Age-Appropriate Low Dosing for Food Protein-Induced Enterocolitis Syndrome Oral Food Challenges: Proposing a Standardized Approach

Authors

• Sara Anvari
• Mary Grace Baker
• Theresa Bingemann
• J Andrew Bird
• Terri Brown-Whitehorn
• Antonella Cianferoni
• Raquel Durban
• Malika Gupta
• Erin Hosein
• George Konstantinou
• Stephanie Leonard
• Melanie A Ruffner
• Allison Schaible
• Amy M Scurlock
• Pooja Varshney
• Antonella Muraro
• Alessandro Fiocchi
• Alexandra F Santos
• Stefania Arasi
• Marta Vazquez-Ortiz
• Hideaki Morita
• Ichiro Nomura
• Julia E M Upton
• Michael Levin
• Eric Lee
• Cesar Galvan
• Rodrigo Hoyos-Bachiloglu
• Pantipa Chatchatee
• Kirsten Beyer
• George du Toit
• Purificacion Gonzalez-Delgado
• Lydia Su Yin Wong
• Marion Groetch
• Anna Nowak-Wegrzyn

Language

English

Publication Date

7-1-2026

Journal

The Journal of Allergy and Clinical Immunology: In Practice

DOI

10.1016/j.jaip.2026.03.035

PMID

41999915

Abstract

Current oral food challenge (OFC) protocols for food protein-induced enterocolitis syndrome (FPIES) exhibit significant variability, creating potential for inconsistent diagnostic outcomes and severe reactions. Based on the published evidence and our clinical experience, we propose a practical, standardized OFC dosing protocol that emphasizes patient safety, goals based on age-appropriate servings (AASs), and clinical monitoring. A recent systematic review reported that most patients with persistent FPIES who underwent OFCs reacted to just 25% of an AAS, with low rates of severe reactions. Thus, we recommend that most patients undergoing a medically supervised FPIES OFC receive a cumulative dose of 25% AAS, followed by observation for a minimum of 4 hours. Supervised challenges should be followed by gradual up-titration to an AAS at home. A lower dose may be considered for patients with a history of severe FPIES symptoms to trace amounts of food. For patients with atypical FPIES, we recommend a slightly modified protocol, using graded dosing per IgE-mediated food allergy protocols, followed by extended FPIES OFC monitoring. Anticipated outcomes from implementation of this standardized OFC protocol include improved diagnostic accuracy, enhanced patient safety, and a structured approach to food reintroduction. Standardizing practices for FPIES OFCs will also permit harmonization of data to advance research.

Keywords

Humans, Food Hypersensitivity, Enterocolitis, Dietary Proteins, Administration, Oral, Allergens, Syndrome, Age Factors, Immunoglobulin E, Allergic reaction, Atypical FPIES, FPIES, Food protein-induced enterocolitis syndrome, Gastrointestinal symptoms, Non-IgE food allergy, OFC, Oral food challenge, Standardized dosing, Vomiting

Published Open-Access

yes

Recommended Citation

Anvari, Sara; Baker, Mary Grace; Bingemann, Theresa; et al., "Age-Appropriate Low Dosing for Food Protein-Induced Enterocolitis Syndrome Oral Food Challenges: Proposing a Standardized Approach" (2026). Faculty, Staff and Students Publications. 7655.
https://digitalcommons.library.tmc.edu/baylor_docs/7655