Victor's Story: Second Episode
Victor is part of the abovementioned 2% patients suffering from multiple FPIES in our casistic; his story was not ended. When he was six months old he ate corn at home and at the second administration he showed his fourth FPIES episode. After a time, an OFC was performed in DH with lentils, potato and semolina wheat and Victor presented his fifth episode caused by wheat. At home, his mother gave him chickpeas and Victor had his sixth adverse reaction. In summary, if we had followed Sicherer's suggestions this baby would not have shown three of his six FPIES episodes. However, as we have already said, the probability of encountering a child affected by multiple FPIES is quite low and considering our 55 clinical cases, Victor is the only one. So, we struck a compromise that somehow takes into account the suggestion of Sicherer. In fact, we suggest patients perform a DH OFC with a mix of cereals, legumes and poultry, since the probability that the child tolerates such foods is very high. In this way we avoid an enlarged diet in children who actually do not need it. This was, for example, the advice given to Bridget. We did not propose the same management to Ernst as, when he came to our attention, he had already eaten these foodstuffs without any problem. Moreover, especially for CM FPIES, in case of lack of breast-milk, there was a strong recommendation to give an extensively hydrolyzed casein formula instead of cow milk and to avoid soy milk ingestion. Nowadays, this prescription is declining and this is mainly due to the publication by Katz et al., which reported that the majority of 43 children suffering from CM FPIES tolerated soy milk. In conclusion, it is certain that the culprit food has to be excluded from patient's diet until he spontaneously reaches tolerance, but it is not certain that further dietary restrictions are needed. So, in an attempt to improve the quality of life of the child with FPIES, we perform OFCs with a mixture of other foods hypothetically involved, without deleting them from the diet prejudicially. In the case of fish FPIES, we suggest OFCs with other types of fish, while in case of CM or hen's egg FPIES we propose challenges with the baked food. Of course, ours is a working hypothesis and studies are in progress to demonstrate its validity.
Expert Rev Clin Immunol. 2013;9(8):707-715. © 2013 Expert Reviews Ltd.