can fpies cause hives?

But if your child has a rare allergy called food protein-induced enterocolitis syndrome (FPIES), the reaction may not happen until a few hours after they eat. Unlike other food allergies, this one won't make your child wheeze, break out in hives, or get a rash. Instead, they may vomit or get diarrhea.

This FAQ has been developed to assist understanding about FPIES, and includes information that was previously in the ASCIA FPIES Dietary Guide. This FAQ should be provided in addition to the ASCIA FPIES Action Plan www.allergy.org.au/patients/food-other-adverse-reactions/fpies-action-plan

Food protein-induced enterocolitis syndrome (FPIES), is a delayed (non-IgE mediated) gut allergic reaction to a food(s), usually presenting in the first two years of life, with an estimated incidence in this age group of 1 in 7,000 children. FPIES can occur in adults, although this is uncommon.

Acute FPIES presents with repetitive, profuse vomiting that typically starts one to four hours after a triggering food is eaten. Some infants can become floppy, pale, cold and develop diarrhoea.

Chronic FPIES is uncommon, and usually occurs in infancy, due to repeated exposure to a food trigger (usually cow’s milk protein or soy). It presents with persistent vomiting and/or diarrhoea (which can result in poor weight gain over time). If the trigger is reintroduced before the condition is outgrown, an acute FPIES reaction can occur.

Although any food can trigger FPIES, the most common triggers for infants and children are rice, oat, cow's milk (dairy) and egg. FPIES in exclusively breastfed infants is rare.

The most common food trigger for adults is seafood.

It is possible for a child with FPIES to also have Immunoglobulin E (IgE) mediated allergies to other foods, and/or have eczema and/or asthma.

However, FPIES is not caused by IgE, and:

There are no blood or skin tests that can confirm a diagnosis of FPIES and the diagnosis is made on the history of reactions and symptoms. Some tests that are not useful include serum IgE testing, skin prick testing and atopy patch testing to food proteins.

Blood tests may be ordered to look for conditions that have similar symptoms to FPIES.

During an FPIES reaction some children may have a high white cell and platelet count, and therefore the child may be mistaken for having an infection. However, unlike when there is an infection, fever is rare, inflammatory markers (such as C-reactive protein) are usually not elevated and recovery within hours typically occurs after an acute FPIES reaction.

Medically supervised oral food challenges can be useful when the history is not clear or to establish when a child has outgrown FPIES.

Currently the only management option for prevention of FPIES reactions is to avoid the trigger food/s.

FPIES reactions are managed by giving fluids to maintain hydration. In some cases, your specialist may recommend giving ondansetron wafers that dissolve in the mouth to help stop the vomiting. In more severe cases where the vomiting is excessive, and the child is pale and floppy, intravenous fluids may be needed.

There is no role for the use of adrenaline injectors in the management of FPIES.

FPIES reactions are rarely triggered via breastmilk, and so in most cases there is no need for a breastfeeding mother to exclude an infant's FPIES triggers from her own diet.

Your child’s allergy specialist and dietitian will discuss which foods to avoid and which foods to introduce to your child. Having FPIES to certain foods may increase the risk of FPIES to another specific food.  These foods are outlined in the table below. It is important to leave any food in your child’s diet that they are already tolerating, and to continue to introduce your child to a wide range of foods. For example, if your child has FPIES to rice but already tolerates oats, leave oats in their diet, keep introducing other foods and just avoid rice.

Most children (75%) will only have one food trigger for FPIES and only need to avoid one food.

If your child reacts to more than one food, it is best to discuss management with your allergy specialist, and an experienced paediatric allergy dietitian.

The first episode of FPIES can be traumatic for some parents, who may be hesitant to give new foods in case it happens again. It is important to continue to offer a wide range of foods during the first year of life so that children will accept a variety of foods and textures.

