Trust Your Gut: It Might Be FPIES

[MUSIC] In continuing education credits, including ADP maintenance of certification, for physicians and other healthcare professionals, provided by the Penn Medicine Continuing Medical and Interprofessional Education. Check out our website at www.cribsiders.com for more information. [MUSIC] The Cribsiders Podcast is for entertainment, education, and informational purposes only. The views and statements expressed in this podcast are solely of those of the hosts. [MUSIC] >> Welcome back to the Cribsiders. I'm Chris the Chewman Chewman here with my good friend and co-host, Sam Azir, as well as our producer, Olivia. Hey guys. >> Hey Chris. >> Hello. >> It's really late. >> Hello. Tonight we have Dr. Jessica Medougal to discuss food protein-induced intercollitis syndrome, better known as f-pies. But first, Sam, do you want to remind our listeners what the show is about? >> We'd love to. >> So we are the pediatric medicine podcast. We interview leading experts in the fields to bring clinical pearls, practice, change, acknowledge, and answering latering questions about core topics in pediatric medicine. >> We have a fantastic conversation with our guest, Dr. Jessica McDougal. She is the director of the Berghart Food Allergy Center at Oregon Health and Science University in Portland, Oregon. She's very proud to have completed her Medical Education Residency and Allergy and Immunology Fellowship Training at UNC Chapel Hill. Her clinical and research interests include food allergy prevention, treatment, and education. During her fellowship training, she was awarded a grant from the Allergy Foundation for her research on transitions of care of adolescent and young adults with food allergy. And she plans to continue this work at OHSU. She started the Food Immunotherapy Program at OHSU in 2024 with the goal to provide both oral and sublingual immunotherapy options to food allergy patients in the Pacific Northwest. She teaches us how f-pies differs from classic IGE-mediated food allergies, how to recognize both acute and chronic presentations, and how this differs from milk protein allergy. So you can trust your gut when it really counts. >> Yes. >> I think our listeners will enjoy a nice slice of this f-pies episode. >> It's one of my better ones, yeah. >> Yeah, yeah. >> No one took some thought, too, so that's why I appreciate it. >> Hello, Dr. Medugal. Thank you for coming back on the show. >> Hi, I'm so excited to be here again. >> So I happen to have you. It's been more than a year since the last time you've been on. >> Yes, a year and a half, I think. I now have 14 month olds. >> Wow, the slice is changing fast. >> Crazy, but so as you remember, we're an informal group. Is it okay if you go by your first name on the show? >> Absolutely. >> Excellent. So to remind our listeners who you are, can you tell us a little bit about yourself and something outside of medicine that you enjoy? >> Yes, of course. So I'm a pediatric allergist right now at OHSU, and so I help run the Food Allergy Center, and do a lot of things with IGE-mediated allergies, and prevention, education, treatment, which is super exciting. And then outside of work, I love hanging out with my 14-month-old twins, Astrid and Lilian, our dog, and eating as much brunch as possible. >> So if people want to hear about your favorite failure and best advice, they should go back and check out your allergy episode. I don't remember, I think it's like 134. So people should go back to check that out, but I think Olivia's got a question for you today. >> Yeah, so those who know will know, there's some reality TV drama that's hot right now. So I was wondering what your favorite trash TV show is. Currently, it's Summer House, and you're correct. There is a scandal going on, and I'm shook, and I'm honest, I'm through a Reddit rabbit hole. It is so bad, y'all. I need to get off these subreddits, off of these groups. I'm commenting to strangers. I was like, this really has a hold on my life right now. I need to get off. We'll have to do another podcast on that topic, too. We actually have three cases we're hoping to hit today. So we're going to jump right in. Olivia, if you wouldn't mind starting with the first one, let's get going. (upbeat music) >> Hey, Cribs, editors, listeners. Whether this is your first episode, or you've been with us since day one, you know our goal has always been to share real wisdom about practicing medicine. So let's talk about something that actually changed my day today as a hospitalist. That's fake scrubs. I can't walk into a clinic or hospital without seeing people in fake scrubs. And I get it, I wear them, too. They're incredibly soft, form fitting, and durable, and it's not just us. If you've been watching a certain popular ER drama on TV, yep, they're in Figs, too. These scrubs get it. That's what drew me in and what keeps me coming back. And because we work with kids and kids come with messes, I love that Figs are into microbial. When stuff gets on your scrubs and it will, you just wash them and they come out wrinkle free. I've washed mine well over 50 times and they still look brand new. All of that, and so much more, is why we've teamed up with Figs. Now crib centers listeners can get 15% off. Just go to wearfigs.com and use code FigsRX. That's w-e-a-r-f-i-g-s.com and use code FigsRX for 15% off. (upbeat music) - Okay, so you are working in the emergency department when in-rolls oatmeal omali. He's a seven-month-old who had oatmeal for breakfast this morning and an hour later turned pale, became lethargic and had projectile vomiting. He was rushed to you in the emergency department. On arrival, he's already perking up. So let's start with the basics. Can you go over what F-Pies is and for some of us exactly what it stands for? - Yeah, so F-Pies is food protein-induced intercalitis. It's a mouthful, say it five times fast, but essentially it's a delayed food allergy. So it's something that's non-IG mediated. It's gonna present later in time in your typical immediate food allergies. And so a lot of times actually kids end up in the ED and it gets missed as a diagnosis. And it might take multiple reproducible episodes with the food before the family even realizes, oh wait, I gave oatmeal or I gave sweet potato or I gave this or that. And every time they've had this reaction, so compared to our IG mediated food allergies, which get diagnosed pretty quickly, I would say, like it's very easily recognized. It could be a median time delay diagnosis up to seven months in some other literature review. So there's a huge from time of onset to when someone's officially diagnosed, it could be months to a year, which is a big deal for families. - Can you explain a little more exactly how it's different from other food allergies? 'Cause you're seeing IG and non-IG and I don't see, it's been a while, so I think I might need a refresher. - No, I'm happy to provide a refresher. So I think the biggest difference is when I'm thinking about immediate food allergies, I'm thinking IgE allergic antibody. That is something where your mass cells are activated, whenever you see that food, cross-links and leaks all these yucky chemicals like histamine, et cetera, to produce very, I think well-known symptoms for people of high swelling, difficulty breathing, vomiting, but that's really occurring within, and 30 minutes of ingestion usually, we say up to two hours, but we're really seeing those symptoms onset very, very quickly. This is in comparison to some of your other food problems or the spectrum is very large with food allergy, but for delayed symptoms with F-pies, it has nothing to do with your mass cells. It's still an immune system process. There's some thought that there's some T-cell mediated or delayed aspect to this. There's intestinal permeability that happens when the food is introduced, and there's even thoughts about the serotonin channels, which is some of why some of the anti-naujemeds are used and help in management. Those symptoms are gonna look very different, right? So you're not gonna have these skin symptoms, you're not gonna have respiratory symptoms, but you are going to have significant gastrointestinal symptoms like vomiting, diarrhea, abdominal pain, and in cases, lethargy or dehydration, depending on how severe it is, but those aren't gonna show up to one to four hours later. So if you're that person that happens three to four hours later, people may not recognize that it's associated with that particular food. Does that kind of help separate those two a little bit, and then management's different, and we'll talk about that. If it's an immune-based condition, not IgE-mediated, but I'm guessing we would put it on to the type four hypersensitivity reaction if it's a T cell thing, or is that incorrect? Let's even start with there, because you're already giving me a question mark. So let's start with there. - I think the true mechanism of apais is still being studied. I don't think it's definitely not as well understood as IgE immediate food allergy, but I would put it in the delayed category of a type four hypersensitivity. It's occurring later, T cells are involved. There's other mechanisms happening behind the scenes in order to get that result of what the symptoms are. - Awesome. So then the following question I was going to say to that is does that cause gut inflammation? Like is that truly an inflammatory condition, or would you not put it under that category? - I would say that it is inflammation, right? Because when you're looking, and again, it's a spectrum right, because it could be as simple as, and I think we're going to talk about it in another case, but it could be as simple as your