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ISSN: 2161-105X

Case Report Open Access

Optimizing an Aversion Feeding Therapy Protocol for a Child with Food

Protein-Induced Enterocolitis Syndrome (FPIES)
Rhonda Mattingly1*, Vincent Mukkada2, Alan Smith1 and Teresa Pitts3
1
Department of Otolaryngology-Head and Neck Surgery and Communicative Disorders School of Medicine, University of Louisville, USA
2
Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, USA
3
Department of Neurological Surgery and Kentucky Spinal Cord Injury Research Center, School of Medicine, University of Louisville, USA

Abstract
This case study examines the difficulties of treating food aversion in a 9-month old child with a diagnosis of Food
Protein-Induced Enterocolitis Syndrome (FPIES). Given the need to first identify a set of “safe foods” with which to
work, the twin goals of doing food challenges and minimizing aversion are initially not complimentary, and require an
approach outside the standard of care. The chosen plan encouraged flexibility and a positive relationship with feeding-
related items, while only introducing one food item at a time. Mom and child accomplished goals surrounding food
play easily. She has successfully introduced a wide variety of new foods in small quantities and is currently working
on reducing dependence on breast milk. Therapists must be prepared to modify currently accepted interventions to
accommodate and support the required medical intervention.

Keywords: FPIES; Feeding aversion; Dysphagia population-based birth cohort found that 0.34 percent of infants (44 of
13,019) was diagnosed with FPIES [3]. Making the FPIES diagnosis is
Patient challenging due to the lack of a gold-standard diagnostic test because of
this, it is a clinical diagnosis that can be easily missed without a careful
A 9-month old Caucasian female was referred for therapy due to diet history. More recent focus on the acute phenotype has led to more
initial concerns of difficulty transitioning from breast-feeding to cup. children being identified and a possible reduction of chronic cases due
She was 7lbs-5oz at birth. At the initial visit with the speech-language to the availability of hypoallergenic formulas [1].
pathologist she was 15 lbs 3 oz and this weight had reportedly been
unchanged for 3 months. The child was born to middle-class parents FPIES is associated with oral feeding aversion and delay. Feeding
and there was no history of feeding problems in the family. Cognition disorders are quite common in children, with reported incidence of
and motor skills were within normal limits, but the child was scheduled minor problems ranging between 25-35%, and upwards of 40-70% in
to receive occupational therapy services due to a delay in self-help skills, premature infants or children with chronic medical conditions [4].
increasing oral facial aversion, poor sleep, and inability to be calmed In this case, the intersection between early gastrointestinal issues and
by anyone other than her mother. She was also refusing to accept feeding aversion is quite complicated. The early food related restrictions
any stimulation around or in her mouth. Speech-language pathology reduce the child’s natural interaction with food, environment, and
services were ordered due to the child’s increasing feeding aversion. family. In fact, feeding difficulties are often associated with food
Table 1 is a detailed list of hospitalizations and diagnosis, which led to allergies, and they are now included in the National Institute of Clinical
therapy recommendations. Excellence guidelines in the United Kingdom as a possible symptom
to assist in the diagnosis of non-IgE mediated allergies affecting the
The food aversion was characterized by refusal of any oral liquid gastrointestinal tract [5].
besides the breast, and was further complicated by severe reactions
(primarily vomiting and diarrhea) to solid food presentation. These Therapeutic intervention for infants and children with feeding
reactions resulted in three hospitalizations. She had an upper endoscopy problems focuses on either developing the oral motor skills necessary
during one of these episodes, with relatively normal appearing mucosa, to tolerate a varied diet and/or the sensory flexibility to accept an
and histologic findings of a non-uniform duodenitis with increased adequate variety to support nutritional intake. Underlying medical,
number of eosinophils (peak count of 83 with normal expected peak social, developmental, and cognitive issues also impact outcomes.
of 28) and some associated crypt abscesses. Given that this was done Food chaining is a widely used protocol in which attributes of accepted
in the context of an active vomiting episode, this was felt to be most foods are gradually used to increase the child’s acceptance of a wider
likely due to a reaction to food rather than a chronic eosinophilic repertoire of foods [6]. Restrictions external to those the child places
gastrointestinal disease, and she was diagnosed with Food Protein- on himself through aversion and avoidance (as, for instance, in the
Induced Enterocolitis Syndrome (FPIES). case of foods that need to be avoided due to their risk of triggering an
immunologic reaction) can multiply the difficulty when attempting to
Diagnosis
FPIES is a non-immunoglobulin E-mediated food allergy
affecting the gastrointestinal tract [1]. The etiology of FPIES is not *Corresponding author: Rhonda Mattingly, Assistant Professor and
Clinical Director, Speech-Language Pathology, University of Louisville,
well understood. Antigen-specific T cells, antibodies and cytokines USA, Tel: 502-852-0347; E-mail: [email protected]
lead to inflammation causing decreased mucosal barrier function
Received April 27, 2015; Accepted August 18, 2015; Published August 25, 2015
and increased fluid losses into the gut lumen [2]. Symptoms of acute
FPIES may include severe vomiting, diarrhea (frequently bloody), Citation: Mattingly R, Mukkada V, Smith A, Pitts T (2015) Optimizing an Aversion
dehydration and lethargy, frequently leading to shock requiring hospital Feeding Therapy Protocol for a Child with Food Protein-Induced Enterocolitis
Syndrome (FPIES). J Pulm Respir Med 5: 287. doi:10.4172/2161-105X.1000287
admission. Chronic cases are associated with less severe vomiting and
loose stools, feeding problems and failure to thrive. Recent studies [1] Copyright: © 2015 Mattingly R, et al. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
suggest a higher incidence of FPIES than once thought. A large Israeli unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.

