Food Protein-Induced Allergic Proctocolitis (FPIAP)

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Food protein-induced allergic proctocolitis (FPIAP) is a type of delayed inflammatory non-IgE mediated gut food allergy. Symptoms usually start at one to four weeks of age and range from having blood and/or mucous in bowel movements, to blood stained loose stools or diarrhoea. Infants with FPIAP are usually otherwise healthy and growing well. FPIAP mostly occurs in breastfed infants, but can also occur once a cow’s milk or soy based formula is commenced. The main triggers are cow’s milk or soy.

Diagnosis of FPIAP

Allergy tests (skin tests or blood tests for Immunoglobulin E [IgE] antibodies) are negative for infants with FPIAP and therefore not useful.

Diagnosis is based on:

  • Excluding diagnosis of other causes of blood in bowel movements or blood stained diarrhoea, such as gastroenteritis, infections, anal fissures, or bowel malformations/anomaly.
  • If FPIAP is considered likely, then symptoms should resolve once the offending food/s are eliminated from the breastfeeding mother’s and/or infant’s diet.
  • After symptoms have resolved, the offending food/s may be re-introduced to confirm the diagnosis.

Management of FPIAP

If breastfeeding:

  • Cow’s milk (and all dairy) should be removed from the breastfeeding mother’s diet (a dietician may be required to assist). Most cases resolve with elimination of cow’s milk within 48–72 hours, but sometimes longer.
  • If symptoms do not resolve, further changes to the breastfeeding mother’s diet should only be made after seeking medical advice.
  • Once symptoms have resolved, the eliminated foods may be re-introduced into the breastfeeding mother’s diet to confirm the offending food/s.
  • If more than one food protein is restricted from the breastfeeding mother’s diet, this will need supervision by a dietitian, to ensure nutritional adequacy and to prevent excess weight loss in the mother. Maternal calcium requirements during breastfeeding are 1,000mg/day which can be supplied with 800mL/day of calcium fortified cow’s milk replacement such as soy (unless you have been asked to avoid this), rice, almond or oat milk. A calcium supplement may be recommended as this quantity of milk replacement is difficult to consume on a daily basis . If it is a nut, grain or coconut milk substitute then an additional serve of protein should be eaten daily and also a multivitamin taken containing Vitamin B2 (riboflavin).

If an infant is formula fed:

  • It is important to seek medical advice before restricting an infant’s diet, to ensure they receive optimal nutrition. Improvement is usually seen within three to seven days, but it can take up to two weeks.
  • If no improvement is seen, your doctor may recommend an extensively hydrolysed formula (EHF) or occasionally an amino acid formula (AAF). You will need a specialist referral, especially if AAF is recommended.

Resolution of FPIAP

Resolution of FPIAP usually occurs in 50% of infants by the age of six months, and 95% of infants by the age of nine months.

It is generally recommended to reintroduce the offending food/s to the mother’s or infant’s diet after it has been eliminated for six months or at 12 months of age.

For infants who have more severe symptoms, such as blood stained diarrhoea, the offending food/s may be gradually introduced under the supervision of a dietitian.

References

Caubet, J. C., Szajewska, H., Shamir, R. & Nowak-Wegrzyn, A., (2017). Non-IgE-mediated gastrointestinal food allergies in children. Pediatr Allergy Immunol, 28, 6-17. DOI: 10.1111/pai.12659

Venter, C., Brown, T., Meyer, R., Walsh, J., Shah, N., Nowak-Wegrzyn, A., Chen, T. X., Fleischer, D. M., Heine, R. G., Levin, M., Vieira, M. C. & Fox, A. T., (2017). Better recognition, diagnosis and management of non-IgE-mediated cow's milk allergy in infancy: iMAP-an international interpretation of the MAP (Milk Allergy in Primary Care) guideline. Clin Transl Allergy, 7, 26. DOI: 10.1186/s13601-017-0162-y

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