colon's involved with milk protein allergy, right? And you have inflammation, it's colitis. This is interacolitis. So there's indeed inflammation going on throughout the gut. The gut's becoming more permeable, more inflamed, because of its reaction to this trigger protein from the food, and then you're getting all of these symptoms as a result. Long-term inflammation for acute apais, no, right? It goes back to it's normal. Hopefully there's not this underlying level of inflammation happening. But when you see that trigger food again, you're going to become inflamed. - Perfect, perfect. So that brings you to the next question, which you were talking about triggers. So you mentioned in our last podcast a long time ago, there's nine common food allergens. For f-pies, is there a similar list? of foods or common triggers that we should be aware of. Yeah, I was about to say throw that top nine in the trash. It's different for F pies. Cal's milk and soy are still very common for F pies triggers, but you're also going to see things like oat, rice, sweet potato. Oat and rice are extremely common both here in the United States as well as in Australia. And then honestly, the geographic location of where you are matters to what your triggers are. So for example, in European countries, you might actually see fish implicated more than anything else. And there's a question of does it have to do with when things get introduced to the diet, right? So in European countries, fish is one of those first foods that white fish is what they're getting introduced to. First, whereas we start with oat cereal. We used to, you know, or rice cereal, things like that. And does that kind of shape why we have these differences? And we've noticed, and is it a strong enough correlation? Or cause, you know, you can't say causation. It's a strong enough correlation that as we've had this learning early about peanut, early introduction of peanut, or now kids are really into their avocado. I'm like, I've never had an avocado until I was in my 20s. But now here we are eating avocado at six months old. We've actually seen an uptick in peanut and avocado F pies, whereas those were previously considered lobus foods. So I think we are changing potentially our trigger foods just by how we're incorporating and early introducing foods. It doesn't mean to stop to do that. Please continue to introduce the peanut. But it's just an interesting trend that we've seen. And so I see food allergies all the time in clinic as an outpatient pediatrician. And F pies, I do not come across often. So how common is this? Are we just, am I missing a diagnosis? Or is it just less common? I would say it's be less common than your IgE-mediated food allergies. So if you're looking at the population studies that have been done in the US, it's about 0.5% prevalence for children. And then about a 0.2% prevalence for adults. And then it's probably like a 0.17% incidence based on these population studies for like new cases. I think we are, you know, I'm an academic center. Others of us are academic centers. And you might see it more often than you're seeing it in the community. But certainly, I think there are times where it's just delayed diagnosis. So by the time they get to me, they've been seen for viral gastro or something like that. And I'm like, oh, this is actually F pies. This is what's going on. So I think it's more common than we think, but definitely not as common as some other food issues. It's interesting that you say that kind of delayed diagnosis viral gastro. You know, we wrote this case where it's, you know, okay, patient had oatmeal. Then an hour later turned pale with our Jack, projectile vomiting, right? But that's a history that's framed around the oatmeal. If you think about it, if I asked the family what happened, they would have been like, she just threw up out of nowhere. You know, like, you don't really know that this happened. Like, oh, we should put that oatmeal that we had an hour ago into this situation where I'm doing my history. But so when this patient does present, regardless of whether we can get that great history or not, is there any initial workup you'd recommend us doing, trying to think through this type of thing? Yeah. So I think it's, you know, I have the luxury, the economic allergy side of things, where someone's coming referred to me and we already have an idea of what's going on, right? Like, I've already gotten my brain. This may be F pies based on the history. And so I can have a luxury of saying, you don't need any labs, you don't need any imaging, right? Because what this is is a clinical diagnosis. I think for those who are in the ED or on that side of things, you are probably already doing a workout because you don't have a luxury of having five episodes of the same thing happening with this family. And now someone's put together that it's happening because of food. And so I think automatically a lot of times, like a CBC, a CMP, those things are already done. And you may notice like a left shift with neutrophilia. You may see if it's really severe, you might actually see a metabolic acidosis on these kids. You might see hemoglobinemia on these children. But the odds that they've actually had those workup or even need those labs is lower. It's just they sometimes are incidentally done in the ED for workup of viral illness or other GI conditions where there's concerns. And I guess that just kind of jumps in. Maybe we should do it the other way. We should ask, what's the diagnostic criteria? How do you diagnose this disease? And then we can try to figure out what we actually need for testing as we keep our differential wide. Yeah, so there is diagnostic criteria for F pies. For acute F pies specifically, the major criterion is going to be repetitive vomiting that occurs one to four hours after ingestion of the food. That is especially true in infants, toddlers. Like I really do need to see that symptom before I'm like, this is as severe as something like F pies. Interestingly enough, to be on the flip side of things for adults, we're actually seeing F pies more. And there's this thought that they actually see more of the side of diarrhea and abdominal pain, rather than vomiting. And it maybe isn't actually a major criterion on the adult side. But at least on the peak side it is. There are other minor criteria and so things like dehydration, lethargy, obviously, after being exposed, reproducibility. Like it's happened on multiple triggers with the same food diarrhea up to 24 hours later from that. So those are some of the minor criteria. But you really need to see that major criterion. I'm probably not diagnosing F pies without the vomiting history. Is there testing that you would consider to rule out other differentials? Like will we see if we get inflammatory markers? Will we see some of that here? Or at least lack of that? Or should we do standard allergy testing to rule out other types of, you know, and actually IG mediated allergy reaction? That's a great question. I think from the primary care perspective, I don't think you necessarily need to run other IgE testing. I think we talked about that in the last podcast, too. It's like, it's very non-specific and it can have a lot of false positive. And so certainly not running any IgE panels. There are very specific circumstances where I think about IgE testing in this group. And this case is actually a good one to talk about because it's on the cusp, right? Mr. Oatmeal O'Malley or whoever this little seven-month-old is eating oat, he had perfused vomiting in these symptoms only an hour after ingestion. How'd it been four hours, three hours? I've been like, this is pretty much clear-cut. I'm really convinced of F pies. We have no skin symptoms, no respiratory symptoms. I don't think we necessarily need to do testing. But I do have kids that come in with this kind of, I don't know, nebulous picture of, oh, well, it was only an hour. Parents think it was only an hour afterwards. And I'm like, well, I can't actually say for sure for certain that we don't have an IgE-mediated component going on here. So in that case, I will actually test them in the office and do skin testing. A lot of times they are negative. And we just move forward. The next time that I'm doing skin testing, we'll probably go over this later too. Talking about management is before I'm thinking about an F pies challenge, because there are some kids who become sensitized and develop, even develop an IgE-mediated allergy to this food they'll be avoiding. But I think from the primary care perspective, I wouldn't go chasing too many things unless you had other red flag symptoms where you're like, I'm concerned about like an inflammatory bowel disease or something like that. But I feel like this becomes a pretty clear, hey, every time I have a oat, every time I have rice, this, I don't think you need to put them through blood work or any kind of paint like other tasks that are going to be painful for them or unpleasant, especially if it's not going to do anything for that diagnosis. It feels like all you need is, you know, this kid's obviously losing volume. And so all you need is that one low blood pressure. You had a low blood pressure plus that, you know, that piece in the setting of it. And before you know it, you're going down in a phlexus for all those things as we're trying to figure out. It is so hard to tell with these kids that present really honestly quickly after the food ingestion. So this was a good case to kind of talk through because it's not clear-cut. Right. When the thing is they noticed the food, as I said earlier, like that might not have come up even on the history that you're taking is to