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FPIES: The poorly understood food allergy you’ve never heard of

Rice, cow milk and eggs have been found to trigger an allergic reaction in the stomach that affects children under two years, a new Australian study has found.

A population-based survey of paediatricians using the Australian Paediatric Surveillance Unit network estimated acute FPIES affects 15 out of 100,000 infants under two years of age each year, but new research suggests this number might be greatly underestimated.

Our limited knowledge on food protein-induced enterocolitis syndrome (FPIES) has led doctors to confuse it with sepsis or gastroenteritis in erroneous diagnoses in infants.

The new research, which was published in the Medical Journal of Australia, is shedding new light on this poorly understood food allergy – which was previously considered a rare affliction – and indicates it may be more common than previously thought.

“Diagnosis is often hampered by the lack of awareness of FPIES, absence of reliable biomarkers, the non-specific nature of the presenting symptoms, and the delay between allergen exposure and symptoms,” wrote Dr Sam Mehr, paediatric immunologist and allergist at Royal Melbourne Hospital, and Professor Dianne Campbell, Chair of Paediatric Allergy and Clinical Immunology at the University of Sydney.

FPIES announces itself with lethargy, an unnatural paleness and profuse vomiting between one and four hours after the ingestion of a set of trigger foods that include, in descending order, rice, cow’s milk, egg, oats and chicken.

Other symptoms can include diarrhoea, hypotension, hypothermia, neutrophilia and thrombocytosis.

“It is likely that improved understanding of the immunological basis of FPIES will, in the future, facilitate the development of a sensitive and specific biomarker,” said Mehr and Campbell, co-authors of the paper.

“Until that time, use of standardised diagnostic criteria, improved recognition, timely fluid resuscitation, avoidance of trigger foods, and education form current best practice.”

Currently, there are no blood tests to reliably detect FPIES, and the treatment consists of fluid replacement with the prescription of the medication Ondansetron – marketed under the brand name Zofran – commonly used in cases of gastroenteritis and also used to prevent nausea and vomiting occasioned by cancer chemotherapy, radiation therapy and surgery. Ondansetron can be given orally or via an intramuscular or intravenous injection.

The researchers suggest diagnosis can be confirmed through a patient food challenge that involves testing and avoiding the known trigger foods.

FPIES was included in the International Statistical Classification of Diseases in 2015, and there were no agreed criteria among the scientific community regarding its diagnosis until 2017. What’s worse, only a handful of countries had come up with specific guidelines to deal with it.

The paper concludes there is an urgent need to come up with standardised criteria to avoid it being confused with other disorders.

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