J Pulm Respir Med Volume 5 • Issue 4 •1000287

ISSN: 2161-105X JPRM, an open access journal
Citation: Mattingly R, Mukkada V, Smith A, Pitts T (2015) Optimizing an Aversion Feeding Therapy Protocol for a Child with Food Protein-Induced Enterocolitis Syndrome
(FPIES). J Pulm Respir Med 5: 287. doi:10.4172/2161-105X.1000287

Page 2 of 4

Precipitating
Age Location Provider Tests/Diagnosis Medications Recommendations
Symptoms
Physician’s Difficulty transitioning to Refer to Pediatric
6.5 months Pediatrician FPIES None
office rice or oat cereal. Gastroenterologist.
Continue advancement
Emesis/diarrhea for 2 Lansoprazole (Prevacid) 3
Dehydration, emesis, diarrhea of infant diet, Zofran
6.8 months Hospital Pediatrician days; post ingestion of mg/mL, and ondansetron
secondary to FPIES prn, and speech therapy
carrot (Zofran) 4 mg/5 mL.
consult.
1. Upper GI test: nonsignificant Esomeprazole (Nexium)
Pediatrician Emesis of bright yellow pylorospasm with delayed 5 mg, daily for 30 days; Discontinue the Zantac,
7 months Hospital and pediatric color and diarrhea post gastric emptying; 2. Mild ondansetron (Zofran) 4 and avoid new foods until
gastroenterologist breastfeeding erythema of the body of the mg/5 mL, every 8 hrs for follow-up with GI.
stomach 4 days.
1. MRI brain: no evidence of
Pediatrician
Reoccurrence of emesis mass lesion or increased intra- *Orapred 1 mg/kg BID for Mother’s diet restricted
7.1 months Hospital and pediatric
and diarrhea cranial pressure; 2. GI biopsy: 6 weeks. from dairy and soy.
gastroenterologist
duodenal eosinophilia.
Feeding aversion and Initiate plan to encourage
Speech-Language refusal to accept liquid Feeding Aversion and Delayed increased flexibility
9.1 months Home None
Pathologist except directly from the Oral Motor Feeding Skills around food, liquid, and
breast food-related items
Trial elemental formula,
Pediatric Continuation of
Continue Zofran prn, Referral to allergist to
10.26 months Hospital Gastroenterologist previous symptoms and FPIES
Zantac prn consider food challenge,
(VM) management of disorder
Initiate pears
*Steroids are not typically indicated in the treatment of FPIES, but in this patient given the severity of her illness and the possible diagnosis of eosinophilic duodenitis a
decision was made to do a prolonged course of swallowed corticosteroids.
Table 1: Summary of significant medical events prior to starting speech/feeding therapy.