associate that with the food. I wouldn't expect it to, honestly. They'd be like, "Oh, maybe this is a start of a viral gastroenteritis." Maybe this was like an intolerance to something. Maybe you just had a one-off or reflux or you just gagged on something. There's so many other things, right? So when we are gathering that history, is it usually, this happens during their first exposure to the food or is it consistent with FPs if they've tolerated it in the past? Most of my kids, this is probably not their first exposure to the food, honestly. I think most of them are like, "Oh man, we thought we were good." This was like our third time having it. Or they really loved avocado. Or they finally ate enough of it, right? Because when we're introducing food to six-month-olds, they're playing at it. They're taking a fingerle. They're tasting, right? That's the whole goal. It's just to taste things. But then all of a sudden, they eat an entire avocado and then have the issue. So it's not necessarily that first exposure. It possibly could be. But usually it's, I think, second, third, fourth exposure where I'm starting to see these cases. And then it becomes pretty reproducible quickly. All right, let's get into treatment a little bit. So clinical diagnosis. You know, we say that we got this kind of ER visit. But say this was like the 17th time. And like, we finally figured it out. Well, what's our game plan here? What do you recommend for treatment and walk us through everything? Yeah, absolutely. So I think in the emergency setting, it really depends on severity of the symptoms, right? So a kid comes in, mild symptoms. The vomit, Mr. Oatmeal, O'Malley, person. I don't know whatever his name is. He has perked up, right? He is no longer vomiting. He is looking in good spirits. He does not look lethargic to you. He is playing in the room. But we got to make sure he's drinking something. I think for this kid, you could do oral rehydration, right? Maybe if he's still feeling a little uneasy to the stomach, you could do on dance-a-tron. And you could do 0.15 mix per kick of that to his dose. If you have a kid where they are not looking good, they are still vomiting. on arrival, they're looking listless to you, they are heading towards lethargic, they look dehydrated, that's a kid you're going to put an IVN, you're going to do your normal bullets of normal saline fluids and you're probably going to do them to try to 0.15 mix per cake and you're going to potentially do methyl prinous alone at 0.1 mix per cake because there is a sterile component component that can be helpful especially in those severe cases. Notice in none of those scenarios do we treat with epinephrine because that is not going to help solve or manage that reaction for F pies in particular. Once they're at home, that's a little bit different, right? Like hopefully we're not going to have another exposure to oat or whenever food it may be, but I do send my kids home with on danzitron prescriptions and make sure that they know when to use it if they have those episodes of bombing to see if we can prevent the progression to having to go to the emergency department. Let me just ask about the steroid for a second. Is that a one-time dose that you just give them once and hope that they get better or is it of course okay it's a one-time dose? Yeah, I usually do a one-time dose or you could even do dexamethaside. You could do whichever steroids on hand. Sure. It's going to last a little bit but I don't think it's not an ongoing, doesn't need a taper or a burst like an asthma exacerbation necessarily would. Great. So if we're like, I don't really have any contraindications to giving a steroid right now and I think this might be that it sounds like it could be relatively stable. It's reasonable. Yeah, absolutely. Great. What should we tell them about the oatmeal? Please don't eat the oatmeal again. Now this is a great question, right? Because by the time they're getting to allergy, we may have more than one trigger. Maybe we only have one trigger, right? But the next question the family is going to ask me is, well how do we introduce more foods or how do we go about this? What do we need to avoid? And so we talk about one. We're not going to eat oat for a while and we can talk about how we manage that and the allergy clinic, how we follow up on it and what we expect that course to be for them for the oat. But as far as other foods, there is actually a beautiful table. I need to link the resource for you guys or send you guys the article so you can link it. But it has low risk, medium risk, high risk foods. I tell them, start with your low risk foods. Not because I'm necessarily worried about them introducing those other foods, but it's just I think it eases families into it. Once you've had a big reaction like that, it becomes very, I would be very anxious as a parent, especially now that I am a parent introducing foods. I think it just gives all this anxiety to introduce the next food. And so having a plan in place and saying, Hey, do these low risk foods. And then I move on to the medium risk foods. And then I go to the high risk foods that aren't the grains. And then finally, I go to something like halas chai rice if you haven't had rice yet. And we kind of go through it step-wise like that to get them to a place where maybe oh, is the only food they have the issue with. And if it's not, we've figured it out and we can keep introducing other foods. So is there a high risk for for having multiple F pies to multiple different foods if you have one. So like if, you know, if they have rice and they can't have fish later or I don't know like, or is it or there is or there pairs that are common like rice. Yeah. So I think it's with it. Yeah. It's within the same category, right? So grains are together. Then like we have like little gooms and nuts. We have like calcium, soy and egg that kind of run together. And then we have fruits. And then we have vegetables. Like if you think about like sweet potato is like one of the higher risk foods. And that's in the same category as other things. And so there are different categories. I would say before we were like, oh, one trigger foods, that's more common, right? You're going to have one trigger and it's less common to have multiple. I don't think I have a single kid in my clinic that doesn't have multiple triggers. I feel like two or more is more common than we think. I would probably say half my kids have multiple triggers. And that's usually why they're coming to me at such an early age, right? There's nothing I can do about their current trigger food. But the problem becomes how do I introduce the other foods and what about my nutrition and how do I move on from this? The sort of counseling sound sort of can be complicated. Is this something like if we have this table of foods that we should feel comfortable as pediatricians providing or should I definitely, if like, you know, those F pies, I should refer to analogous to help with this counseling or should I refer to a nutritionist who might be or a dietitian who might be able to give some of this because a certain elimination diet almost so maybe complicated. Yeah, no, I agree with you. I think in the time span that a primary care doctor has in their clinic, it would be nearly impossible to do all of this counseling. I think if it's something quick and easy, they've had one trigger families feeling really comfortable with other introductions, providing the table as just guidance isn't a bad thing to do. But I think families who are more anxious or they have more than one trigger, I think it's reasonable to refer to allergy. Certainly our dietitians are wonderfully helpful. They help me on a lot of my multiple food allergy kids, but not every dietitian is going to be well-versed or really comfortable in the F pies world just because it is less common not a lot of people have seen it. And so I'm actually working with our OHSU GI team and dietitians to do a talk to talk about like how do we introduce these foods because it's just not something that they're used to seeing or necessarily comfortable in. And so we're working together because we share these patients because sometimes they get sent to GI before they ever get sent to me because it's not clear that it's F pies yet or someone hasn't put it together. They're like the kids vomiting. We just need to send them. I hope that was helpful and kind of answered that. Yeah, that was a little hand-madey. That was perfect though. And so, you know, obviously we've been teasing this for a bit and just so the audience knows we're going to get to reintroducing in case three. So stay tuned. Good reason to listen to the rest of the episode. Yeah, don't give up yet. Yeah, exactly, exactly. But Olivia, if you want to start with case two, maybe we can get into another case that's very, very common that we'd love to talk about. Yeah. Okay, so now let's talk about Madeline Milky, a five-month-old exclusively breastfed baby. Over the past few weeks her parents noticed that she's been having multiple episodes of looser stool and some blood streaking. The pediatrician initially thought it might be reflux or a stomach bug, but things haven't improved after switching to different formulas. Growth is noted to be slightly slowed today. So what could be going on here and how might this process be different than the acute symptoms that we saw with our first patient? Yeah, no, I actually loved this case. I was telling Olivia earlier because I think that again, this leads into this one does have a good differential diagnosis, right? When you're looking at this case, it is not a slam dunk into any of the diagnoses. And so we have a spectrum