Non-IgE-Mediated Gastrointestinal Food Allergies in Children: An Update

Abstract

Non-immunoglobulin E-mediated gastrointestinal food allergic disorders (non-IgE-GI-FA) include food protein-induced enterocolitis syndrome (FPIES), food protein-induced enteropathy (FPE) and food protein-induced allergic proctocolitis (FPIAP), which present with symptoms of variable severity, affecting the gastrointestinal tract in response to specific dietary antigens. The diagnosis of non-IgE-GI-FA is made clinically, and relies on a constellation of typical symptoms that improve upon removal of the culprit food. When possible, food reintroduction should be attempted, with the documentation of symptoms relapse to establish a conclusive diagnosis. Management includes dietary avoidance, nutritional counselling, and supportive measures in the case of accidental exposure. The prognosis is generally favorable, with the majority of cases resolved before school age. Serial follow-up to establish whether the acquisition of tolerance has occurred is therefore essential in order to avoid unnecessary food restriction and potential consequent nutritional deficiencies. The purpose of this review is to delineate the distinctive clinical features of non-IgE-mediated food allergies presenting with gastrointestinal symptomatology, to summarize our current understanding of the pathogenesis driving these diseases, to discuss recent findings, and to address currents gaps in the knowledge, to guide future management opportunities.

Keywords: FPE; FPIAP; FPIES; food allergy; gastrointestinal reactions; non-IgE-mediated; nutrition; pediatrics.

Figure 1

Classification of gastrointestinal food allergies. FDEIAn, food-dependent exercise-induced anaphylaxis; FPE, food protein-induced enteropathy; FPIAP, food protein-induced allergic proctocolitis; FPIES, protein-induced enterocolitis syndrome; IgE, immunoglobulin E; OAS, oral allergy syndrome.

Figure 2

Gastrointestinal organs affected in the different non-IgE-mediated gastrointestinal food allergies. FPIAP and FPE affect the colon and small intestine, respectively, while in FPIES, the whole gastrointestinal tract can be affected. FPE, food protein-induced enteropathy; FPIAP, food protein-induced allergic proctocolitis; FPIES, protein-induced enterocolitis syndrome.

Figure 3

Classification scheme of FPIES. FPIES, food protein-induced enterocolitis syndrome; sIgE, food-specific immunoglobulin E; T21, trisomy 21 (Down syndrome).

Figure 4

Multidisciplinary approach for diagnosis and management of non-IgE-mediated gastrointestinal food allergies. ER, emergency room; OFC, oral food challenge; PCP, primary care physician.