increase flexibility and variety of intake. The Sequential Oral Sensory a list of tolerated foods, while trying to minimize food avoidance.
Approach is also a frequently used program to treat children with Unfortunately, to this point the available clinical allergy tests have
feeding difficulties including aversion. This treatment method is based not reliably identified trigger foods, resulting in the need for food
on the understanding that infants and children develop a relationship challenges that are often laborious and time-consuming. Due to the
with food through the Steps to Eating Hierarchy. For example, before potential severity of the reactions, the food challenges require one food
a child tastes food he must be able to tolerate it in the room, touch it, to be presented each week (i.e., pears), and in a large enough quantity to
and smell it. Through the process of systematic desensitization and in assess the child’s response. Conversely, traditional food aversion therapy
the context of the hierarchy infants and children begin to interact with includes familiarizing the child with a wide variety of food and textures,
and eat a wider variety of foods without anxiety [7]. The foundation chaining from an already accepted food to new foods, and providing
of this program is also linked to increasing a child’s flexibility and social feeding experiences, with no restrictions on the amount of foods
comfort with interacting with new foods. In conjunction with the to be introduced in a given time. Given the need to first identify a set
hierarchy concept it is understood that infants are born with reflexes of tolerated foods with which to work, the twin goals of doing food
that support oral feeding. These reflexes evolve into mature skills based challenges and minimizing aversion can initially be counterproductive,
on the experiences the infant has with his environment and feeding and require an approach outside the standard of care.
[8]. Medical issues, developmental delays, and sensory problems can
Our feeding treatment plan encouraged flexibility and a positive
negatively impact feeding development and contribute to feeding
relationship with feeding-related items and was presented as follows:
disorders [9]. Food restrictions necessary to diagnose and treat FPIES
using the initial elimination diet and gradual oral food challenge further A. Obtaining toy food so the infant would become familiar with the
limit the variety of nutrition to which the child is exposed. Negative visual representation of edible items and including utensils, cups, and
reactions that occur as the child potentially reacts to re-introduced dishes in a variety of play.
foods reinforce aversive behaviors. For this reason it is critical that
B. Offering water via spoon, and if accepted increasing to straw and
providers understand the importance of appropriate feeding therapy in
sippy cup.
the form of encouraging oral motor skill development, flexibility, social
acceptance of snack time and meal time activities, shaping of a positive C. Neocate Nutra, a hypoallergenic, semi-solid medical food
relationship with safe foods, and extensive parent education. designed for individuals needing elemental formula due to severe food
allergies was presented.
Though the prognosis for children with FPIES is favorable, in
that it typically resolves by 3-5 years of age [1,10,11] the impact of the D. Presentation of Elecare (an elemental formula which would be
disorder results in decreased opportunities to practice oral motor skill a safe alternative as mother was weaning from breast milk-her mother
development with a variety of foods and can result in learned feeding was also doing a strict elimination diet to minimize potentially harmful
aversion. Even in children with nonorganic feeding problems who are antigens in the breast milk) from a cup and a spoon.
still able to thrive nutritionally, negative behaviors around feeding can
result in a greater risk for poor health, social and emotional problems, E. Presentation of Neocate Jr Vanilla (another elemental formula
nutrient deficiencies, social problems, and disruption of family life [12]. for children for the dietary management of cow milk allergy, multiple
food protein intolerance and food-allergy-associated conditions) from
Treatment Plan a cup, a spoon, and made as a pudding.
Medical therapy in FPIES is focused on food challenges to identify F. Present first food item for allergy testing (in this case, pears on

J Pulm Respir Med Volume 5 • Issue 3 •1000287

ISSN: 2161-105X JPRM, an open access journal
Citation: Mattingly R, Mukkada V, Smith A, Pitts T (2015) Optimizing an Aversion Feeding Therapy Protocol for a Child with Food Protein-Induced Enterocolitis Syndrome
(FPIES). J Pulm Respir Med 5: 287. doi:10.4172/2161-105X.1000287

Page 3 of 4

week 1, followed by apples, green beans, green pepper, asparagus, etc.

in subsequent weeks). This includes presentation in as many forms (i.e.
frozen, pureed, cooked, raw, made into crispy “chips, etc.) of the food
as available.
G. Present second food item one week later, and continue on with
food challenges as directed by the physician.
If negative physiological responses to food occurred the food
was discontinued. If the child rejected a food it was presented again,
sometimes in other forms, on several occasions. Preferred and tolerated
foods were continually offered but would initially be withheld to permit
the child an opportunity to interact with new food. Breast-feeding was
maintained throughout to allow the child to remain hydrated and to
take in nutrition. The mother’s diet was restricted due to concerns that
the child would react to foods with higher risk for a negative response.
Avoided foods included rice, oats, carrots, nuts, grains, soy, and dairy.