of disorders that can happen. And I kind of alluded to it during that first case. We have all the way from food protein induced allergic proctor colitis, which is involving a small part of the colon, or it's locally known as milk protein allergy, which is what I think a lot of people. All the way and it can be a complete spectrum all the way up to food protein induced intercalitis. And then there are two subtype, well, really three subtypes. And we'll get into that as well. But the two major subtypes of F pies are going to be acute and chronic. So the big difference between what we saw in case one and case two is going to be the case one, this kid one hour after multiple episodes of vomiting, then slows down. He perks up. That was his like one, two, whatever exposure to oat. But it's not something he's having every day. It's not something he's building up to. Chronic F pies is more insidious. It's something where this is can start earlier than what we see with solid introductions, right? Because we might be introducing cow's milk formula. We might have breast milk, well, mom, mom is having dairy, soy, soy milk formula, whatever it may be. And all of a sudden, over time, kid is having vomiting. They're having looser stools, diarrhea. There's failure to die. Thrive. There's concerns for poor weight gain. There's other things going on that all of a sudden is going to red flag you. Like, hey, something's not right with what's going on with this kid. And then you have that component of maybe at first or vomiting, we think it's reflux. But really, this vomiting is going to contend you. It is severe. It is perfused. It is causing a lot of issues where a lot of our reflux kids, they're speddy babies, but they're otherwise healthy. And even in those kids where we end up having to do potentially anti reflux Spencer sense or something like that, it's not as severe as what's going on. The entire gut is involved. So where reflux, I might only see vomiting. Now in chronic F pies, I'm seeing diarrhea too. It's coming from both sides of the equation over there. So I think this is a really good case because Madeleine Milky, she is having some blood trickstools. She's having some diarrhea, but there's no mention of vomiting. Only now is her weight slowed in growth. And yeah, they've made some formula switches and it hasn't improved. But you could almost say, are we quite there yet for chronic F pies potentially, right? We might be moving in that direction. Or is this just a really bad case of milk protein allergy? I mean, you think about elimination. So like I think this case is not as clear cut as some of the other ones I see where these kids are can be severely ill, whether hospitalized. And it isn't until we switched what hyper allergenic formula. And we might see improvement after three to 10 days of that switch. As pediatricians, we spend a lot of time telling families, make sure you're drinking enough fluids. And then I go on rounds and realize it's 3 PM and I've had nothing. So you know, lead by example. But that's one of the reasons why I've really been liking instant hydration. It's an electrolyte drink mix that's super easy to throw into water and most importantly, it actually tastes really good. The flavors are refreshing and there's a little saltiness to it without tasting like you're drinking the ocean. And speaking of salt, instant hydration uses French gray sea salt imported from France, naturally harvested and rich and naturally occurring trace minerals. Apparently, even my salt can travel. And so most commonly, I'll drink instant hydration after exercise, but I also like having it during a long work day when I know I should probably be drinking more water. It's just an easy, tasty way to make hydration something I actually want to do. So Cribsiders listeners, for a better way to stay hydrated, go to instanthydration.com/cribsiders and use our promo code Cribsiders for over 40% off your first subscription order. It's instant hydration's best offer available. That's instanthydration.com/cribsiders. Promo code, crib sideers. So we definitely need to talk about the colloquial difference between Chronic F pies and milk protein allergy. We seem to be using them roughly interchangeably based on what it seems to be based on location in the GI tract. Can you at least walk us through what is supposed to be the definition and that we can talk about to make sure we understand what people use when they say it locally? Yeah, so I think everyone uses milk protein allergy because that's the most common trigger. Really give both of these, right? So Cal's milk worldwide is going to be one of the most common triggers for this. However, we know other food triggers cause it. And so I tend to lean on the actual names of things because it helps me remember the location of what I should be expecting symptomatology wise because they're both immune system processes. It's both inflammation is just how widespread it is in the gut. So for food protein induced allergic practicalitis, again, Cal's milk, most common trigger. And I think it's what people mostly mean when they say milk protein allergy. It's where we're going to have that very small piece of the colon near the rectum that's going to be involved. There's inflammation there. It's causing maybe looser stools, maybe mucus in the stools, maybe some blood-strict stools, but the kid is otherwise growing well. We're not seeing vomiting. They're pretty much happy babies. And there's a question of do we need to do anything about it if they're otherwise doing well? Maybe not. Versus, as you get towards that chronic F-Pie spectrum, you're now food protein induced in terror clitis. Your entire gut is starting to become involved. Do you see a lot more severity of symptoms? So immune system still involved. Inflammation still there. But now I'm inflamed in my entire gut. I'm vomiting. I'm having diarrhea. I'm getting exposed to the trigger all of the time. And so my symptoms become worse and worse and worse and worse and to lie potentially have this dehydration, this poor weight gain and I end up even potentially being hospitalized before it's realized. And we've had a couple of kids like that when I was in residency where they ended up having a very high nat hemoglobinemia level. We were checking all those things, thinking they had some terrible gas show or a semonella or other thing and it ended up being F-Piece. We switched them to a completely extensively hydrolyzed formula. And within three to four days they were purking around. Like all of a sudden we weren't having these symptoms. We were making slow weight gain. So even knowing about F-Piece, it took me a minute to realize that's what was going on with that kid. So you kind of mentioned some stuff but when we are trying to diagnose F-Piece, you kind of alluded to maybe changing formulas a trial and error but are there other diagnostic criteria that we look at when we're diagnosing the more chronic form of F-Piece. Honestly, it is still a clinical diagnosis. I think again, you're going to see lab disruption, right? Like these kids could be sick enough or have poor weight gain where you are bringing in them into the hospital. You are getting those white counts or getting the C&P levels and you might be seeing them at a metabolic acidosis. In fact, you commonly probably would, depending on how severe they are. You might be seeing the nuchelia. You might end your stool, be seeing leukocytes and esophiles and other things if you're doing a stool sample. Are any of those things necessary or part of the diagnostic criteria necessarily no? So it's still, hey, these symptoms are happening. I think chronic F-Piece could be the reason it's happening. I'm going to switch the formula extensively hydrolyzed go all the way. Like, Medicare, something like that. That's the one I'm thinking of because my daughter was on it for a little bit. And then within three to four or five days, you should start to see some sort of improvement and it could take up to ten days, but usually it's a faster turnaround than that when you've removed the offending trigger. And then that's kind of your test. That's your diagnosis right there. Wow, like all of a sudden we're not having these symptoms. We're turning around the corner and all it took was that switch to the formula. It's very unlikely to be some of these other things. Yeah, this is always super tough and I see this a lot as well. So it sounds like therapeutics are diagnostic in this standpoint. One of the hardest things for us is to figure out, again, kind of how long. If we're doing therapeutics as diagnostics, we've got to be like, okay, do my therapeutics not work because it's never going to work or is it not working because I haven't given it enough time. You mentioned kind of three to four days starting to pick up. I was wondering if there's anything that is a little bit more objective that we can use for that. And it's okay if the answer's no. I was just curious if there's laboratory markers or time or weight or number of vomits or anything that's helpful. Honestly, I would expect vomiting to significantly decrease if not completely stop. Just because you've removed the thing that is causing the issue and really when you're thinking about digestion, if you've changed it over, you should not still have that in your gut or in your system 24 or 48 72 hours later. It should be processed through so I would expect as we've gotten on the right thing, I would love to see almost no vomiting or at least we went from 8 to 10, 12 on the stay and now we're doing two. I could chuck up two to being a little bit of baby reflex, right? A little bit of spit up. All of a sudden our diarrhea is better. You could