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FPIES Dietary Guide

This diet sheet should be read in conjunction with the ASCIA FPIES fact sheet:

www.allergy.org.au/patients/food-other-adverse-reactions/food-protein-induced-enterocolitis-syndrome-fpies

pdfASCIA PCC Dietary Guide FPIES 2016455.1 KB

Acute FPIES is a delayed gut allergic reaction which presents with repetitive, profuse vomiting that typically starts 2-4 hours after a triggering food is eaten. Avoidance of trigger food protein/s is the only effective treatment option. Most children will outgrow their FPIES in the preschool years.

Which foods trigger FPIES?

Although any food can potentially cause FPIES, the most common FPIES triggers are rice, oats, cow's milk (dairy), soy and egg. FPIES rarely occurs in exclusively breastfed infants.

Is it possible to have FPIES to more than one food?
The majority of children only have FPIES to one food. Therefore, avoidance of multiple foods is not recommended in children who have had FPIES to one food.

Dietary adequacy

The first episode of FPIES can be traumatic for parents. Some parents become hesitant to give new foods in case it happens again. It is however, very important to continue to expand the range of foods introduced to encourage a wide acceptance of many foods and textures as infants grow older. Limiting the range of foods can lead to fussiness, food refusal, feeding difficulties and nutritional deficiencies.

Infants with FPIES to certain foods may be at higher risk of FPIES to other foods within the same food group. More rarely, some infants with FPIES to one food may be at increased risk of reacting to another food from a different group. Your doctor and dietitian will discuss with you how to introduce complementary foods for your infant with FPIES, based upon the food/s they have reacted to and whether they have already had other foods introduced into their diet.

In general, the following guidelines can be applied to the introduction and avoidance of additional new foods into the diet of infants with FPIES:

Food to which infant has had FPIES reaction

Avoid these foods unless advised by treating allergy specialist

Cow’s milk

Soy

Rice

Oats (other grains, such as wheat, rye, barely are usually safe)

Chicken

All poultry

Fish

All fish (unless tolerating other fish species)

It is not clear whether children with fish FPIES are at risk of having shellfish FPIES

Fruits/Vegetables

Discuss with your doctor which other fruits and vegetables can be introduced

Currently there have been no studies to determine whether delaying the introduction of certain foods results in a reduced risk of developing FPIES to that food.

The following table may be useful when deciding which foods to introduce to an infant with FPIES. If your infant reacts to an additional food, then you need to discuss what to do next with your clinical immunology/allergy specialist, who may refer you to a specialist dietitian with experience in managing FPIES.

Stage 1 is recommended to begin from 4-6 months when your infant is ready, but not before 4 months. Foods can be introduced one at a time, starting with small amounts and increasing the amount over 2-3 days before moving onto the next food.

DO NOT introduce a food to which your infant has already had a reaction (e.g. if your infant has had an FPIES reaction to rice, do not introduce it at 9-12 months as per the table below, but introduce the other grains).

 

Stage 1

4-6 months

Stage 2

6 – 9 months

Stage 3

9 – 12 months

Textures

Smooth purees moving onto mashed foods

Mashed foods with soft lumps

Soft finger foods

Minced and chopped foods

Suitable* finger foods

Vegetables

Pumpkin, parsnip, broccoli, cauliflower beetroot, capsicum, cabbage, spinach, kale

Expand range e.g. celery, cucumber, eggplant

Sweet potato, zucchini, squash, tomato, carrot,  green beans, white potato

Fruit

Apple, pear, peach, nectarine, melon, berries, grapes

Expand range e.g. Mango, papaya, pineapple, avocado

Banana, orange, kiwi

Grains

Quinoa, millet, buckwheat, rye, amaranth

Corn, barley

Oats, rice, wheat

Meat and alternatives

Beef, pork, kangaroo

Lamb

Turkey, chicken, fish, eggs

Legumes

Beans e.g. Cannellini beans, kidney beans

Peas, lentils, chickpeas, other dried beans, smooth peanut butter

Other nut pastes, nuts, seeds

Soy

If FPIES to any cow's milk based food, delay introduction of soy to around 10 months of age unless already tolerating soy

 

Tofu, other soy products e.g. Soy beans, soy drink, soy yoghurt, soy sauce, meat substitutes/ processed meat

Cow’s milk/dairy

If FPIES to any soy based food, delay introduction of dairy to around 10 months unless already tolerating dairy

 

Butter, milk in crackers and rusks, cheese, yoghurt, home baked foods with fresh milk, custard and fresh milk last

* Small, hard pieces of food should be avoided as they can cause choking. 

References

1. Mehr SS, Kakakios AM, Kemp AS. Rice: a common and severe cause of food protein-induced enterocolitis syndrome. Arch Dis Child. 2009; 94: 220-223.
2. Fogg MI, Brown-Whitehorn TA, Pawlowski NA, Spergel JM. (2006). Atopy Patch Test for the Diagnosis of Food Protein-Induced Enterocolitis Syndrome. Pediatric Allergy and Immunology 17: 351–355. http://pediatrics.aappublications.org/cgi/content/abstract/120/Supplement_3/S116.
3. Sicherer, SH. (2005). Food Protein-Induced Enterocolitis Syndrome: Case Presentations and Management Lessons. Journal of Allergy and Clinical Immunology Vol. 115, 1:149-156. http://www.jacionline.org/article/PIIS0091674904024881/fulltext
4. Nowak-Wegrzyn, A., Sampson, HA, Wood, RA, Sicherer, SH. MD, Robert A. Wood, MD and Scott H. Sicherer, MD. (2003). Food Protein-Induced Enterocolitis Syndrome Caused by Solid Food Proteins. Pediatrics. Vol. 111. 4: 829- 835. http://pediatrics.aappublications.org/cgi/content/full/111/4/829#T1
5. Levy Y, Danon YL. Food protein-induced enterocolitis syndrome – not only due to cow's milk and soy. Pediatr Allergy Immunol 2003:14:325–329.
6. Venter, C., & Groetch, M. (2014). Nutritional management of food protein-induced enterocolitis syndrome. Current opinion in allergy and clinical immunology, 14(3), 255.
7. Leonard, S. A., & Nowak-Wegrzyn, A. (2012). Clinical diagnosis and management of food protein-induced enterocolitis syndrome. Current opinion in pediatrics, 24(6), 739-745.
8. Meyer, R., Rommel, N., Van Oudenhove, L., Fleming, C., Dziubak, R., & Shah, N. (2014). Feeding difficulties in children with food protein‐induced gastrointestinal allergies. Journal of gastroenterology and hepatology, 29(10), 1764-1769.
9. Miceli Sopo, S., Greco, M., Monaco, S., Tripodi, S., & Calvani, M. (2013). Food protein-induced enterocolitis syndrome, from practice to theory. Expert review of clinical immunology, 9(8), 707-715.

© ASCIA 2015
The Australasian Society of Clinical Immunology and Allergy (ASCIA) is the peak professional body of clinical immunology and allergy specialists in Australia and New Zealand.
Website: www.allergy.org.au
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Postal address: PO Box 450 Balgowlah NSW Australia 2093

Disclaimer

This document has been developed and peer reviewed by ASCIA members and is based on expert opinion and the available published literature at the time of review. Information contained in this document is not intended to replace medical advice and any questions regarding a medical diagnosis or treatment should be directed to a medical practitioner. 
The development of this document is not funded by any commercial sources and is not influenced by commercial organisations.

Content last updated December 2015

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