Oral food challenges in food protein-induced enterocolitis syndrome: Practical considerations

Food protein-induced enterocolitis syndrome (FPIES) is a non-immunoglobulin E mediated food hypersensitivity disorder that primarily affects children in the first few years of life but may affect all ages. An FPIES diagnosis remains challenging due to the lack of specific biomarkers and is typically based on the clinical history and oral food challenges (OFC).

This review examines the current literature on diagnosing primarily pediatric FPIES, indications and timing for OFCs, specific considerations for adult and atypical FPIES OFCs, management of co-reactive or cross-reactive foods, and factors that influence the location and approach for conducting OFCs.

An FPIES diagnosis includes meeting specific clinical criteria, with OFCs being the diagnostic standard in cases of diagnostic uncertainty. In the United States, OFCs are generally performed 12 to 18 months after the last reaction to a suspected trigger to assess for tolerance. Regional variations in trigger food prevalence and OFC timing were noted. Nutritional and cultural importance of the offending food, severity of previous reactions, and parental comfort are factors in deciding the timing and setting of OFCs. Management of potential co-reactive and cross-reactive foods remains variable, requiring cautious, supervised reintroduction.

FPIES requires a careful diagnosis and management. OFC timing and approach should be tailored to individual patient needs and factor in past reaction severity and the importance of the food trigger in the regional diet and nutritional value. More research is needed to standardize OFC protocols. Enhanced guidelines and increased awareness among health-care providers can lead to more accurate diagnoses and better FPIES management, ultimately improving patient outcomes.