conceivably see improvement in the markers. If you had a metabolic acidosis, I would expect as your diarrhea decreases, as your vomiting decreases, all of a sudden your lab markers are going to look better. You're not going to have that same gap. You're going to have better by car like all of these things. How often are we trending that? It depends on how severe it was and if they're still hospitalized at the time. I think a lot of people aren't getting those follow-up laps. At least I know in my day, like back in my day. No, I guess just four years ago in residency, that I wouldn't be necessarily repeating prior to discharge. Would you expect a similar timeline for a breastfed baby and is it appropriate for the mom to cut dairy from her diet similar to a male protein allergy or do you really suggest doing one of those hydrolyzed formulas instead? Honestly, depending on the severity of the keto, like if they are someone that's in your clinic and they're otherwise, you know, they're not gaining like we want them to, but they're also not dehydrated. They're not looking listless or like they need to go to the hospital right away. I don't think it's a bad idea to allow mom to eliminate dairy if she would like to. You could even say dairy soy because there's a lot of, in the United States at least we don't see it in other countries interestingly enough, but there's a huge cross-haktivity rate between soy and cow's milk. So you say, "Okay, eliminate these two and see what happens." I probably wouldn't give it more than a week or so, because I think you're going to see whether or not it's improving it. And certainly if the kid gets worse in that time frame, then I would be switching and encouraging and extensively hydroized. But I would love to give mom a chance if that's what she wants to do and she wants to do that dietary elimination. So I have two questions about formulas. We'll start with this one off the bat. Extensively hydroized formula versus what we call elemental or amino acid base formula. Does that part matter or is extensively hydroized all that you need? And are there some cases, for example, like, "Okay, 90 percent will be good with this, but there's the extra 10 percent." So you never know, "Are you the extra 10 percent?" You know that type of thing. I don't have percentages, but I do feel like some people, some of my kids are going to be totally fine with this, since they're really hydroized. Like, I would say like an elemental neutron engine, not leading to go all the way onto the end, but I do have some kids where it's so severe that you really are on the amino acid formulas. So I don't know the percentages for you. I'm willing to give things like a couple of weeks to turn around and see if there's making a difference, as long as the kid's not very severe. A lot of them are going to be improved just by going to extensively hydroized. Certainly, you can make the hop to the next one if you need it too. Because, I mean, this is kind of my question. This is what we all kind of deal with from more of a social determinants health financial, all those types of things, right? The more hydroized we go, the more they break it up in the lab, the more expensive it is. And so sometimes you commit people to, for example, we thought this might have been some other, we got the disease process wrong, where it all got better because of time. Maybe they had a little bug and we just committed them to essentially hydroized formula, or we were an elemental formula. I know this is not black and white guideline based science here. This is just kind of more of your recommendations, any thoughts. But any thoughts about who we should commit to some of these things? No, that's a great question. And I think I understand even more having a daughter who was placed on Alicare, like a amino acid based formula for reflux. And then I'm thinking, oh, she has this milk protein allergy, like all the stuff's going on, and she just really needed time. And now she's on like a normal gentle ease. And we switched her like pretty quickly after getting home, because I was like, this is annoying to do this amino acid thing. And it's really expensive. And then she was totally fine. And she was being committed for months to Alicare. Right, right. And we are the doctors that do that. Yeah, we are the doctors that accidentally do that for more of it. As we said, for more of the diagnosis, the therapeutics is diagnostics. It's like just throw everything. You're throwing the kitchen sink. You're like, this kid is really bad off. Like, I'm just going to do whatever it takes to get them tolerating a feed. And then does time just improve things? I would say I wouldn't necessarily commit everyone to an amino acid based formula. I think it's worthwhile trying one of the, like partially or extensively hydroized and seeing if you get anywhere in that first couple of weeks. And then truly, if you're not tolerating that, we still have extensive vomiting, diarrhea, we're not looking good. Then those people, I think you can move on. I've also had kids where they've been on the amino acid. And there's concern for chronic FIs or other type food issues like that. And I've worked on stepping them back slowly. So I'm like, hey, let's go to this formula. next because they still had the samples, I was like, okay, let's do this. And then let's do that for a month and see how it goes. And then like, let's move on and see if we can get you back to a regular formula, especially when I think is the story really good for chronic F5s. Sometimes I've got a kid coming for chronic F5s and I listen to the story and like I think this was reflux or something else going on and I'm able to work it back. And I think that's appropriate too. And you know, one thing might help us too, is there a negative predictive value for these kids who don't have diarrhea and I know that's a double negative, but essentially saying that if this child does not have diarrhea, is it likely or unlikely for them to have chronic F5s? I think it's more unlikely for them to have chronic F5s just because if the definition itself, you really are getting an extensive involvement of the entire gut and that's what's makes it a little bit different than having gourd or something like that where you're only involving the upper GI area and you're getting the vomiting only. And so I would expect diarrhea and I'll never say never, like people surprise me, but I think ultimately most of my kids that are, that severe chronic F5s, they've got both sides involved. Because I'm just thinking through the case of how I'm, you know, if I'm really committing a family to this, maybe I will commit the family that's vomiting with diarrhea. And if this family is just vomiting for example, you know, maybe I'm missing the reflux exactly. And I would just follow the reflux guidelines which recommend eventually if you really don't get better to try hydrolyze formula for four weeks, I believe that's the guideline. And so we could try for the time, time-limited time. Okay, these are the things that I know are kind of come at me in my real life practice. And so that's why I'm asking all of these questions in this way. No, I'm glad that you're asking all these questions because I think about it all the time when I'm recommending things. I'm like, am I doing the right thing, especially being on the flip side as a parent? And I've had, you know, a medically complex child, like, are we, am I doing all the right things for her? Or am I wanting to see something get better so immediately that I'm jumping and I'm putting everything all at once without thinking, okay, let's do trial and error. Let's see what's really going on here. So is it fair to say that the kids that have diarrhea and some bloodstree gang, there is an overlap between the diagnosis of chronic F pies and a milk protein allergy, but you would categorize those that have poor weight gain more into the chronic F pies. Yeah, I think, I mean, I think if you're looking at it as a spectrum and kind of they flow into one another, this case specifically, I'm not willing to commit this person to a chronic F pies diagnosis quite yet, right? We just have some looser stools. We have the bloodstree gang and only now is there some slow weight gain, but did this kid have a viral illness recently? Is there other things going on and have they previously been perfectly on the curve? And maybe we need another weight check, another point in time, another, like a data point before I'm committing them to chronic F pies, yes, but I think there's probably some kids where they're going to be on the more severe end of that diarrhea and eukus and the stools, blood and the stools, but then also you're noticing, wow, their weight's really slowing down, they're dropping off their curves. They don't quite have the vomiting all the time, but they're not looking well like I would put them closer to being on that chronic F pies doctrine and I would treat them a little bit differently. This person, I'm still like, could we get away with just dietary elimination? Do we want to wait? Give it a couple more weeks and do a weight check and just see if this was a one off? Like was this something that's really going to be a trend for this kiddo? Do I want to commit the family to a dietary elimination if they're breastfeeding? If they're otherwise healthy, maybe not. So getting back to Madeline Milky, say she came back and weight was decreased and eventually she did get a diagnosis of chronic F pies. Now she's six months old and they're starting to introduce solid foods or these kids that have a diagnosis of F pies more likely to develop IGE mediated allergies. So there is a higher association with other