Limiting the range of foods can lead to nutritional deficiencies, poor growth, food refusal and feeding difficulties. Unnecessary delayed introduction of common allergenic foods such as egg or peanut can even increase the risk of developing allergy to these foods. Currently there have been no studies to determine whether delaying the introduction of certain foods results in reduced risk of developing FPIES to that food.

An experienced paediatric allergy dietitian can assist with a feeding plan to encourage successful progression of feeding whilst avoiding FPIES triggers.

The long term outcome for FPIES is excellent. To date, there have been no published reports of a fatality from an acute FPIES reaction.

You should only reintroduce foods that your child has reacted to under the direction of your child’s allergy specialist.

Most children outgrow FPIES by three years of age, but some children will outgrow their allergy earlier or later than this.  A plan for when and how to reintroduce the FPIES trigger food/s will be determined by your child’s allergy specialist. This may be done either as a medically supervised oral food challenge or if recommended by your allergy specialist, a re-introduction of the triggering food at home.

Information about food allergy and other adverse reactions to food is available on the ASCIA website:

www.allergy.org.au/patients/food-allergy

www.allergy.org.au/patients/food-other-adverse-reactions

Allergy & Anaphylaxis Australia: www.allergyfacts.org.au

Allergy New Zealand: www.allergy.org.nz

© ASCIA 2022

Content updated May 2022

For more information go to www.allergy.org.au/patients/food-other-adverse-reactions

A food allergy is when your immune system has a bad reaction to a certain food. This is different from a food intolerance, which does not affect the immune system. This is true even though some of the same signs may be present.

Your body’s immune system fights off infections and other dangers to keep you healthy. When your immune system senses that a food or something in a food is a danger to your health, you may have a food allergy reaction. Your immune system sends out IgE (immunoglobulin E) antibodies. These react to the food or substance in the food. Your body releases histamine and other substances. This can cause hives, asthma, itching in the mouth, trouble breathing, stomach pains, vomiting, or diarrhea. It does not take much of the food to cause a severe reaction in highly allergic people.

Most food allergies are caused by these foods:

Food protein-induced enterocolitis syndrome (FPIES) is also called the delayed food allergy. FPIES often occurs in young babies. It causes vomiting and severe fluid loss (dehydration). The most common cause of FPIES is having milk, soy, or grains.

Allergic symptoms may begin within minutes to an hour after eating the food. Symptoms may be a bit different for each person. Symptoms may include:

The symptoms of a food allergy may look like other health problems. Always see your healthcare provider for a diagnosis.

Anaphylaxis is a severe allergic reaction. It is life-threatening. Symptoms can include:

Anaphylaxis is a medical emergency. Call 911 to get help right away. Severe allergic reactions are treated with epinephrine. You should carry an emergency kit with self-injecting epinephrine. If you have emergency injectable epinephrine, use it before you call 911.

If you think you have a food allergy, see your healthcare provider for a diagnosis. He or she will take your health history and do a physical exam. The healthcare provider will do skin or blood tests or both to find out the exact diagnosis. These tests may include:

At this time, no medicine is available to prevent food allergy. The goal of treatment is to stay away from the food that causes the symptoms. This includes speaking up when you are at a restaurant or at friends' homes. Let them know that you have a food allergy. Don't be shy. And be clear that you could have a severe reaction if you eat a food you are allergic to, even in small amounts.

If you have a food allergy, carry an epinephrine shot to treat emergency reactions. Know how to give yourself this shot. You must be ready to treat any allergic reaction caused by eating a food by mistake that you are sensitive to. You need an emergency kit to stop severe reactions. Talk with your healthcare provider about what to do with the kit.

Medicines are available to treat some symptoms of food allergy after the food has been eaten. These medicines may ease nose and sinus symptoms, digestive symptoms, or asthma symptoms.

Right now, no allergy shot treatment is approved to treat food allergies. But research is ongoing. Strictly staying away from the allergy-causing food is the only way to prevent a reaction.

If you have one or more food allergies, eating out can be a challenge. But it is possible to have a healthy and satisfying meal when dining out. It just means that you may have to plan ahead when you eat out.

