Care Considerations forIgE-Positive Food Protein-Induced Enterocolitis Syndrome

Announcer:
Welcome to On the Frontlines of Food Allergies on ReachMD. On this episode, we’ll hear from Dr. Anna Nowak-Wegrzyn, who’s a Professor of Pediatrics at the New York University School of Medicine and the Director of the Pediatric Allergy Program at Hassenfeld Children’s Hospital at NYU Langone Health. She’ll be discussing how to navigate challenges in managing IgE-positive food protein-induced enterocolitis syndrome. Here’s Dr. Nowak-Wegrzyn now.

Dr. Nowak-Wegrzyn: 
FPIES is classified as a non-IgE-mediated food allergy, which means that allergy tests are negative, but FPIES is also a part of an overall allergic phenotype. And infants and children with FPIES tend to have higher rates of IgE-mediated food allergy to other foods, as well as other additional allergic conditions, such as atopic dermatitis, wheezing, and later in life, allergic rhinitis. So the classic FPIES is IgE-negative, but there’s a category of atypical IgE-positive FPIES, which means that they have a positive skin prick test to the food that cause FPIES reaction, or they may have detectable food-specific IgE to that food that only causes delayed symptoms without any immediate symptoms.

But having the positive IgE—in particular, if the food that causes FPIES is egg, peanut, or milk, which are big allergens for the IgE-mediated food allergy—raises a question. What is the risk for FPIES transitioning to the classic food allergy? This has been described in the literature. So, for instance, up to 30 percent of kids with cow’s milk FPIES may go on to develop IgE positivity to milk. Similar observations in my clinic are true for egg FPIES as well as peanut FPIES. And the challenging part is to know what to expect in case of future exposures because then we have to cover both bases. So we have to be ready to treat FPIES reactions as well as, potentially, more immediate symptoms.

So, unfortunately, this complicates things quite significantly because we’re providing instructions for management of FPIES with antiemetics and oral rehydration, but in case there are more immediate, anaphylactic-type symptoms, we also provide medication for treatment of anaphylaxis. So we have an anaphylaxis emergency treatment plan, which is widely used for IgE-mediated food allergy, so we provide it with antihistamines and epinephrine auto injectors. On the other hand, we also have an FPIES emergency treatment plan that can be found on FPIES.org, and it can be very helpful because it guides the providers on how to address the reaction.

So this is the most confusing and challenging clinical situation when you are dealing with an infant or a child that has a history of FPIES and delayed gastrointestinal symptoms but now—let’s say to peanut—they present for follow-up, they already have atopic dermatitis, and then the skin prick test shows positive reaction to peanut. Then, we really do not know what’s going to transpire during the subsequent exposures. And when we challenge them to evaluate for resolution, we cover both bases, so administer food gradually to account for more immediate symptoms, but also observe them for a long time—up to four hours—to account for potential FPIES symptoms.

Announcer:
That was Dr. Anna Nowak-Wegrzyn talking about treatment considerations for IgE-positive food protein-induced enterocolitis syndrome. To access this and other episodes in our series, visit On the Frontlines of Food Allergies on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!