Food Protein-Induced Entero-Colitis Syndrome

Food Protein-Induced Entero-Colitis Syndrome

Food protein-induced enterocolitis syndrome is also known as FPIES. It is an adverse food reaction involving the immune system. And mainly affects babies and young children. It is caused by an allergic reaction to one or more ingested foods. Resulting in inflammation of the small and large intestine. 

It is typically a non-immunoglobulin E (IgE)-mediated gastrointestinal food allergy. And manifesting as profuse, repetitive vomiting. Often 2-4 hours after ingesting a food. Sometimes with diarrhoea, leading to dehydration and lethargy. Or if it is chronic, watery diarrhoea with intermittent vomiting. Leading to weight loss, failure to thrive, dehydration, and metabolic imbalances.  Some children can become pale, floppy, drop their body temperature, and/or blood pressure during this food-related reaction.

Avoidance of the trigger food protein/s is currently the only effective treatment option. However, most children will outgrow their FPIES in the preschool years.

Common Foods Triggering FPIES

The most common FPIES triggers are rice, cow’s milk (dairy) and soy. Followed by rice, oats, eggs, legumes and meats such as chicken and seafood. However, FPIES rarely occurs in exclusively breastfed infants.

There are no laboratory or skin tests which can confirm a diagnosis of FPIES. This makes diagnosis difficult. The diagnosis is made purely on symptoms.

Management of FPIES

The only treatment is an avoidance of this particular food until the child is older. The typical food allergy treatments and EpiPens do not work with FPIES. Most children outgrow FPIES by three to four years of age. However, this varies between individuals and foods. Only 40-80% of children with FPIES to rice, and 60% to dairy, tolerated these foods by the ages of three to four. The best way to determine if a child has outgrown their FPIES is by a food challenge under medical supervision.

Cows Milk Protein Allergy or Intolerance and Formula Feeding

Cows Milk Protein Allergy or Intolerance and Formula Feeding

Preventing Allergies in Infants with a Family History

What to Feed Your Allergic Baby

Babies can develop food intolerance or food allergy especially if there is a family history of atopic disease e,g. asthma, eczema, auto-immune disease and food intolerance or allergy. Breastfed infants can develop allergy due to food proteins the mother eats passing through her body to her breast milk. Formula-fed infants can show allergy symptoms due to not tolerating the food proteins in infant formula.

Food Intolerance

Symptoms of infant food intolerance can vary and may include colic, reflux or more projectile vomiting and sleep and settling problems.

Baby wakes every 20 minutes – is it reflux?

Reflux medications may help your unsettled reflux baby

Food Allergy

A food allergy occurs when the body’s immune system sees a certain food as harmful. Then reacting to the allergen by causing one or more symptoms. This is known as an allergic reaction.

Foods causing allergic reactions are called allergens. Even a tiny amount of an ingested allergen can cause a reaction.

Symptoms of an infant food allergy may include:

  • bloody, mucousy poo
  • eczema
  • body and facial rash
  • hives
  • severe allergic reaction (anaphylaxis)

What’s normal for baby poo?

Cows milk protein allergy and baby sleep

Breast Milk is Optimal for Preventing Allergy

Breast milk provides optimal nutrition for a baby. Even babies with food allergies can benefit from breast milk. But, the mother may need some dietary restrictions, also known as an “elimination diet.” Many women can continue to breastfeed if they remove an allergen from their diet e.g. dairy or eggs.

Allergies and food reactions in babies and children are common and may be associated with a variety of foods including adapted cow’s milk infant formula. Parents may consider using special infant formulas for preventing or treating allergic disorders.

This includes amino acid-based formula, hydrolysed formula, soy formula and milk from other animal species e.g. goats. However, the evidence is mixed and the routine use of special formulas for preventing allergy is not recommended. An Australian expert panel has made recommendations on the use of soy, extensively hydrolysed and amino acid formulas for treating cow’s milk protein allergy.

Managing eczema in babies and children

Hydrolysed formula

Hydrolysed infant formula, which is cow’s milk-based formula, processed to break down the proteins into smaller particles, may modify the development of the allergic disease.

Infants with a strong history of atopy, there is limited evidence hydrolysed formula, in comparison with cow’s milk formula, is helpful in reducing infant and childhood allergy. Most studies on the use of hydrolysed formulas have involved infants at high risk of atopy. Rather than the general population and benefits have been modest.