Results
Mom and child accomplished goals surrounding food play easily.
She showed significant interest and mouthed all items. The patient
demonstrated significantly delayed oral motor skills which made
straw/sippy cup drinking difficult, however aversion to non-breast
presentation was significantly decreased. The Neocate Nutra® (Nutricia
North America; Gaithersburg, MD), and Elecare® (Abbott Nutrition;
Columbus, OH) were rejected in their original form.
First food item presentations included: sliced fresh, fruit peel, freeze
dried (regular dried could not be used due to preservatives), liquid, and
frozen (in slushy and solid form). Presentation environments included
a high chair in the kitchen, living room floor, and in the bathtub (Figure
1).
The patient was willing to mouth slices, drink from a cup, and
attempted to manage freeze-dried pieces. Due to her oral motor skills
delay she was not adequately able to manage the pieces so it was initially
recommended that they be placed in a feeder bag until she could
develop adequate skill. She could not tolerate pieces so we used a feeder
bag, which she rejected, so we went back to pieces, which she eventually
accepted. Following acceptance of pieces she then began accepting
thick strips of the peel, which she mouthed and then discarded.
The traditional week timeframe for new foods was modified due
to her food aversion, and has been extended to two-three weeks to
allow for adequate assessment of each food item. This timeframe can
be accelerated to the 1-week standard with increased food acceptance.

Practice Implications/Conclusions
Other non-IgE mediated disorders such as food protein-induced
allergic proctocolitis and food protein-induced enteropathy have
similar if less severe symptomology than FPIES and are diagnosed
clinically based on elimination diets followed by reintroduction Figure 1: The therapy schematic is additive function, as you move from one
of suspicious foods. Though a separate clinical entity, eosinophilic stage to the next, while using all tools at the therapist disposal. We recommend
that the child spends at least 1 week in every phase. Note that play is not
gastroenteropathies share many overlapping clinical and histological for purposes of distracting the child, but to involve them in the food based
features with the non-IgE gastrointestinal food allergies [11]. EGs activity. Water can be phased out if the child is advancing, however it may be
include eosinophilic proctocolitis (EP), eosinophilic gastroenteritis necessary to continue because it may be less threatening. The physician must
(EG), and eosinophilic esophagitis (EoE). Diagnosis of EP is primarily be involved in the food trial choices and the amount of time necessary to spend
in these particular phases.
made clinically while some lab parameters and diagnostic tests
including endoscopy may be helpful in diagnosing EG, and upper
endoscopy with biopsy is necessary to definitively diagnose EoE [3]. occurring symptom associated with EoE [13-15] with similar potential
Gastrointestinal symptoms are characteristic of EGs and treatment can complications relating to therapy. Given the existence of these other
include restricting the diet with a gradual reintroduction to determine similar diseases with their associated risk for feeding dysfunction, we
the offending foods [3]. Dysfunctional feeding is a frequently would argue that the concepts illustrated in this patient with FPIES may

J Pulm Respir Med Volume 5 • Issue 3 •1000287

ISSN: 2161-105X JPRM, an open access journal
Citation: Mattingly R, Mukkada V, Smith A, Pitts T (2015) Optimizing an Aversion Feeding Therapy Protocol for a Child with Food Protein-Induced Enterocolitis Syndrome
(FPIES). J Pulm Respir Med 5: 287. doi:10.4172/2161-105X.1000287

Page 4 of 4

have broad applicability to a range of food-allergic conditions. summary of NICE guidance. BMJ 342: d747.

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the underlying medical disorder can interfere with the feeding therapy
8. Morris SE, Klein MD (2000) Pre-feeding skills: a comprehensive resource for
process and make the situation more complex. Therapists must be mealtime development: Pro-ed.
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9. Overland L (2011) A sensory-motor approach to feeding. SIG 13 Perspectives
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J Pulm Respir Med Volume 5 • Issue 3 •1000287

ISSN: 2161-105X JPRM, an open access journal