atopic conditions for kids with F pies, so things like asthma, IGE mediated food allergy. So conceivably yes, they're at higher risk, not significantly over the general population necessarily, but they do have that increased risk similar to a kid who has, XMA has an increased risk for IGE mediated food allergy. Does that stop or change how I want them to introduce the foods? Do I think they need any testing prior to introducing foods? No. The only thing that's going to change is that when I'm thinking specifically about what their chronic F pies sugar is, like cow's milk, I'm not going to be having them introduce cow's milk and I'm not going to be having them introduce it at home. Probably for the first time and the reason that is is because when you eliminate a chronic F pies foods for a long period of time, similar to like if someone was eating something, they have XMA, they were eating peanut and then they stopped altogether for whatever reason and then six months later they have an anaphyl activation. Same can happen with chronic F pies where you can have an acute F pies reaction to that food that you were previously exposed to a lot and then you weren't for a period of time and then we introduce it once and then all of a sudden we got the vomiting one to four hours later. It's a different picture but it can happen and it's a little bit different as far as natural resolution like food protein induced allergic practicalitis or what we a lot of people refer to as milk protein allergy, a lot of those kids are truly outgrowing by 12 months old and so for those kids they were otherwise healthy, I'm not overly concerned about them having developed like an IGE mediated allergy or even an acute F pies picture so I'll have them introduce it at home starting around 12 months. It may look different depending on how the kid does and we can talk a little bit more about that but then for chronic F pies it's a totally different thing just based on severity of how they presented and what they were going through and so again, cow's milk does get outgrown faster than some of our other acute F pies foods but I'm probably waiting like 12 months after I stopped and switched their formula and then I'm doing it in the clinic in a very controlled setting to make sure that they're going to be safe to do it. So it sounds like these kids will get sent to you so we do not have them reintroduce until they get the go ahead and oversight by our local allergist. Yes, that's what I would recommend but for the other kids like the food protein induced allergic practice where they only had the poop in the blood and they were otherwise healthy growing well, I think it's absolutely appropriate for the pediatrician primary care doctor to help them reintroduce it 12 months. And more to talk about the proctor colitis one are often milk protein allergy because we are going to talk about the chronic F pies piece in a little bit for I'm just curious about this physiology in this disease like it seems like we don't fully understand but some sort of T cell mediated inflammatory condition. Why would that one be better at 12 months when you go to do it by mouth this way instead of the infant formula version? Yeah, I honestly think it's the degree of gut involvement and I honestly would have to do more research and see if there's any literature out there to suggest why I think the natural resolution of both right so F pies and this food protein induced allergic particular is a lot of kids are out growing it early in toddlerhood like in the first couple of years of life. I think that just the severity of presentation would make someone more nervous to introduce a chronic F pies food back into the home versus oh, I had a little bit of blood in my stool. I'm okay to reintroduce that I'm unlikely to develop something more severe, although I could get those symptoms again and there is like a small like I think it's about 2% I don't want to like totally quote it, but that might develop a like an actual IG immediate allergy to calcium. But otherwise these kids are going to reintroduce they might get repeat symptoms of diarrhea, looser stools or blood in the stool. We just take it back out of the diet, try again in six months, but that's a very different presentation than do I am I going to have an acute F pies reaction where then am I going to this kid going to show up with object dehydrated, unable to drink anything and have a really serious reaction in the E.D. So we already kind of covered this piece, but just to kind of summarize it just in case we missed anything the treatment sounds like hydrolyzed, extensively hydrolyzed and or elemental formula or elimination if you're best feeding for example, are there any other interventions that you recommend anything else that comes up if say you refer to your dietician in your own clinic for example, we're good on allergies anything we should know from a treatment standpoint before we move on to the next case. No, I think the biggest thing is like how do we deal with the other foods do we need to be eliminating soy, usually we are just because of the high co-reactivity between the two, although that's only 40% 60% of kids might not have any issue whatsoever. And then kind of they're like okay, well what formula can I use, we've got that covered, but then when I'm ready to transition if we're not transitioning to cow's milk or this what other milk can I give that's going to be reasonable and provide nutrition and I'm usually recommending green pea or oat milk for those kiddos to get similar protein concentrations et cetera instead of plant based milks like the tree nut milks and et cetera. But I think that's the biggest thing that they're probably talking to the dietician about is like next steps when I'm ready to get off of my formula, what do I do? Cool, so let's just kind of jump into I think case three, which is going to talk about all the reintroduction things that we can get all of our questions out there because I feel like we're really teasing this so I'll leave you a few in mind. Okay, now we're getting to our final patient, so rice or ronin, a two-year-old with a history of F pies to rice, shockingly, that presented similarly to our first case Mr. Oatmeal. So now we're two and her parents are curious if she's outgrown the condition now that she's a little bit older, so how do you know when it's safe to reintroduce a previously reactive food and what does that oral challenge actually look like? The answer to that is you don't, there is no like guideline of oh this person meets this criteria and therefore they're probably safe to reintroduce. consider all of these reintroductions to be high risk, especially if there was a severe reaction in the past. The question is timing. I think a majority of kids are going to start up growing their foods around 2, 3, 4 years old, some like Cal's Moxoy might be on the earlier spectrum, some like the oats and the grains might be on the later spectrum, but really in that 2 to 4 year old age range, a lot of them are going to be able to reincorporate these foods. I tend to go with 18 months from the last time they reacted to it, especially if it's like an acute FPI, so if it's something that happened at 6 months old around 2 years old, I'm going to want to bring them in to challenge that. What does that look like? And it may depend on the center you're at, the practice you're at, at an academic center, you'll probably see it done more than in your community practice because of the severity of the symptoms that can occur, but it's a long day for families. So we're having them come in the morning, unlike an IGE-mediated challenge where they are doing 4 to 6 steps and we're waiting 15 minutes between each step. We know that there's not really an immediate piece to this, and I'm usually skin-testing beforehand and making sure that I don't have sensitization, like an IGE-mediated issue going on. You test that, we do that and then it's 2 steps. I give them all the food up front and then I wait the amount of time it took them to last have their symptoms. So they could be sitting up into our office for like 6 hours, waiting to see if anything happens, many of them are around 3 to 4 hours, and then truly it is just monitoring for symptoms. There are some places where if it was severe enough, the first time they might consider placing an IV to be able to easily give fluids if needed, we don't do that here at OHSU. Instead, we just have I.M. Odansichan available, and then we would also have IV fluids need it here if we needed them. Most of my kids do well with the Odansichan and then oral rehydration if we need it. Quick question, how much food are you giving them? Have a full spread? I know when you guys do patch testing and things like that, you only need so much to cause a reaction. What will be enough to give you what you want? Here's an example, so there is a wonderful table, there's an oral food challenge, how to conduct one guideline that we have in the QAI, it's a work group report, but essentially it has this amazing table that goes through what the serving size is for each of the different age groups, and then for each of the different foods that we might test for, as comprehensive as it can be for a work group report, and then we take one third of that serving size. So for example, for F.Pi, so for example, for peanut butter, I'm just using one off the top of my head that we do a lot. A serving size for a young kid that's like one, two years old, it's going to be a tablespoon, so I would do a third of a tablespoon. It's about going to be a gram of protein, so they don't have to eat a lot, but it is kind of a lot at the same time, depending on what food it is. I like