Additional randomised studies are needed among infants from families with low risk of atopy. There is no evidence partially hydrolysed infant formula prevents allergic disease when used for supplementary feeds in hospitals. And widespread use for this purpose may undermine breastfeeding.

The Royal Australasian College of Physicians (RAcP) recommends the use of extensively hydrolysed infant formula in infants with proven cow’s milk allergy or cow’s milk protein intolerance who are not breastfed.

Despite what the research has uncovered anecdotally I have helped babies with cows milk protein intolerance or eczema become amazingly settled on a partially hydrolysed formula. Compared to a predominantly cows milk-based formula.

Examples of partially hydrolysed formulae include Aptamil Allerpro Syneo and NAN HA Gold. Extensively hydrolysed formulas include Neocate, Nutramigen, Pepti-Junior and Alimentum.

Soy-based formulas

In the past soy formula was the preferred option. However, soy formula has not been shown to be effective in preventing the development of atopy in ‘at-risk’ children. And may actually worsen atopic illness with prolonged use. Examples of soy formulas include Isomil, Prosobee and Nestle Good Start Soy.

Consuming high levels of soy can have potential risks for babies. For example, the phytoestrogen compounds in soy formula might affect babies’ growing neuroendocrine systems and immune systems. But there’s no compelling research to say what effects these have on babies.

Soy-based formulas don’t prevent or reduce the risk of your child developing allergies.

A Cochrane review concluded that feeding with soy formula should not be recommended for preventing atopy in infants at high risk of developing an allergy.

Further research may be warranted to determine the role of soy formulas for preventing allergy or food intolerance in infants who are unable to be breastfed, who have a strong family history of allergy or cow’s milk protein intolerance.

The RAcP policy for the use of soy formula in infants recommends:

  • infants under 12 months who are not breastfed should be fed infant formula, not a soy drink or dairy-based milk marketed for older children or adult consumption
  • soy-based infant formula should not be used for preterm infants
  • the possible interaction of soy-based formula with thyroxin replacement therapy should be considered for children with thyroid disorders.
  • A number of concerns have been raised about soy-based infant formulas, on the basis of possible physiological effects of isoflavone compounds on the infant’s developing neuroendocrine system. There is no clear clinical or scientific evidence to support the position that these compounds are harmful, although no long-term studies have conclusively documented the product’s safety in infants. It is appropriate to use soy infant formula in the management of galactosaemia. Its use may also be appropriate for infants who cannot consume dairy-based products for cultural or religious reasons.

    Goat’s milk formula

    Compared to cow’s milk formulas, there have been fewer studies evaluating the safety and efficacy of goat’s milk formulas. Goat’s milk is not considered to have any role in preventing or treating allergic disease. many infants who are allergic to cow’s milk are also allergic to goat’s milk and soy drinks. The use of goat’s milk formula is not recommended.

    Amino acid-based formula

    Amino acid-based or elemental formula is “built” from component nutrients including individual amino acids. Its use in preventing atopic disease has not been studied. Examples of amino acid-based formulas are Neocate and Elecare.

Infant formulas with probiotics or prebiotics

The evidence on probiotics or prebiotics in infant formula to prevent atopic disease varies. two Cochrane reviews and a review by the European society for Paediatric gastroenterology, Hepatology and nutrition (esPgHAn) committee on nutrition concluded there was insufficient evidence to recommend their use.

Maternal dietary restriction

There is no evidence that avoiding any particular foods or food allergens during pregnancy, lactation or infancy provides any benefit in preventing allergy and this is no longer recommended.

However, once your baby has been diagnosed with cows milk protein intolerance or allergy An elimination diet is recommended to remove all dairy and usually soy from the mum’s diet.

Cows milk protein allergy and baby sleep

Table 8.6: Minimising the risk of allergy in infants with a family history

• Do not smoke during pregnancy and provide a smoke-free environment for your child after birth

• Dietary elimination of potential allergens during pregnancy is not recommended for preventing childhood allergy

• If breastfeeding is discontinued for any reason, there is no advantage in using special formulas, except under medical supervision

• Soy-based formulas do not prevent or reduce the risk of developing allergies and are not a suitable alternative to cow’s milk-based formulas

  • soy or goat’s milk-based formulas are not suitable alternatives for infants with allergies to cow’s milk-based formulas unless used under medical supervision.
  • Avoiding any particular foods or food allergens during pregnancy, lactation or infancy does not prevent allergy development.

