outcomes are poorly established. This consensus document is the result of work done by an international workgroup convened through the Adverse Reactions to Foods Committee of the American Academy of Allergy, Asthma & Immunology and the International FPIES Association advocacy group. These are the first international evidence-based guidelines to improve the diagnosis and management of patients with FPIES. Research on prevalence, pathophysiology, diagnostic markers, and future treatments is necessary to improve the care of patients with FPIES. These guidelines will be updated periodically as more evidence becomes available.

The prevalence of allergic conditions (atopic conditions) has been increasing and affects up to a third of the global population. The effects of early nutrition on the development of allergic conditions and its role in their dietary management is well-recognized. The purpose of this chapter is to review the role of early nutrition on specific allergic conditions, focused on atopic dermatitis, the most common allergic disease in infancy, and on emerging evidence related to the role of nutrition in food protein induced enterocolitis syndrome and eosinophilic esophagitis. Implications of nutrition during this early period of growth and development has the potential to impact the quality of life of children and their long-term health.

There is increasing recognition of the non–IgE-mediated gastrointestinal food allergy known as food protein–induced enterocolitis syndrome (FPIES), with several recent publications summarizing the clinical experience with FPIES in the United States, the United Kingdom, Europe, and Australia. Our understanding of the mechanisms linking food exposure to typical symptoms of vomiting, hypotension, and diarrhea has lagged far behind our understanding of the immune mechanisms of IgE-mediated food allergy. The goal of this overview is to summarize and critique the current state of knowledge of the immunology of FPIES and to identify major gaps in our knowledge that need to be addressed to make significant gains in developing therapies and prevention strategies for FPIES.