Food Protein-Induced Enterocolitis Syndrome (FPIES)

Frequently Asked Questions

This document has been developed by ASCIA, the peak professional body of clinical immunology/allergy specialists in Australia and New Zealand. ASCIA information is based on published literature and expert review, is not influenced by commercial organisations and is not intended to replace medical advice. For patient or carer support contact Allergy & Anaphylaxis Australia or Allergy New Zealand.

This FAQ includes a Dietary Guide and should be used with an ASCIA FPIES Action Plan.

ASCIA PC FPIES FAQ 2024174.96 KB

Q 1: What is food protein-induced enterocolitis syndrome (FPIES)?

Food protein-induced enterocolitis syndrome (FPIES) is a delayed, non-IgE mediated gastrointestinal system (gut) food allergy. FPIES causes allergic reactions to food/s that involves the gut and usually starts in the first two years of life. It is estimated to affect 1 in 7,000 children under two years. FPIES is uncommon in adults.

Q 2: What are the symptoms of food protein-induced enterocolitis syndrome (FPIES)?

FPIES causes lots of vomiting, over and over, usually one to four hours after a trigger food is eaten. Some infants (babies) can become floppy, pale, cold and have diarrhoea.

Chronic (long-term) FPIES is uncommon, and usually occurs when infants continue to eat a trigger food, which is usually cow’s milk (dairy) protein or soy. Symptoms include ongoing vomiting and/or diarrhoea that can lead to poor weight gain over time.

Any food can trigger FPIES. The most common triggers for infants and children are rice, oat, cow's milk and egg. FPIES rarely happens in infants who are only being breastfed.

The most common food trigger of FPIES for adults is seafood.

Q 3: How is food protein-induced enterocolitis syndrome (FPIES) different to other food allergy?

FPIES is different to Immunoglobulin E (IgE) mediated food allergy because:

It is usually a delayed reaction (IgE mediated food allergy reactions are usually immediate).
Reactions only involve the gut.
It does not cause hives, welts or swellings.
It does not cause anaphylaxis, so adrenaline (epinephrine) is not used.

It is possible for a person with FPIES to also have food allergies that are IgE mediated.

Q 4: How is food protein-induced enterocolitis syndrome (FPIES) diagnosed?

The diagnosis of FPIES is made by a doctor based on the history of reactions and symptoms:

A person with FPIES usually gets better within hours after an acute FPIES reaction.
There are no blood or skin tests that can confirm a diagnosis of FPIES – allergen specific IgE testing, skin prick testing and atopy patch testing are not useful.
Blood tests may be ordered to look for conditions that have similar symptoms to FPIES. Some blood test results may look similar to infection but usually, other signs of infection are not present.

Q 5: How is food protein-induced enterocolitis syndrome (FPIES) prevented and managed?

The only way to prevent FPIES reactions is to avoid the trigger food/s.

FPIES reactions are managed by giving fluids to maintain hydration. In some cases, ondansetron wafers (a medication that dissolves in the mouth) are prescribed to help stop vomiting. In cases where the vomiting is very bad and the child is pale and floppy, intravenous fluids may be needed.

Q 6: FPIES Dietary Guide: What foods need to be avoided?

Your child’s clinical immunology/allergy specialist and dietitian should discuss which foods to avoid and which foods to introduce to your child. These foods are outlined below.

If your child has FPIES to:	Foods to avoid introducing - unless advised by your child’s clinical immunology/allergy specialist
Cow’s milk (dairy)	Do not feed soy
Rice	Do not feed oats Introduce other grains such as wheat and corn
Chicken	Do not feed any poultry
Fish	Do not feed any fish (unless already tolerating some types of fish) Your child’s clinical immunology/allergy specialist or allergy dietitian will advise whether your child can have other seafood
Fruits or Vegetables	Avoid those your child has reacted to, and introduce others If you are not sure, discuss which other fruits and vegetables to introduce with your child’s immunology/allergy specialist or dietitian

Note:

Do not stop any foods that your child is currently eating without issues. Continue to introduce your child to a wide range of foods. For example, if your child has FPIES to rice but already tolerates oats, avoid rice but leave oats in their diet and keep introducing other foods.
FPIES reactions are rarely triggered by breastmilk, and so in most cases there is no need for a breastfeeding mother to exclude the infant's FPIES triggers from their own diet.
Most children outgrow FPIES by three years of age, but this can sometimes be earlier or later. If the trigger food is given to the child before they grow out of FPIES, they can have a reaction. A plan for when and how to reintroduce the FPIES trigger food/s will be advised by your child’s clinical immunology/allergy specialist. The long-term outcome for a child with FPIES is excellent.
Having FPIES to certain foods may increase the risk of FPIES to another food. However, most children (75%) will only have one food trigger for FPIES and only need to avoid one food. If your child reacts to more than one food, discuss management with your clinical immunology/allergy specialist and an experienced paediatric allergy dietitian.
After the first episode of FPIES it can be difficult for parents to give new foods due to fear that FPIES will happen again. It is important to continue to offer a wide range of foods during the first year of life so that children will accept a variety of foods and textures.
Limiting the range of foods given to a child can lead to poor nutrition including a lack of vitamins and minerals, poor growth, food refusal and feeding difficulties in the child. Giving allergenic food like egg or peanut later than is recommended could increase the risk of a child developing allergy to these foods.
A paediatric allergy dietitian can make a feeding plan to help with progress in feeding while avoiding FPIES triggers.