Recently, Dr. Victoria Martin gave our group an excellent update on cow’s milk protein allergy/food protein-induced allergic proctocolitis (FPIAP).  My notes below may contain errors in transcription and in omission. Along with my notes, I have included many of her slides.

• iMAP guidelines for FPIAP were published in 2019. 2023-2024 guidelines have now been published

• Guaiac testing in infants is usually not helpful (in the absence of visible blood). In one study, 34% of healthy infant controls tested positive

• Clinical management: when restricting a food, it may take 2-4 weeks to determine if it is helping. In breastfed infants, there is not data supporting restrictions beyond cow’s milk and soy. If other foods are eliminated, foods that were previously eliminated could be reintroduced
• In families who selected watchful waiting rather than dietary elimination, symptom resolution was similar in GMAP cohort. This was an observational study and findings could be influenced by selection bias

• In the GMAP cohort, there was a disparity in allergen introduction among different ethnicities (Ref: M Marget et al. Frontiers in Pediatrics; 2023: https://doi.org/10.3389/fped.2023.1207680. Open Access! Factors influencing age of common allergen introduction in early childhood). Compared to White children, Black children were less likely to have been introduced to peanut and egg, and Asian children were less likely to have been introduced to peanut as early (P < 0.05).
• In families concerned about food challenges, the families could challenge near a medical setting (eg. ER); however, anaphylactic reactions could occur after the first dose
• Challenging patients with FPIAP to establish diagnosis is generally recommended 2-4 weeks after resolution. In some patients, the FPIAP may have resolved and in some the diagnosis of FPIAP may be inaccurate. In those with more severe symptoms (eg required hospitalization), challenging at a later timeframe should be considered
• Probiotics: no clear role in their use for FPIAP at this time

Related blog posts:

• Good Bowel Sound Podcasts: Cow’s Milk Intolerance and Hirschspurng Disease
• ESPGHAN Guidance for Suspected Cow’s Milk Allergy in Infants
• Current Approach for FPIES (2023)
• Allergy Prevention Strategy: Early Exposure Beneficial (Long-term Data for Peanuts)
• Overdiagnosis of Milk Allergy in Infancy and New Consensus Recommendations
• Overdiagnosis of Cow’s Milk Protein Allergy in Infants and Formula Industry Influence
• Best of Allergy Articles 2021 -Cow’s Milk Allergy/Allergic proctocolitis (Part 4)
• Best Allergy Articles 2021 -Cow’s Milk Allergy (Part 3)
• Best Allergy Articles 2021 -Cow’s Milk Allergy (Part 2)
• Best Allergy Articles 2021-Cow’s Milk Allergy

Recently, Dr. Victoria Martin gave our group an excellent update on cow’s milk protein allergy/food protein-induced allergic proctocolitis (FPIAP).  My notes below may contain errors in transcription and in omission. Along with my notes, I have included many of her slides.

• The nomenclature is not perfect. FPIAP was used for this presentation –though many don’t truly have proctocolitis and others may have involvement in other parts of GI tract
• There is not a good biomarker for FPIAP

• Victoria and her colleagues have a cohort of 1003 children who were enrolled at their 1st well-child visit as part of their Gastrointestinal Microbiome and Allergic Proctocolitis (GMAP) study. These participants are now ~8 years old and will be followed until they are 18 years old

• In the GMAP cohort, 17% were given a diagnosis of FPIAP (mainly by PCPs). This group had increased likelihood of eczema, family hx/o food allergy and sibling with FPIAP.
• The presence of heme-positive stools, vomiting and fussiness are common and usually do not require dietary restrictions unless other symptoms are present (eg. diarrhea, visible blood)

• In the GMAP cohort, the risk for FPIAP was higher if fed formula than breastfeeding. However, exclusive breastfeeding was associated with a higher prevalence than those who received both breastmilk and formula

• A diagnosis of FPIAP was associated with a 2-fold risk of developing an IgE-mediated food allergy. (This indicates that early introduction of food allergens may be beneficial as has been shown with peanut introduction.)

• The microbiome/taxa in FPIAP was unique and present prior to the development of symptoms

• Unique microbiome differences may be identified in FPIAP cohort that precedes and follows FPIAP symptoms
• Allergy testing is generally not helpful in infants less than 6 months of age with FPIAP. RAST testing less than 6 months of age is not sensitive and most FPIAP is not IgE-mediated

• FPIAP may be analogous to eczema of the GI tract

Related blog posts:

• Good Bowel Sound Podcasts: Cow’s Milk Intolerance and Hirschspurng Disease
• ESPGHAN Guidance for Suspected Cow’s Milk Allergy in Infants
• Current Approach for FPIES (2023)
• Allergy Prevention Strategy: Early Exposure Beneficial (Long-term Data for Peanuts)
• Overdiagnosis of Milk Allergy in Infancy and New Consensus Recommendations
• Overdiagnosis of Cow’s Milk Protein Allergy in Infants and Formula Industry Influence
• Best of Allergy Articles 2021 -Cow’s Milk Allergy/Allergic proctocolitis (Part 4)
• Best Allergy Articles 2021 -Cow’s Milk Allergy (Part 3)
• Best Allergy Articles 2021 -Cow’s Milk Allergy (Part 2)
• Best Allergy Articles 2021-Cow’s Milk Allergy