that there was a real answer to that question, Chris. Yes, there is. Yes, but there's like an evidence base put together, or at least an expert guideline put together answer to that. Yes, we reference it all the time. No, because I reference it every day for my food challenges. When I'm helped to run them, I'm like, what is that dose again for that food? You start to just memorize them, but yes, so it's about third of the serving size that you would expect for that each group is what we give. And to summarize, it sounds like there's little that you can figure out other than just picking a time frame with which to try that. Is that correct? Exactly, and it may be different depending on the provider you're with, right? There are some countries where they might try reintroduction as early as 12 months after the last reaction. I tend to go on the side of it. I'm like, I'm between the 12 and 24 months, I just land on 18 months because it seems to be the easy and it usually lands me after two years old for most kids. And that's kind of when we start to see that natural resolution for a lot of the foods, so it kind of works out that I have a lot of people tolerate when I bring them back. And is this true for acute F pies and chronic F pies or just acute F pies? Yeah, so while usually you could consider for the chronic F pies doing it like 12 months after whenever they switched the formula, that's my expert opinion of when I would do it. You might see different people doing different things depending on where they are. And some people might do it even earlier. They might say after 12 months old, we're going to give it a shot. Gotcha. So sometimes you say 12 months. So for example, we have our Madeline Milky was five months old, you know, and then so we made it to 12 months and then we switched. So maybe around 18 months, maybe around 18 months, I'm doing cow's milk. Right, perfect. So we switched to the, you know, we did our dietician recommendation. We're going to use oat milk to get the protein and liquids if they would like to drink that, otherwise they can just, you know, drink water and eat table food, but, you know, whatever they choose to do, do that until 17 to 18 months, as you'd say, and then you'd reintroduce at that time. And, and we'll hope for the best. And you know, you know, a lot of people do tolerate them and you're able to outgrow these F pies foods. And I will say just thinking about is there a marker that helps me know how the course is going to go or what might be. So I brought up that there are three subtypes of F pies. We've really only covered acute and chronic F pies, which are the major categories, but there's also a typical F pies, which you may have heard of. But essentially it's, you have the typical F pies symptoms, but you also have IGE mediated sensitization to the food. It doesn't necessarily mean that you have anaphylaxis that food, although some people do go on to develop IGE mediated allergy, but it does tell me a little bit more about that person's course. They may have a more protractic course, meaning it might take them a longer time to outgrow their F pies reaction. And they could have more severe symptoms with their reactions. So it just kind of gives me a heads up. I might be thinking a little bit differently about that kid of like, maybe we wait a little longer or maybe I'm more prepared for a severe reaction than I would be with somebody else. So by and large, like from a prognostic standpoint, like they're most, like we're doing this food testing because we're just trying to find the good time and we can actually allow this patient to restart food because most of the time, it will resolve unless they happen to have, you know, conversion to IGE mediated allergy. Is that correct? Yeah, so we're doing these food challenges to be like, yes, we're confirming that you've outgrown this and that the reason is is we don't want them to be accidentally exposed or go home and do this themselves. And then they have a terrible severe reaction where they end up in the E.D. extremely dehydrated needing ibifluid resuscitation and looking really bad in hypervolymic shock, which that is a very severe, severe presentation and not all my kids look like that when they have their F pies reactions, but there are this small amount of people that do and you, I just don't want my kids to be one of those. So we end up doing it in the office. What if in a very strange case, what if I, you know, I've a patient who had to change the, they move states to me and they're maybe in the foster system or something. They were diagnosed with F pies, but now they're eight years old. And this whole time they've been like restricting all this food all this time and you're like, you're eight, ten, whatever, like do we need to send you back to a food challenge or but you're eight. I know there's a very strange case, but how would you know? We have a right where people, people got lost to fall up during pandemic and I've got now five, six, seven year olds coming back. They were like, we were told to come back in two years, but then the pandemic happened. And so we haven't been back. And for those kids, I'm usually testing to make sure there isn't IGE-mediated sensitization there to make sure I don't need to change how I approach the challenges, but I'm probably still going to challenge them in clinic unless there was something a little off about their presentation or we weren't quite sure it was F pies. Then in that case, I might say, let's at least get to IGE testing because it's been years since you've had the food and you have an increased risk. We do that testing. It's all negative and I might come up with a plan with family of like, okay, we're not quite sure this was even F pies. Let's introduce it one at a time at home, have a good plan, do it on a weekend, do it on Saturday morning. Please don't do it at 11 PM at night. Please have both parents home or caregivers home to make sure we're okay, have the medicine at the table ready to go. And this is how you would do it. But a lot of people were still bringing them for challenges. I just want to confirm really fast, but we've said already, is it sounds like I have no other diagnostic tests both for both for a positive and negative predictive value, other than trialing, you know, trialing my, my hydrolyzed formula. Yeah. Sounds correct. Okay. Yes. Because we also say, is this a diagnosis of exclusion or something along those lines? And it's not in the sense that you would like, but you want a hydrolyzed formula on that and that should do it. I always the question that asked me that you might be not be the best person to answer is like, I'm asking myself, what else does hydrolyzed formula treat? Do you happen to know a differential diagnosis in that case? I think it's honestly going to treat any spectrum of like the F pies, food protein, induced allergic proctoclides, but it could also, I mean, potentially treat things like re, I mean, reflux, right? Like if it's a broken down formula, they tolerate it better. It's improving gourd, not necessarily on an anti-reflex medication. You could see improvement conceivably on that. Although, again, reflux is not going to look as severe, probably as someone with chronic F pies. I think, I think it all comes to severity. And I think the main thing is it's on your differential, right? I think knowing about it, putting it on the differential and being like, I've rolled out some of these other things. And I think we're severe, we're on a severe enough path that we're going to switch over. And then you can always say, I'm going to let the specialist figure out what's really F pies are not and how they're going to treat it. And I say that knowing I have the luxury, like you're referring to me, you've already kind of made up in your mind what it is. I'm trying to leave my allergy body and be like, what would I do as a pediatric resident with this beyond my differential? And sometimes I don't know if it would have been right. - That part is easy, keeping it on the differential is very easy, what's harder is trying to figure out if I do this, what else am I accidentally treating with this, and so therefore am I committing them to this diagnosis that is not actually correct versus committing them to this, versus not doing that, you know, that's what it comes down to, how am I accidentally committing them to this diagnosis because by diagnosing them, I'm saying their symptoms have improved on this extensively hydrolyzed formula, that's kind of how I made that diagnosis, so I'm trying to figure out like, does this, like if you just have gastritis, does that get better with this, you know, in the sense that, you know. - Or is it time, that's the part that's hard for me, is it not the change of formula, and it's just four weeks of past, you know, longer, have a four week old baby, and, you know, exactly, exactly. - That's a hard part for me. - I think again, it comes down to those red flags and symptoms, right? I think it's potentially conceivable that time is gonna heal a lot of things. Like time is gonna heal a lot of reflex issues, gassiness, like normal baby things that like are just gonna get better as they get older and their gut figures out how to digest a food, but these kids are gonna be sick. Like they are gonna be on your weight checks every week because you're significantly worried about them dropping off the curve. They're not gonna be gaining weight. They're the people you're thinking, do I need a hospitalized? It's not gonna be these ones that are like, oh, I spit 20 times a day, but I'm a chunky monkey and I'm living my best life otherwise. And I'm happy like these kids are not looking well in comparison. And