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Safety of Performing Oral Food Challenges to Food Protein-Induced Enterocolitis Syndrome Patients in the Outpatient Clinic
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Severe Food Protein Induced Enterocolitis Syndrome (FPIES) in the Pediatric Intensive Care Unit (PICU): A Retrospective Chart Review Tamar Weinberger1, Elizabeth Feuille, MD1, Anna H. NowakWegrzyn, MD, FAAAAI2, Cecilia Thompson Physician3; 1Icahn School of Medicine at Mount Sinai, 2Icahn School of Medicine at Mount Sinai, New York, NY, 3One Gustave L Levy Place Box 1202 B, Icahn School of Medicine at Mount Sinai, New York, NY. RATIONALE: FPIES is a diagnosis that is often missed and, if untreated, can lead to severe complications. METHODS: Patients from birth to 7 months admitted to the PICU at Mount Sinai Hospital from June 2012 to June 2014 with the diagnosis codes of failure to thrive, metabolic acidosis, hypovolemic shock, dehydration, vomiting, feeding problems in a newborn, and allergy to milk were selected for medical record review. RESULTS: Out of 100 infants, 10 were identified with likely FPIES; 5 males, 5 females; all presented with vomiting, stool containing blood or mucous, lethargy, pallor, or dehydration with the majority having 5 symptoms. Age of onset ranged from 3 days to 2 months and delay to admission from 2 days to 2 months. All patients had failure to thrive and had presented to a physician or emergency department prior to PICU admission. One patient was exclusively breastfed, 9 were fed cow’s milk formula. Eight patients had anion gap metabolic acidosis; all required fluid resuscitation, 8 underwent a sepsis workup, and one patient underwent a diagnostic laparotomy. Eight patients were switched to a hypoallergenic formula and demonstrated resolution of symptoms. One patient was readmitted to the PICU 10 days later and was then placed on hypoallergenic formula with symptom resolution. One patient was never trialed on hypoallergenic formula and remains symptomatic at the age 9 months. CONCLUSIONS: FPIES is a severe disease that if not promptly diagnosed requires admission to the PICU and must be recognized early in order to prevent complications. Food Induced Gastroenterocolitis Syndrome(FPIES): A Case Series of 51 Children Liseth Villafana, MD, Soledad Terrados Cepeda, MD, Nuria Perez, MD, Belen De La Hoz, MD, PhD, Emilio Alvarez-Cuesta, MD, PhD; Hospital Universitario Ramon y Cajal, Madrid, Spain. RATIONALE: FPIES is a non IgE mediated gastrointestinal food hypersensitivity whose clinical features are severe vomiting, diarrhea and dehydration within a few hours of ingesting food. The foods most frequently implicated in published series are cow’s milk, soy, rice, fish. METHODS: A retrospective study of 51 patients, diagnosed by history and/or oral challenge test between 2006 and 2014. RESULTS: 51 patients, 31 boys and 20 girls (mean age at diagnosis: 12.7 months) were included. The offending foods were fish(27 patients), milk(10), egg(7), beef(3), chicken(1), lentil(1), peanut(1) and chickpeas(1). The most frequent symptoms were vomiting (49 patients), letargy(18), dehydratation(12) and diarrhea(10). 20 patients have other atopic diseases, Skin prick tests y/or specific IgE against implicated food were positive in only one patient . In 12 patients, patch tests were conducted and were positive in 2 cases. 37 oral challenges test were performed in 27 patients 12 or more month after diagnosis We found that no patient outgrew FPIES by fish by 2 years of age, 44% by 3 years, 66% by 6 years and 88% by 8 years of age. By contrast 80% of FPIES by milk recovered by the age of 2 years and 100% at 3 years old. In case of egg, all patients recovered by 4 years old. CONCLUSIONS: This is one of the largest series published of FPIES. It seems to be an increase in prevalence of this syndrome. The most frequent culprit food is fish with an elder age of achieved tolerance compared to other foods.
Safety of Performing Oral Food Challenges to Food ProteinInduced Enterocolitis Syndrome Patients in the Outpatient Clinic Andrew T. Dang, MD, Irene Mikhail, MD; Nationwide Children’s Hospital, Columbus, OH. RATIONALE: Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food reaction typically occurring in young infants that resolves over time, and the oral food challenge (OFC) remains the gold standard for evaluating its resolution. We wanted to investigate utilization and safety outcomes of OFCs in FPIES patients seen in the outpatient setting. METHODS: Chart review was performed of 1460 patients with a visit diagnosis of ‘‘food allergy’’ or ‘‘food hypersensitivity’’ seen in a tertiary care referral allergy clinic between Oct 2009 and Dec 2013. Twenty five patients were identified with FPIES. RESULTS: The mean age at diagnosis was 8.5 months. 40% of patients were male, 12% had concomitant IgE-mediated food allergy, and 20% had other atopic conditions (most frequently atopic dermatitis). Most common foods implicated were rice (64%), oat (48%), and cow’s milk (28%). 68% of patients had reactions to more than one food. 38 OFCs were performed, with a mean age of 34 months at first OFC. 12 challenges were performed at home and 26 challenges were performed in the office, 22 as food reintroductions after a previous reaction and 16 as initial food introductions. One OFC failed at home and five OFCs failed in the office. Milk was the most common trigger for failed challenges. Most failed challenges were treated with observation and oral hydration but one challenge required transfer to the emergency department and treatment with intravenous fluids and steroids. CONCLUSIONS: In carefully selected patients, OFC can be performed in the clinic without intravenous access if emergency services are easily accessible.
