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

Anvari S.; Baker M.G.; Bingemann T.; Bird J.A.; Brown-Whitehorn T.; Cianferoni A.; Durban R.; Gupta M.; Hosein E.; Konstantinou G.; Leonard S.; Ruffner M.A.; Schaible A.; Scurlock A.M.; Varshney P.; Muraro A.; Fiocchi A.; Santos A.F.; Arasi S.; Vazquez-Ortiz M.; Morita H.; Nomura I.; Upton J.E.M.; Levin M.; Lee E.; Galvan C.; Hoyos-Bachiloglu R.; Chatchatee P.; Beyer K.; du Toit G.; Gonzalez-Delgado P.; Yin Wong L.S.; Groetch M.; Nowak-Wegrzyn A. · Journal of Allergy and Clinical Immunology: In Practice (2026) · DOI: 10.1016/j.jaip.2026.03.035

Resumen

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.