I think we have to remember that piece of it too. It's like, yes, like you could treat other things by switching to a formula that's more hydrolyzed because you're breaking down those things, making it easier for them to digest, but you're gonna see a pretty clear cut. Like it's kind of like milk, you know, food protein induced allergic practicitis. You're gonna make that switch and within three days, you're gonna start to see no blood in the poop. I mean, that's a pretty obvious one or you're gonna like diarrhea is gonna be better. Like I think, I think you're not committing to that person to the wrong thing if all of a sudden they get way better and they're gaining weight. And then you could always say, okay, think back on it be like, do they really meet this definition? Like do I really think this is what was going on? And you could do a trial. You could say, okay, we're gonna reintroduce your milk and if it gets bad again, I think you have your answer. That's essentially what I'm doing, right? I'm just reintroducing at a certain time point and I'm saying, well, let's go for it. I'm just doing it like in the office. But I've had people go home and switch those formulas back, right? And say, okay, well, if we don't think that maybe we'll be about grown it or maybe it was not anything to do with chronic f-pies, let's go back and you're gonna see a quick shift. It is not like these people are gonna be like weeks and weeks and weeks before they start to have symptoms again. It's gonna be a pretty quick onset for them of being reintroduced out foods similar to what you would see with food protein induced into allergic particleitis. If you reintroduce, you're gonna get blood in that stool within a week. And if they're still reactive, right? And if they're not and it was still chronic f-pies, then yay, they resolved it. They're better now. - Awesome. - Is there a world in which like there is another food besides like in a kid that has failure to thrive and I know you guys are doing a failure to thrive thing but like either kid that has already started solids themselves or something else in mom's diet that is sneakily causing this failure to thrive picture when really it's a chronic f-pies to something other than cow's milk. - There are other triggers, right? Which I think is why I'm so interested in getting us to switch away from milk protein allergy because it actually can be a lot of different food triggers that cause issues. And you may have a mom that eliminates dairy and you probably see this picture all the time in your practice where you have a mom that's eliminated dairy swears there is no dairy in her diet and her kid is still having issues. Then she takes that soy, then she takes out egg and then she takes out 18 more foods and maybe finally we have some improvement and that kid probably needs to be on extensively hydrolyze or an amino acid formula. Like they probably have more than one trigger or there's something else going on. We haven't quite figured out and they just need a break. Their gut needs to have a break from everything but conceivably it may not be the cow's milk. Yes, it's the number one trigger. It's what we most commonly see but other things happen. I have a kid that was an egg trigger. It wasn't dairy, it wasn't soy, it was egg. Mom took egg out of the diet immediately gets better. What are some barriers that you've seen in diagnosing and managing FPI's, especially in the more underserved communities? And are there strategies that healthcare providers or systems can implement to improve access to care or support earlier diagnoses? Yeah, I think the biggest thing is education, right? As I said, FPI's I think is becoming more acknowledged by people and taught and thought about on the differential but I still think there is a lot in the community, especially in rural areas, where FPI's is not on the brain of most emergency providers when they see a vomiting kid. It's not always top of mind for a primary care physician that's out in the community. They may have never heard of it. So I think the biggest key is education. We do a lot of that here, a lot of outreach, community outreach, OHSU where I'm giving talks to community providers. I'm going to Grand Rounds of Hospitalists and Emergency Providers to kind of give these updates and say, hey, this is what FPI's is. This is what you should be looking for. This should be on your differential for this type of person. And I think that's one of the best things that we can do for those underserved populations is getting the diagnosis out there and saying, hey, this is what this looks like. This is what you need to do with this. And I feel like that leads into some of the resources that I use for patients. I, International FPI's.org or IFPI's.org, has a lot of great information but not only that, it has a FPI's action plan, similar to what you see on fair for their anaphylaxis action plan. So you can write what the trigger foods are, write what your medications are, what symptoms still out for. This is something they can take to school that they can take to the emergency department. I also have an emergency department letter that I got off of IFPI's.org where it says, hey, ED provider, this is what this diagnosis is. This is what it looks like. I'm diagnosed with it. If I present with these symptoms, please treat with these medications at this dose. So it lays all of that out there. And then it leaves the, it takes away the gas work. The parents not trying to explain what IFPI's is to someone. They hand a paper, they're like, I think my kid was exposed. This is how my doctor would treat it. And I think providing, you know, making it so that patients can also advocate for themselves. Once they're diagnosed with it, like, not everyone's gonna know in the community where they're going, might have a reaction and giving them the tools to say, hey, I have this. And this is what I get treated with. Makes a difference, too. - So we are now coming to the end of our show. I would love it if you could give our listeners maybe some main take home points. - Yeah, absolutely. I think main take homes are IgM mediated food allergies. So what you think of causing anaphylaxis and IFPI's reactions are gonna look very, very different. Although sometimes it can seem like there's overlap. And so with IFPI's, I'm really looking for vomiting only, dehydration, lethargy, diarrhea, those types of symptoms, GI, gastrointestinal, heavy symptoms happening one to four hours later. It is managed differently. I'm not gonna pull out an EPIPin IV or an epinephrine autoinjector or other form an epinephrine for an FPI's reaction. I'm looking at anti-nauging medicine like undezatron. I'm looking at steroids, IV fluids, if it's severe. So it's treated very differently. And then keep it on your differential. So if someone is coming back, this is their third episode of vomiting that you're seeing them for. I'll start to think about that food history. Do they have a common trigger food like cow's milk, soy, oat, rice, something that we see a lot of in the United States for IFPI's? And wow, was that food given each of those times? Maybe this should be on my differential. Maybe I need to be thinking about an allergy referral or at least talk to them about other introduction of foods. Another thing is, there's a spectrum when we think about inflammation of the gut. It's still in immune process, but we have food protein-induced allergic practicalitis. That's going to look a lot different. That's your bloodstrix tools, your diarrhea, your mucus, and your shoals. But that kid is healthy. They're gaining weight, they're happy. Compared to somebody with this maybe potentially acute or chronic FPI's picture. So food produce induced interaclytus where they're coming with vomiting, diarrhea, poor weight gain, dehydration, looking the thargic potentially, depending on which subtype they're in. And so I think it's important to remember that that's a big spectrum and it's managed differently as well. FPI's is out there. It is common, and it'll slightly different foods than what you see for IGE mediated allergy. And so I think the biggest thing is educate your patients, educate yourself and educate the other providers that work with you about FPI's. - Before we leave, is there any resources you'd like to plug? - Yeah, I plug them a little bit, but IFPI's.org is fantastic for like patient parent resources, but it's also nice from my side of things where I can look at an action plan and I can look at an emergency letter that I can then create a smart phrase for and make it much easier for myself in managing these patients. But I think IFPI's.org just in general for patients, it's kind of like the equivalent affair for IGE mediated food allergies and makes people feel less alone. It's got support there. So I would plug that resources. - Awesome, thank you so much for spending time with us today. I definitely learned a lot. We all learned a lot and hopefully our listeners got something from this as well. Thank you. - Perfect, thanks for having me guys. - Good to be back. (upbeat music) - This has been another episode of The Crib Siders. - It's for the kids. - Get show notes on our website at www.TheCribSiders.com. - We're committed to providing you with high-value prostitution knowledge and to do that. We need your feedback. So please subscribe, rate, and review the show on Apple Podcasts or content test at the [email protected] Special thanks to our producer for this episode of Dr. Olivia Baggett and our wonderful social media team Which is mostly Denise Cruz on ex-Busky and Instagram. I've been Sam Mazer. I'm Olivia and this has been Chris the Q-Man T Thank you. Good night. See y'all [MUSIC]