FPIES Dietary Guide

Dietary Guide for introducing complementary foods to children with food protein-induced enterocolitis syndrome (FPIES) 

ASCIA PCC Dietary Guide FPIES 2018318.55 KB

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

Acute FPIES is a delayed gut allergic reaction which presents with repetitive, profuse vomiting that typically starts 1-4 hours after a triggering food is eaten. Infants can become pale and lethargic. It usually presents within the first 2 years of life, and in Australia is estimated to occur in 1 in every 7,000 children less than 2 years of age. Avoidance of the trigger food/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 cause FPIES, the most common FPIES triggers are rice, cow’s milk, chicken and egg. FPIES does not commonly occur in exclusively breastfed children, so in most cases there is no need for breastfeeding mothers to exclude foods from their diet.

Is it possible to have FPIES to more than one food?

Most children in Australia only have FPIES to one food. Therefore, avoidance of multiple foods is not necessary in children who have had FPIES to one food unless recommended by your child’s clinical immunology/allergy specialist.

The first episode of FPIES can be traumatic for parents.  Some parents become hesitant to give new foods in case it happens again. However, 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 can lead to fussiness, food refusal, feeding difficulties, poor growth and nutritional deficiencies. Unnecessary delayed introduction of common allergenic food such as egg or peanut can even increase the risk of developing allergy to these foods.

Which foods should my child avoid if they have FPIES?

Children with FPIES to certain foods may be at higher risk of FPIES to other foods.  Your doctor and dietitian will discuss which foods to introduce for your child based upon the food/s they have reacted to, whether they have a higher risk of being allergic to a related second food, and whether they are already eating other foods.

If your child has FPIES, you may need to avoid foods in the table below. Leave any food in your child’s diet that they are already tolerating. 

If your child has FPIES to:	Avoid these foods unless advised by treating allergy specialist
Cow’s milk	Soy
Rice	Oats (introduce other grains, such as wheat and corn)
Chicken	All poultry
Fish	All fish (unless already tolerating other fish species) It is not clear whether children with fish FPIES are at risk of having shellfish FPIES
Fruits/Vegetables	Avoid the fruits or vegetables your child has reacted to and introduce others. You may wish to discuss with your doctor or dietitian which other fruits and vegetables can be introduced or use the following table as a guide.

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.

What if my child has FPIES to more than one food?

If your child reacts to more than one food, 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.

If your child has reacted to more than one food, the following table may be useful to decide which foods to introduce next. Stage 1 foods in the table are low risk foods and can be introduced first, followed by Stage 2 and Stage 3 foods. Introduce one new food every 2-3 days if your child reacts to more than one food. Solids should be introduced around 6 months of age, but not before 4 months and when your child is ready.

Start with smooth pureed foods, moving on to mashed, lumpy and soft finger foods as your child gets older. It is important to give iron rich foods, like meats and grains, early. Small, hard pieces of food should be avoided as they can cause choking.

AVOID any food to which your child has already had a reaction and do not stop giving any foods your child is already tolerating.

Suggested introduction for children with FPIES to more than one food.

	Stage 1 Introduce first	Stage 2 Introduce next	Stage 3 Introduce last (by 12 months)
Vegetables	Parsnip, broccoli, cauliflower, turnip, beetroot, capsicum, cabbage, spinach, kale, tomato, zucchini	Pumpkin, squash, carrot, white potato, green bean, mushroom	Sweet potato, green pea
Fruit	Blueberries, strawberries, plum, watermelon, peach, apricot	Apple, pear, orange, avocado, other melons (eg rockmelon)	Banana
Grains	Quinoa, millet, buckwheat, rye, amaranth, sorghum	Wheat, corn, barley	Oats, rice
Meat, legumes and nuts	Lamb, pork, Tree nuts, seeds (appropriate texture)	Beef Peanut Legumes (e.g. chick peas, lentils)	Turkey, chicken, fish, other seafood, eggs Soy, tofu
Cow’s milk			Cow’s milk, cheese, yoghurt, custard

When can foods be reintroduced?

You should only reintroduce foods that your child has reacted to on under the direction of your clinical immunology/allergy specialist. Most children outgrow FPIES by three to four years of age but some children will outgrow their allergy earlier or later than this. A medically supervised oral food challenge is usually needed to test whether your child has outgrown their FPIES allergy. 

References

1. Nowak-Wegrzyn, A., Chehade, M., Groetch, M. et al (2017). International consensus guidelines for the diagnosis and management of food protein-induced enterocolitis syndrome: executive summary- Workgroup report of the adverse reactions to foods committee, American Academy of Allergy, Asthma & Immunology. Journal of allergy and clinical immunology, 139(4), 1111-1126.
2. Mehr, S., Frith, K., Barnes, E., Campbell, D (2017). Food protein-induced enterocolitis syndrome in Australia: a population-based study, 2012-2014. Journal of allergy and clinical immunology, 140(5), 1323-1330.
3. Venter, C., & Groetch, M. (2014). Nutritional management of food protein-induced enterocolitis syndrome. Current opinion in allergy and clinical immunology, 14(3), 255.
4. 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.
5. 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.
6. 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 2018  

ASCIA is the peak professional body of clinical immunology/allergy specialists in Australia and New Zealand

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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 updated May 2018