Children with FPIES face risks for iron deficiency
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Key takeaways:
- Caregivers may avoid feeding their infants iron-rich foods, which are high-risk triggers for FPIES.
- Six of 20 patients with FPIES and iron deficiency met criteria for stunting.
Infants with food protein-induced enterocolitis syndrome face risks for iron deficiency, with potential impacts on their growth, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.
Previous research has associated food protein-induced enterocolitis syndrome (FPIES) with risks for malnutrition due to dietary restrictions, Mary Grace Baker, MD, MS, assistant professor, and Marion Groetch, MS, RDN, director of nutrition services, Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, and colleagues wrote.
“Childhood FPIES is thought to have a number of effects on nutrition,” Baker and Groetch told Healio in a joint statement. “This is related to the FPIES diagnosis itself as well as the impact of the condition on the patient and family.”
Since iron is a critical nutrient in early childhood, the researchers continued, iron-rich foods should be introduced into infant diets at age 6 months. But iron-fortified grains and other iron-rich foods are high-risk FPIES triggers, so caregivers may avoid giving their infants these foods.
That is why the researchers suspected that iron deficiency could be a concern for children with FPIES, Baker and Groetch said.
“Additionally, children with FPIES may have a limited diet related to food aversion from the unpleasant FPIES symptoms, personal or parental anxiety about trying new foods due to fear they could cause FPIES reactions, or additional food avoidances necessitated by other allergic conditions,” they continued.
Study design, results
The researchers reviewed the records of 20 patients (11 girls; 10 white) aged younger than age 18 years diagnosed with FPIES and iron deficiency or iron deficiency with anemia at their institution between Jan. 1, 2015, and Oct. 14, 2022. Alternatively, patients may have taken part in documented hemoglobin, ferritin or iron studies.
The first FPIES reaction occurred at a median of age 6 months. Other median ages included 8 months for FPIES diagnosis and 9.5 months for the consult visit.
There were 43 different triggers, with a median of two triggers per child and four children who had a single trigger. Triggers included grain (n = 12), fruit (n = 10), milk (n = 5), vegetables (n = 4), legumes (n = 3), soy (n = 2), egg (n = 2) and tuna (n = 1).
Fruit triggers included avocado (n = 8), banana (n = 3) and peach (n = 1). Grain triggers included oat (n = 7), rice (n = 6) and wheat (n = 1). Vegetable triggers included sweet potato (n = 3) and squash (n = 1). Legume triggers included peanut, pea and beans (one each).
The researchers classified atopic comorbidities as common, including atopic dermatitis (n = 12), IgE-mediated food allergy (n = 9), food protein-induced allergic proctocolitis (n = 5), asthma or recurrent wheeze (n = 4) and eosinophilic esophagitis or eosinophilic gastrointestinal disease (n = 2).
The patients with food allergy and food protein-induced allergic proctocolitis avoided additional foods. Food allergens included egg (n = 8), tree nuts (n = 5), peanut (n = 4), soybean (n = 2), sesame (n = 2), other legumes (n = 2), wheat (n = 1) and milk (n = 1).
Six of the patients had iron deficiency, and 14 had iron deficiency with anemia. Patients were diagnosed with iron deficiency or iron deficiency with anemia at a median of age 12 months. Iron supplementation was recommended for all 20 patients, and a dietitian evaluated 12 of them.
Dietary evaluations, conducted at a median age of 11.5 months, revealed that human milk was the primary milk source for 14 patients. Ten patients did not eat any legumes.
Also, five did not eat any grains, and 16 did not eat any wheat, even though only one patient had wheat-triggered FPIES and one had a wheat food allergy. Ten patients ate only one grain, including corn (n = 4), rice (n = 3), quinoa (n = 2) and oat (n = 1). The researchers noted that iron-fortified quinoa and corn are not widely available.
Similarly, none of the patients had FPIES triggered by meat, but eight of them did not eat any meat, and five only ate one meat including beef (n = 3) and lamb (n = 2).
The researchers also classified two patients as underweight, defined as a standard deviation of greater than 2 below the weight-for-age mean. None of the patients were classified with wasting, defined as a standard deviation of greater than 2 below the weight-for-height mean.
But six patients were classified with stunting, which is considered a form of malnutrition and defined as a standard deviation of greater than 2 below the length/height-for-age mean. One patient was classified as severely stunted, with a standard deviation of greater than 3 below the length/height-for-age mean.
Conclusions, next steps
Overall, the researchers called early FPIES onset in infancy, FPIES to grains and multiple FPIES triggers as risk factors for iron deficiency or iron deficiency with anemia among patients with FPIES. The high rates of comorbid food allergy, food protein-induced allergic proctocolitis and limited diets also contributed to the avoidance of foods that FPIES did not necessitate.
“These features overlap with risk factors for iron deficiency in the general population, which include exclusive breastfeeding beyond 4 months of age without a dietary source of iron or supplementation, feeding problems, poor growth or inadequate nutrition,” Baker and Groetch said.
Since the widespread dietary restrictions among these patients were out of proportion with medical necessity and possibly due to caregiver anxiety, food aversion or poor feeding skills, the researchers said the need for improved patient education was urgent.
The poor growth among these patients due to undernutrition and iron deficiency underscore the need for early identification of and intervention in iron deficiency, the researchers said.
“In our cohort, most cases of iron deficiency were identified after screening for anemia on routine health maintenance bloodwork. Iron deficiency anemia is caused by late-stage iron deficiency,” Baker and Groetch said.
“Far fewer patients had formal iron studies to evaluate for iron deficiency specifically,” they continued. “This is likely because of low awareness about risk factors for iron deficiency.”
In fact, the researchers noted, the American Academy of Pediatrics (AAP) recommend universal screening for iron deficiency with anemia with hemoglobin at age 12 months as well as iron deficiency screening with serum ferritin for infants and toddlers with risk factors such as feeding problems, poor growth and exclusive breastfeeding after age 4 months, which children with FPIES often frequently exhibit.
“We hope our results will improve awareness about the potential risk of iron deficiency in FPIES, encourage screening when appropriate, and allow for prompt initiation of dietary changes or iron supplementation to correct iron deficiency, ideally before anemia occurs,” Baker and Groetch said.
Although the AAP recommendations have been implemented widely, Baker and Groetch continued, the AAP also recommends screening infants and toddlers for iron deficiency with serum ferritin and C-reactive protein at any time in the presence of risk factors.
“Risk factors include a history of premature birth, low birth weight, low socioeconomic status, exposure to lead, exclusive breastfeeding beyond 4 months of age without supplemental iron or complementary iron-fortified/iron-rich foods, feeding problems, poor growth or inadequate nutrition,” Baker and Groetch said. “This targeted screening may not be performed as broadly.”
The researchers also called for additional studies to better characterize these risks and predictors as well as management of iron deficiency in children with FPIES.
“Understanding the nutritional risks and optimal strategies to improve nutrition in FPIES are areas of opportunity in our field,” Baker and Groetch said.
“Going forward, we would like to more comprehensively assess nutrition among children with FPIES, understand who may be at-risk for malnutrition or nutritional deficiencies, and develop evidence-based treatment plans,” they said.
For more information:
Mary Grace Baker, MD, MS, can be reached at marygrace.baker@mssm.edu. Marion Groetch, MS, RDN, can be reached at marion.groetch@mssm.edu.