Atypical Food Protein-Induced Enterocolitis Syndrome (FPIES) Christopher P. Parrish, M.D.1, Andrew K. Wong, M.D.2, Salima A. Thobani, M.D.1, Lyne G. Scott, M.D.1, Marilyn Li, M.D.1; 1University of Southern California, 2University of Southern California, Los Angeles, CA. RATIONALE: FPIES is a non-IgE-mediated food hypersensitivity that typically presents in infancy with severe vomiting and lethargy within hours of eating the offending food. It may also present in a chronic form with diarrhea, emesis, and failure to thrive. Milk FPIES often has a prolonged course, especially with a positive milk-specific IgE. We present an infant with chronic milk and soy FPIES without significant emesis and tolerance of milk products at 12 months of age. METHODS: Case Report. RESULTS: This Hispanic male was born at full-term without complications and fed cow’s milk infant formula but frequent, watery, nonbloody stools began by 3 weeks of age. The patient was admitted twice for suspected sepsis and failure to thrive by 6 weeks of age, with associated metabolic acidosis and dehydration. Infectious workup was unrevealing and symptoms resolved after the patient was kept NPO and then switched to amino acid-based formula. Serum IgE to milk and soy were elevated. The patient subsequently did well on amino acid-based formula with avoidance of milk and soy products. Other foods were introduced without difficulty. Just prior to 12 months of age mom reported that successful introduction of yogurt at home without symptoms. CONCLUSIONS: This case of FPIES is unique because of the lack of emesis in the initial presentation. The tolerance of milk products prior to one year of age is also highly unusual, especially in the setting of elevated serum IgE to milk.
SATURDAY
Abstracts AB47
J ALLERGY CLIN IMMUNOL VOLUME 135, NUMBER 2
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Severe Food Protein Induced Enterocolitis Syndrome (FPIES) in the Pediatric Intensive Care Unit (PICU): A Retrospective Chart Review Tamar Weinberger1, Elizabeth Feuille, MD1, Anna H. NowakWegrzyn, MD, FAAAAI2, Cecilia Thompson Physician3; 1Icahn School of Medicine at Mount Sinai, 2Icahn School of Medicine at Mount Sinai, New York, NY, 3One Gustave L Levy Place Box 1202 B, Icahn School of Medicine at Mount Sinai, New York, NY. RATIONALE: FPIES is a diagnosis that is often missed and, if untreated, can lead to severe complications. METHODS: Patients from birth to 7 months admitted to the PICU at Mount Sinai Hospital from June 2012 to June 2014 with the diagnosis codes of failure to thrive, metabolic acidosis, hypovolemic shock, dehydration, vomiting, feeding problems in a newborn, and allergy to milk were selected for medical record review. RESULTS: Out of 100 infants, 10 were identified with likely FPIES; 5 males, 5 females; all presented with vomiting, stool containing blood or mucous, lethargy, pallor, or dehydration with the majority having 5 symptoms. Age of onset ranged from 3 days to 2 months and delay to admission from 2 days to 2 months. All patients had failure to thrive and had presented to a physician or emergency department prior to PICU admission. One patient was exclusively breastfed, 9 were fed cow’s milk formula. Eight patients had anion gap metabolic acidosis; all required fluid resuscitation, 8 underwent a sepsis workup, and one patient underwent a diagnostic laparotomy. Eight patients were switched to a hypoallergenic formula and demonstrated resolution of symptoms. One patient was readmitted to the PICU 10 days later and was then placed on hypoallergenic formula with symptom resolution. One patient was never trialed on hypoallergenic formula and remains symptomatic at the age 9 months. CONCLUSIONS: FPIES is a severe disease that if not promptly diagnosed requires admission to the PICU and must be recognized early in order to prevent complications. Food Induced Gastroenterocolitis Syndrome(FPIES): A Case Series of 51 Children Liseth Villafana, MD, Soledad Terrados Cepeda, MD, Nuria Perez, MD, Belen De La Hoz, MD, PhD, Emilio Alvarez-Cuesta, MD, PhD; Hospital Universitario Ramon y Cajal, Madrid, Spain. RATIONALE: FPIES is a non IgE mediated gastrointestinal food hypersensitivity whose clinical features are severe vomiting, diarrhea and dehydration within a few hours of ingesting food. The foods most frequently implicated in published series are cow’s milk, soy, rice, fish. METHODS: A retrospective study of 51 patients, diagnosed by history and/or oral challenge test between 2006 and 2014. RESULTS: 51 patients, 31 boys and 20 girls (mean age at diagnosis: 12.7 months) were included. The offending foods were fish(27 patients), milk(10), egg(7), beef(3), chicken(1), lentil(1), peanut(1) and chickpeas(1). The most frequent symptoms were vomiting (49 patients), letargy(18), dehydratation(12) and diarrhea(10). 