FPIES: Food Protein Induced Enterocolitis

Acute FPIES, the most common form of the disease, presents between 2 to 7 months of age with repetitive vomiting occurring 1–4 h after ingestion of a trigger food. Vomiting is often severe and can lead to dehydration, lethargy, and pallor. These infants need immediate medical attention and sometimes even hospitalization for IV fluids. Diarrhea can also develop 5–10 h after food ingestion and can be watery or bloody. Symptoms generally resolve within 24 h of removal of trigger food.

Chronic FPIES is much more difficult to diagnose and it has a slow onset. It can be seen in formula fed and in breastfed babies and typically peaks around 4-6 months of age. Often parents are aware of symptoms long before the diagnosis but it is thought to be due to chronic spitting up, colic, gas and generalized fussiness.

Chronic ingestion of cow’s milk-based or soy-based formula leads to chronic vomiting, diarrhea, and failure to thrive. Patients improve within days after removal of the inciting food. Of note, patients develop symptoms of acute FPIES upon re-exposure to the culprit food.

The diagnosis of FPIES is challenging for several reasons. An overall lack of familiarity with the illness, in conjunction with symptoms that often mimic other conditions and many mothers are told or made to believe that they are imagining their symptoms. Further, there is a lack of understanding and awareness of diet affecting breast milk. Many mothers assure you that they can tell by their child reaction of what they ate and know fully well that what they consumed affected their baby, however there remains a strong belief in the breastfeeding world that women should be sheltered and protected from the nutritional make-up of their milk and learning about throw their diet affects their milk as they would then feel compelled to switch to formula. Clearly, that is not a position we take and believe that data is not informative but imperative.

What complicates FPIES even more so is that there are low allergic potential of trigger foods such as grains and vegetables may contribute to the under recognition of FPIES as a clinical diagnosis.

The elimination of trigger food(s) from the diet is the mainstay of treatment in FPIES. There currently do not exist any tools to determine, what concentration and what types of proteins are in mother’s milk and how best to proceed with an elimination diet. 

Common nutritional deficits in patients with FPIES include vitamin D, zinc, and iron due to avoidance of cow’s milk and grains. Dieticians can help ensure proper substitutions for foods eliminated from the diet and educate on avoidance, including how to prepare allergen-free food recipes and how to properly read food labels. We recommend that all breastfeeding mothers who suspect their child is experiencing acute or chronic FPIEs consult their physician immediately and work with their healthcare providers to not only assess maternal intake and diet (including potentially check in some blood levels of key nutrients in mom) but also examining and screening their infants early to make sure that they are meeting all developmental milestones and potentially screening heir early for possible iron deficiency anemia.

Take home message: What you eat does affect your milk, your baby and it is not in your head!


Groetch M, Henry M, Feuling MB, Kim J. Guidance for the nutrition management of gastrointestinal allergy in pediatrics. J Allergy Clin Immunol in Practice. 2013;1(4):323–31. https://doi.org/10.1016/j.jaip.2013.05.002

Guidelines for nutritional management of patients with FPIES and other gastrointestinal allergy and the role of dieticians in management.

Feuille E, Nowak-Węgrzyn A. Definition, etiology, and diagnosis of food protein-induced enterocolitis syndrome. Curr Opin Allergy Clin Immunol. 2014;14(3):222–8.

Nowak-Węgrzyn A, Chehade M, Groetch ME, Spergel JM, Wood RA, Allen K, et al. International consensus guidelines for the diagnosis and management of food protein-induced enterocolitis syndrome: executive summary—Workgroup Report of the Adverse Reactions to Foods Committee, American Academy of Allergy, Asthma & Immunology. J Allergy Clin Immunol. 2017;139(4):1111–1126.e4. https://doi.org/10.1016/j.jaci.2016.12.966. Guidelines addressing the most recent recommendations for the diagnosis and management of FPIES, including diagnostic criteria.

Cherian, S., Varshney, P. Food Protein-Induced Enterocolitis Syndrome (FPIES): Review of Recent Guidelines. Curr Allergy Asthma Rep 18, 28 (2018). https://doi.org/10.1007/s11882-018-0767-9

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