Oral Food Challenge in Food Protein-Induced Enterocolitis Syndrome by Fish: Is There Any Room for Improvement?

Abstract

Background: Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated gastrointestinal food hypersensitivity usually due to cow’s milk or soy. Among the solid foods, rice is one of the most causative foods worldwide, but it varies depending on the geographic area. In the Mediterranean countries, fish is one of the most important triggers of FPIES. There is not a specific biological marker for the disease that allows us to confirm the diagnosis or to predict when tolerance to the offending food has been achieved, so all patients with a FPIES diagnosis undergo an oral food challenge (OFC) at least once. The OFC is a risky procedure and many patients develop severe symptoms. Objective: We sought to evaluate the safety of a new OFC protocol in children with fish-FPIES. Methods: A retrospective study was performed over a 22-year period (1996–2018). We compared two methodologies used in the OFC: Method 1 that consisted in giving several doses during the same day versus Method 2 that consisted in giving a unique dose per day on 2 or three non-consecutive days. Results: A total of 75 positive OFC with fish done in 40 children were included. Forty-three (57.3%) OFC were performed following Method 1 and 32 (42.7%) with Method 2.The severity of the symptoms of the OFC done with Method 1 was mostly moderate (41.9%) followed by severe (39.5%) and mild (18.6%). The adverse reactions with Method 2 were mostly mild (68.8%) and only 18.8 and 12.5% presented moderate or severe symptoms, respectively. Conclusions: OFC performed in children with fish-FPIES are risky and many patients develop moderate or severe symptoms after this procedure. We propose a new protocol that has demonstrated to improve safety.

A modified oral food challenge in children with food protein‐induced enterocolitis syndrome

“…In conclusion, our results, as the method 2 of Infante, show that a quarter of the full dose, as a trigger dose, is sufficient for eliciting reactions and that the temporal latency between the first and second dose should be longer than the 30 minutes as recommended by the current guidelines.…”

“…A variety of protocols for FPIES‐related OFC have been published, differing in amount and number of doses and timing …”

“…Recently, Infante et al compared two methodologies used in the OFC for patients with FPIES to fish: the method 1 consisted in giving several doses (1/8 + 1/4 + 1/2 + the remaining of the whole meal) over 30 minutes during the same day vs method 2 that consisted in giving 25% of the serving size per age on day 1, 48 hours later, a 50% of the serving size per age and finally, after other 48 hours, a normal serving size per age on the third non‐consecutive day. In 41 (95.3%) positive OFCs performed with the method 1, the symptoms started after the complete serving size per age was given, while only in 6 (18.7%) the OFC performed with method 2, and the symptoms appeared after the whole meal was eaten.…”

“…A variety of protocols for FPIES-related OFC have been published, differing in amount and number of doses and timing. [3][4][5][6][7][8][9] In particular, Infante et al 3 performed OFCs on 2 non-consecutive days: on the first day, the child was given a single dose slightly <50% of the serving age. If tolerated and the child remained free of symptoms for 48 hours, a full serving dose was offered.…”

'Diagnosing food protein‐induced enterocolitis syndrome'

“…38,40 This has led to particular weaning A variety of other protocols for OFC have been published, differing in amount and number of doses and timing between the administered dose. 12,14,20,60,[68][69][70][71][72][73] Since the different OFC protocols have not been studied or compared systematically, it is at the supervising physician's judgement to adopt the protocol that best suits the patient's characteristics. 30 The timing and severity of previous reactions, as well as the amount of food ingested, should be considered when tai-…”