20 patients have other atopic diseases, Skin prick tests y/or specific IgE against implicated food were positive in only one patient . In 12 patients, patch tests were conducted and were positive in 2 cases. 37 oral challenges test were performed in 27 patients 12 or more month after diagnosis We found that no patient outgrew FPIES by fish by 2 years of age, 44% by 3 years, 66% by 6 years and 88% by 8 years of age. By contrast 80% of FPIES by milk recovered by the age of 2 years and 100% at 3 years old. In case of egg, all patients recovered by 4 years old. CONCLUSIONS: This is one of the largest series published of FPIES. It seems to be an increase in prevalence of this syndrome. The most frequent culprit food is fish with an elder age of achieved tolerance compared to other foods.
Safety of Performing Oral Food Challenges to Food ProteinInduced Enterocolitis Syndrome Patients in the Outpatient Clinic Andrew T. Dang, MD, Irene Mikhail, MD; Nationwide Children’s Hospital, Columbus, OH. RATIONALE: Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food reaction typically occurring in young infants that resolves over time, and the oral food challenge (OFC) remains the gold standard for evaluating its resolution. We wanted to investigate utilization and safety outcomes of OFCs in FPIES patients seen in the outpatient setting. METHODS: Chart review was performed of 1460 patients with a visit diagnosis of ‘‘food allergy’’ or ‘‘food hypersensitivity’’ seen in a tertiary care referral allergy clinic between Oct 2009 and Dec 2013. Twenty five patients were identified with FPIES. RESULTS: The mean age at diagnosis was 8.5 months. 40% of patients were male, 12% had concomitant IgE-mediated food allergy, and 20% had other atopic conditions (most frequently atopic dermatitis). Most common foods implicated were rice (64%), oat (48%), and cow’s milk (28%). 68% of patients had reactions to more than one food. 38 OFCs were performed, with a mean age of 34 months at first OFC. 12 challenges were performed at home and 26 challenges were performed in the office, 22 as food reintroductions after a previous reaction and 16 as initial food introductions. One OFC failed at home and five OFCs failed in the office. Milk was the most common trigger for failed challenges. Most failed challenges were treated with observation and oral hydration but one challenge required transfer to the emergency department and treatment with intravenous fluids and steroids. CONCLUSIONS: In carefully selected patients, OFC can be performed in the clinic without intravenous access if emergency services are easily accessible.
Atypical Food Protein-Induced Enterocolitis Syndrome (FPIES) Christopher P. Parrish, M.D.1, Andrew K. Wong, M.D.2, Salima A. Thobani, M.D.1, Lyne G. Scott, M.D.1, Marilyn Li, M.D.1; 1University of Southern California, 2University of Southern California, Los Angeles, CA. RATIONALE: FPIES is a non-IgE-mediated food hypersensitivity that typically presents in infancy with severe vomiting and lethargy within hours of eating the offending food. It may also present in a chronic form with diarrhea, emesis, and failure to thrive. Milk FPIES often has a prolonged course, especially with a positive milk-specific IgE. We present an infant with chronic milk and soy FPIES without significant emesis and tolerance of milk products at 12 months of age. METHODS: Case Report. RESULTS: This Hispanic male was born at full-term without complications and fed cow’s milk infant formula but frequent, watery, nonbloody stools began by 3 weeks of age. The patient was admitted twice for suspected sepsis and failure to thrive by 6 weeks of age, with associated metabolic acidosis and dehydration. Infectious workup was unrevealing and symptoms resolved after the patient was kept NPO and then switched to amino acid-based formula. Serum IgE to milk and soy were elevated. The patient subsequently did well on amino acid-based formula with avoidance of milk and soy products. Other foods were introduced without difficulty. Just prior to 12 months of age mom reported that successful introduction of yogurt at home without symptoms. CONCLUSIONS: This case of FPIES is unique because of the lack of emesis in the initial presentation. The tolerance of milk products prior to one year of age is also highly unusual, especially in the setting of elevated serum IgE to milk.
SATURDAY
Abstracts AB47
J ALLERGY CLIN IMMUNOL VOLUME 135, NUMBER 2