From breast to bite: Nutritional management in infantile food protein-induced enterocolitis syndrome (FPIES)

Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food allergy that presents primarily in infancy. Managing nutrition in infants with FPIES presents unique challenges due to its lack of diagnostic biomarkers and the high potential for feeding difficulties, restricted diets, and growth faltering. Breastfed infants may occasionally react to trace food proteins in human milk, requiring maternal elimination diets and cautious reintroduction strategies. Formula-fed infants with cow's milk- or soy-triggered FPIES may need extensively hydrolyzed or amino acid-based formulas. Introduction of complementary foods requires a careful, stepwise approach informed by each child's specific food triggers. In addition to increased risk for IgE-mediated food allergy, delayed introduction of higher risk foods may compound nutritional risk, particularly for energy, protein, iron, zinc, and other nutrients. Feeding difficulties, food aversion, and caregiver anxiety can further affect growth and quality of life for both infant and family. Regular growth monitoring, caregiver education, and involvement of a multidisciplinary team including a dietitian experienced in food allergy are essential to optimize outcomes. Three illustrative cases highlight practical management strategies from management of an exclusively breastfed infant with FPIES to reintroduction of previously avoided foods. A proactive, individualized nutritional approach is vital to supporting healthy growth and quality of life in this vulnerable population.