Food protein-induced allergic proctocolitis in infants: Literature review and proposal of a management protocol

Abstract

Food protein-induced allergic proctocolitis (FPIAP) is a condition characterized by inflammatory changes in the distal colon in response to one or more foreign food proteins because of immune-mediated reactions. FPIAP prevalence estimates range widely from 0.16% in healthy children and 64% in patients with blood in stools. In clinical practice, FPIAP is diagnosed when patients respond positively to the elimination of a suspected triggering food allergen. Nevertheless, significant proportions of infants get misdiagnosed with IgE mediated allergy and undergo unnecessary dietary changes. Diagnosis is based on clinical symptoms, a good response to an allergen-free diet and the recurrence of symptoms during the “allergy challenge test”. Sometimes clinical features may be non-specific and the etiology of rectal bleeding in childhood may be heterogeneous. Therefore, it is crucial to exclude a variety of other possible causes of rectal bleeding in the pediatric age group, including infection, anal fissure, intestinal intussusception and, in infants, necrotizing enterocolitis and very early onset inflammatory bowel disease. The diagnostic workup includes in those cases invasive procedures such as sigmoidoscopy and colonoscopy with biopsies. The high prevalence of FPIAP contrasts with the lack of known information about the pathogenesis of this condition. For this reason and due to the absence of a review of the evidence, a literature review appears necessary to clarify some aspects of allergic colitis. The aim of the review is to fill this gap and to lay the foundations for a subsequent evidence-based approach to the condition.

Non–IgE- or Mixed IgE/Non–IgE-Mediated Gastrointestinal Food Allergies in the First Years of Life: Old and New Tools for Diagnosis

“…For these reasons, it has been suggested, for otherwise seemingly well infants with suspected FPIAP, to wait 2–4 weeks for spontaneous resolution without initiating an elimination diet [ 17 , 18 ]. If symptoms continue, an elimination diet is started; if the hematochezia stops, a specific IgE or SPT test for the suspected food may be useful.…”

Nutritional Aspects of Pediatric Gastrointestinal Diseases

“…In these cases, a universal agreement on treatment approach has not been reached and each case must be discussed individually. Options include choosing to proceed with breastfeeding irrespective of bleeding, or replacing breastfeeding with a hydrolyzed or aminoacidic formula [ 156 ]. The latter is the more often recommended treatment plan.…”

“…In contrast to the early elimination diet protocol, some authors have recently proposed a “wait and see” approach during the first month of rectal bleeding, considering that those episodes in infants are often self-resolving [ 156 , 158 ]. Multiples studies have reported symptom improvement without maternal dietary modifications in up to 20% of breastfed infants [ 156 , 159 ].…”

Food protein-induced enterocolitis syndrome presenting after necrotizing enterocolitis in a preterm neonate: a case report

“…The pathophysiology of NEC intervention; a third of these patients eventually die (3). Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE cell-mediated gastrointestinal food allergy that is characterized by inflammatory changes in the distal colon in response to one or more different food proteins (4). The symptoms typically begin in the first month of life.…”