Here are some tips for dealing with food allergies when you are eating away from home:

Another tip for dining out is to carry a food allergy card. You can give it your server or the manager before you order food. A food allergy card contains information about the specific items you are allergic to. It also has more information. This includes a reminder to make sure all utensils and equipment used to make your meal are thoroughly cleaned before use. You can easily print these cards yourself using a computer and printer.

The Food Allergen Labeling Consumer Protection Act (FALCPA) was passed into law in 2004. It helps ensure clearer labeling of food by manufacturers. Here is more information about FALCPA:

FPIES is food protein-induced enterocolitis syndrome. It is commonly pronounced “F-Pies”, as in “apple pies,” though some doctors may refer to it as FIES (pronounced “fees,” considering food-protein as one word). Enterocolitis is inflammation involving both the small intestine and the colon (large intestine).

FPIES is a non-IgE mediated immune reaction in the gastrointestinal system to one or more specific foods, commonly characterized by profuse vomiting and diarrhea. FPIES is presumed to be cell-mediated. Poor growth may occur with continual ingestion. Upon removing the problem food(s), all FPIES symptoms subside. (Note: Having FPIES does not preclude one from having other allergies/intolerances with the food.) The most common FPIES triggers are cow’s milk (dairy) and soy. However, any food can cause an FPIES reaction, even those not commonly considered allergens, such as rice, oat and barley.

A child with FPIES may experience what appears to be a severe stomach bug, but the “bug” only starts a couple hours after the offending food is given. Many FPIES parents have rushed their children to the ER, limp from extreme, repeated projectile vomiting, only to be told, “It’s the stomach flu.” However, the next time they feed their children the same solids, the dramatic symptoms return.

IgE stands for Immunoglobulin E. It is a type of antibody, formed to protect the body from infection, that functions in allergic reactions. IgE-mediated reactions are considered immediate hypersensitivity immune system reactions, while cell-mediated reactions are considered delayed hypersensitivity. Antibodies are not involved in cell-mediated reactions. For the purpose of understanding FPIES, you can disregard all you know about IgE-mediated reactions.

FPIES reactions often show up in the first weeks or months of life, or at an older age for the exclusively breastfed child. Reactions usually occur upon introducing first solid foods, such as infant cereals or formulas, which are typically made with dairy or soy. (Infant formulas are considered solids for FPIES purposes.) While a child may have allergies and intolerances to food proteins they are exposed to through breastmilk, FPIES reactions usually don’t occur from breastmilk, regardless of the mother’s diet. An FPIES reaction typically takes place when the child has directly ingested the trigger food(s).

As with all things, each child is different, and the range, severity and duration of symptoms may vary from reaction to reaction. Unlike traditional IgE-mediated allergies, FPIES reactions do not manifest with itching, hives, swelling, coughing or wheezing, etc. Symptoms typically only involve the gastrointestinal system, and other body organs are not involved. FPIES reactions almost always begin with delayed onset vomiting (usually two hours after ingestion, sometimes as late as eight hours after). Symptoms can range from mild (an increase in reflux and several days of runny stools) to life-threatening (shock). In severe cases, after repeatedly vomiting, children often begin vomiting bile. Commonly, diarrhea follows and can last up to several days. In the worst reactions (about 20% of the time), the child has such severe vomiting and diarrhea that they rapidly become seriously dehydrated and may go into shock.

Shock is a life-threatening condition. Shock may develop as the result of sudden illness, injury or bleeding. When the body cannot get enough blood to the vital organs, it goes into shock.

Always follow your doctor’s emergency plan pertaining to your specific situation. Rapid dehydration and shock are medical emergencies. If your child is experiencing symptoms of FPIES or shock, immediately contact your local emergency services (911). If you are uncertain if your child is in need of emergency services, contact 911 or your doctor for guidance. The most critical treatment during an FPIES reaction is intravenous (IV) fluids, because of the risk and prevalence of dehydration. Children experiencing more severe symptoms may also need steroids and in-hospital monitoring. Mild reactions may be able to be treated at home with oral electrolyte re-hydration (e.g., Pedialyte®).

