Diagnosing Paediatric Mild Acute Food Protein–Induced Enterocolitis Syndrome: Proposal of New Criteria

Researchers evaluated the ability of preexisting criteria for food protein–induced enterocolitis syndrome (FPIES) to identify pediatric patients with mild acute FPIES. These were compared with new criteria proposed by the authors.This study enrolled 15 patients who attended an academic pediatric allergy clinic in Rome, Italy. Inclusion criteria consisted of patients younger than 18 years and those who received a diagnosis of mild acute FPIES between 2004 and 2023.This retrospective study evaluated the accuracy of 3 preexisting criteria sets, along with the study’s newly developed criteria, in identifying mild acute FPIES in the study population. Preexisting criteria included (1) FPIES International Consensus Guidelines (ICG), (2) Miceli Sopa’s criteria, and (3) Vazquez-Ortiz and Infante’s criteria. The new proposed diagnostic and suspicion criteria, in which oral food challenge is unnecessary and necessary, respectively, consist of (a) symptom resolution in 6 to 8 hours, except diarrhea, (b) absence of food ingestion without adverse reactions after first episode, and (c) absence of immunoglobulin E–mediated skin or respiratory symptoms. Diagnostic criteria must include one of the following: (a) 2+ episodes of emesis 1 to 4 hours after ingestion with pallor or lethargy, (b) 3+ episodes of emesis 1 to 4 hours after ingestion without pallor or lethargy OR with pallor or lethargy in 1 episode, or (c) 3+ episodes of emesis more than 4 hours after ingestion with pallor or lethargy. Suspicion criteria must include one of the following: (a) 1 episode of emesis 1 to 4 hours after ingestion with pallor or lethargy, (b) 2 episodes of emesis 1 to 4 hours after ingestion without pallor or lethargy OR with pallor or lethargy in 1 episode, or (c) 2 episodes of emesis more than 4 hours after ingestion with pallor or lethargy.No preexisting criteria set identified all 15 cases of mild acute FPIES (FPIES ICG: 0/15, Miceli Sopa: 3/15, Vazquez-Ortiz and Infante: 11/15). The authors’ new diagnostic and suspicion criteria correctly identified all 15 cases.Preexisting criteria for FPIES can underdiagnose milder presentations of the disease. New criteria developed by the authors identified all cases of mild acute FPIES within the study population.This study highlights the challenges preexisting criteria have in accurately identifying cases of mild acute FPIES. Strengths of this study include the creation of a novel criteria set, which can benefit general pediatricians who may overlook milder cases of FPIES and lead to potential mismanagement. Although promising, this new criterion has not been prospectively validated and is limited by the study’s small sample size. However, the authors raise a valid point that no published criteria have been previously validated in prospective studies and, rather, are a product of expert opinion.