Food Protein-Induced Enterocolitis Syndrome Food Challenges: Experience from a Large Referral Center.

BACKGROUND: Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food allergy that is diagnosed based on clinical findings, but can be confirmed with oral food challenge (OFC). OFC is more often performed to assess the development of tolerance. Most studies describing OFCs in FPIES are limited in size. OBJECTIVE: We sought to describe our experience with OFCs using our FPIES protocol. Patients were given one-third of serving size with a 4-hour observation period, followed by home titration to full dose. METHODS: We conducted a retrospective chart review of patients who underwent OFC via the FPIES protocol from 2014 to 2017. Data regarding the history of reaction, age at the time of challenge, and reactions during challenge or with home introduction were collected. RESULTS: A total of 169 OFCs were completed under the FPIES protocol, in 119 patients to 19 different foods. Thirty challenges (18%) were positive, with 17 challenges (10%) during initial challenge and 13 (7.7%) during home dosing. Most reactions during initial challenge required intravenous fluids (IVF), but hypotension was uncommon. One hundred thirty-nine (82%) OFCs were negative with home introduction, indicating tolerance to the challenged foods. The mean age of passing a challenge to milk, soy, and grain was earlier than that of other solid foods. CONCLUSIONS: Our data suggest that our FPIES OFC protocol is safe. Early administration of IVF may prevent the development of hypotension. It is difficult to stratify the risk of severe or delayed reaction based on patient characteristics, and more data are needed to identify those appropriate for home introduction.

Food allergy. Mechanisms, diagnosis, and management in children.

We eat approximately two to three tons of food in our lifetime, but most people do not have an adverse reaction to foods. Many people believe that they have an allergic reaction to foods; however, the actual incidence confirmed by history and challenges suggests a prevalence rate closer to 2% to 8% in young infants and less than 2% in adults.

Atopy patch test for the diagnosis of food protein-induced enterocolitis syndrome.

Food protein-induced enterocolitis syndrome (FPIES) is thought to be a non-IgE mediated food allergy syndrome. Affected infants typically demonstrate gastrointestinal symptoms after hours after ingestion of the offending food. Traditional allergy testing is not useful for this disorder because tests for food specific IgE are routinely negative. A diagnostic oral food challenge (OFC) is the only method to confirm the diagnosis of FPIES. This prospective study was undertaken to determine whether the atopy patch test (APT) is able to predict the results of the OFC. Nineteen infants with suspected FPIES by clinical history underwent APT to the suspected foods. After APT was performed, subjects underwent OFC to determine whether FPIES was present. The results of APT and OFC were compared and used to calculate sensitivity and specificity of the APT. APT predicted the results of oral food challenges in 28/33 instances. There were 16 cases of FPIES confirmed by oral food challenges. In all 16 cases of FPIES, the APT was positive to the suspected food. However, the APT was positive in five instances where the oral food challenge was negative. All 12 patients with a negative APT had a negative oral food challenge to the suspected food. APT appears to be a promising diagnostic tool for the diagnosis of FPIES.

Development and validation of an instrument to measure asthma symptom control in children.

BACKGROUND: Few instruments exist to measure control of asthma symptoms in children. A brief instrument administered at healthcare visits could provide a more consistent approach to symptom recognition for patients and providers. OBJECTIVE: To develop a Pediatric Asthma Control Tool to measure asthma symptom control at pediatric healthcare visits and evaluate the instrument compared to expert assessment and an asthma-related quality-of-life (QOL) measure. DESIGN/METHOD: A preliminary 14-item instrument was generated through a process of literature review, meetings of institutional experts, and focus groups of parents and providers. The preliminary survey measured asthma control over the past 3 months in 2 domains: frequency of asthma flares and presence of symptoms when the child was at their best. Persistent symptoms were categorized according to published national asthma guidelines (NAEPP). The instrument and an asthma-related QOL measure were administered in the waiting room before a specialist visit for asthma. After the visit the specialist independently assessed asthma control in both domains on a 7-point Likert scale. Internal consistency and assessments of criterion and construct validity were calculated using standard statistics. RESULTS: A total of 200 subjects ranging from 1 to 18 years of age and their caregivers were enrolled; 60% were male. During the prior 3 months, 19% had an emergency visit and 24% described persistent asthma symptoms. After item review the instrument was shortened to five items each for frequency of flares and symptoms at best. Internal consistency was high for each of these domains (Cronbach's alpha = 0.81/0.83, respectively). Correlation of each domain was good when compared to expert assessment (r = 0.54/0.59) and QOL (r = 0.61/0.77). CONCLUSIONS: Responses to a 10-item instrument to measure control of asthma symptoms in children at a healthcare visit demonstrated internal consistency and criterion and construct validity.

Correlation of initial food reactions to observed reactions on challenges.

BACKGROUND: Food allergies occur in 2% to 3% of the pediatric population. These reactions can vary from mild cutaneous manifestations to severe life-threatening reactions. Limited information is available on which specific factors may predict the severity of subsequent reactions. OBJECTIVE: To determine whether the organ system or the specific food involved in the initial allergic reaction predicts the outcome of subsequent food challenge. METHODS: Retrospective review of all food sensitive children who underwent food challenges at The Children's Hospital of Philadelphia, Philadelphia, PA, in a 5-year period (n = 998 challenges). The specific food, initial symptom on presentation, and reaction on open challenges were recorded. RESULTS: A total of 413 of 998 food challenges produced positive results. Milk, egg, and peanut were the most common foods to be associated with a positive challenge result. The most common presentation of food allergy was cutaneous followed by multiorgan reactions. Peanut, milk, and egg sensitivities were more likely to cause a multiple-organ system reaction on challenge than wheat or other foods. Patients with egg allergy were more likely to have a different reaction on rechallenge than other foods. CONCLUSIONS: Milk, egg, and peanut are the most common foods associated with food challenges. Patients will typically experience similar reaction on re-exposure to the initial reaction. However, multiple-organ system reactions can occur after any initial clinical presentation, with milk, egg, and peanut having more multiple-organ reactions than other foods.