Not usually, because epinephrine reverses IgE-mediated symptoms, and FPIES is not IgE-mediated. Based on the patient’s history, some doctors might prescribe epinephrine to reverse specific symptoms of shock (e.g., low blood pressure). However, this is only prescribed in specific cases.

The most common FPIES triggers are traditional first foods, such as dairy and soy. Other common triggers are rice, oat, barley, green beans, peas, sweet potatoes, squash, chicken and turkey. A reaction to one common food does not mean that all of the common foods will be an issue, but patients are often advised to proceed with caution with those foods. Note that while the above foods are the most prevalent, they are not exclusive triggers. Any food has the potential to trigger an FPIES reaction.

FPIES is difficult to diagnose, unless the reaction has happened more than once, as it is diagnosed by symptom presentation. Typically, foods that trigger FPIES reactions are negative with standard skin and blood allergy tests (SPT, RAST) because they look for IgE-mediated responses. However, as stated before, FPIES is not IgE-mediated.

Atopy patch testing (APT) is being studied for its effectiveness in diagnosing FPIES, as well as predicting if the problem food is no longer a trigger. Thus, the outcome of APT may determine if the child is a potential candidate for an oral food challenge (OFC). APT involves placing the trigger food in a metal cap, which is left on the skin for 48 hours. The skin is then watched for symptoms in the following days after removal. Please consult your child’s doctor to discuss if APT is indicated in your situation.

Treatment varies, depending on the patient and their specific reactions. Often, infants who have reacted to both dairy and soy formulas will be placed on hypoallergenic or elemental formula. Some children do well breastfeeding. Other children who have fewer triggers may just strictly avoid the offending food(s).

New foods are usually introduced very slowly, one food at a time, for an extended period of time per food. Some doctors recommend trialing a single food for up to three weeks before introducing another.

Because it’s a rare, but serious condition, in the event of an emergency, it is vital to get the correct treatment. Some doctors provide their patients with a letter containing a brief description of FPIES and its proper treatment. In the event of a reaction, this letter can be taken to the ER with the child.

Typically, no. Many children outgrow FPIES by about age 3. Note, however, that the time varies per individual and the offending food, so statistics are a guide, but not an absolute. In one study, 100% of children with FPIES reactions to barley had outgrown and were tolerating barley by age 3. However, only 40% of those with FPIES to rice, and 60% to dairy tolerated it by the same age.

Together with your child’s doctor, you should determine if/when it is likely that your child may have outgrown any triggers. Obviously, determining if a child has outgrown a trigger is something that needs to be evaluated on a food-by-food basis. As stated earlier, APT testing may be an option to assess oral challenge readiness. Another factor for you and your doctor to consider is if your child would physically be able to handle a possible failed challenge.

When the time comes to orally challenge an FPIES trigger, most doctors familiar with FPIES will want to schedule an in-office food challenge. Some doctors (especially those not practicing in a hospital clinic setting) may choose to challenge in the hospital, with an IV already in place, in case of emergency. Each doctor may have their own protocol, but an FPIES trigger is something you should definitely NOT challenge without discussing thoroughly with your doctor.

Vomiting

Repeated and usually severe, around two hours after the trigger food is eaten (could be one to four hours ). In undiagnosed cases of FPIES, this is often confused with viral infections.

Diarrhea

Not as common as vomiting in acute FPIES: starting around five hours after the trigger food is eaten (could be up to 10 hours). In chronic FPIES, infants can have intermittent, watery diarrhea.

Lethargy

Children may be pale, limp, and less active than usual, due to vomiting.

Dehydration

In severe cases, the vomiting can cause dehydration that may lead to low blood pressure, poor circulation, and/or shock.