Advice for parents

Formulas for managing other infant conditions

A number of infant formulas marketed in Australia claim that they are suited for managing minor conditions and symptoms. An extensive literature review failed to find any evidence of their efficacy.

Special infant formulas for managing metabolic, renal, hepatic, immunological and malabsorptive conditions are available (standard 2.9.1 of the FsAnZ code). Inborn errors of metabolism are outside of the scope of these guidelines.

Reflux and moving your baby onto solids

A new Baby and Toddler Tantrums Have Gone Through The Roof!

A new Baby and Toddler Tantrums Have Gone Through The Roof!

This is a Typical Toddler Behaviour Case Study

Hi Karen, we did a phone consultation a few months back regarding my 3-year-old boy Jake and managing toddler behaviour. At the time the tantrums really weren’t that bad but we wanted to nip it in the bud before they got worse.

All has been going well until recently. We moved house in early May and had a baby girl 2 weeks ago. He took to the move fine but this week his toddler behaviour and tantrums have gotten worse. So I’m not sure if it’s linked to the new baby.

At the moment he flips from happy to whinging in a matter of seconds. He seems to kick off for no reason. He’s in daycare 5 days a week so the 4 of us are only really together a lot on the weekends.

Toddler Behaviour

An example of his toddler behaviour: yesterday we went for a walk down to Maroubra beach. He brought his bike then 2 mins in didn’t want it then wanted it, didn’t want his helmet on, wanted it on. When he cries he doesn’t even make any sense in what he’s saying – it’s more baby talk.

Then we went for lunch, he got ice cream but then kicked off because it wasn’t in a tub, then when he got the tub he started again because he couldn’t scoop some out. It’s one thing after the other at the moment. He never used to be like this. He’s also started whinging if there’s stuff on his fingers, e.g. melted ice cream.

Bossy and Demanding

He’s also very bossy and demanding. He gets jealous when we have visitors over and when having a conversation with them he’ll start demanding our attention.

We also went out for a short stroll yesterday evening and he kicked off because of the wind. He’s sensitive to the wind and really loud noises (like a drill).

Just wondering if you could give us some tips/pointers to manage this phase. I’m assuming it’s a phase and it’s typical of a 3-year-old?

New Baby On The Scene

Any change in a strong-willed child’s world is going to flick their switch and escalate behaviours. Children with strong temperaments do not like change at all. They are likely to act out, tantrum and refuse to do as you asked. This is when their defiant little streak comes to the fore. You will see behaviours you have never laid eyes on previously.

Your well-behaved toddler has suddenly turned into a fire breathing dragon and you probably never saw any of this coming. Previously they were the centre of your world, they had no competition at all. Now you’ve brought a newer better model home and they’ve worked out that it’s here to stay! Eeek. If you asked any self-respecting toddler if they wanted a sibling I’m sure you’d get a resounding NO!! Especially if they knew what it involved…

Escalation of Toddler Behaviour

When children feel stressed and threatened they will escalate behaviour to get your attention in an attempt to get back to where they were. Change feels uncomfortable and the strong-willed child struggles with change. They may walk around the baby who is laid playing on his mat on the floor looking at you out of the corner of their eye pretending to nearly stand on the baby.

They are testing you and what you are going to do about it. Remember a toddlers job is to test the boundary. Whereas your job is to pull the boundary back to where it should be. This push-me pull-me resistance is a normal part of the toddler years and it is them testing your boundary. Remember boundaries are creating security and they need to see a firm boundary.

Working Out His New World

Your toddler has gone from being the focus of your entire world to suddenly being on the outer. Your attention is strongly focussed as it should be on the new baby. And he is acutely aware of this. To try and get your focus back on him he tries to grab your attention the best way he knows how. By doing naughty and cheeky things he knows will raise a reaction from you.

The Expectation of Good Behaviour

There is an unsaid expectation from you the parent that all behaviour should be positive or good. Children naturally want to behave well. However good or positive behaviour hardly features on her radar because we see it as expected.

Naughty or negative behaviours alert our alarm bells and the flashing amber and red lights in our brain are triggered to notify us. And the toddler knows this. Suddenly they are the focus of our full attention again. The more we pay attention to bad or naughty behaviour the more it will appear. So how do we get rid of this and turn this around?

Managing The Toddler Behaviour

Here are my top strategies to help you

  • Use labelled praise to increase the likelihood of more positive behaviours e.g. well done Jack for putting your toys away, high-5. The emphasis needs to be in this area.
  • Use the child’s game as the glue to stick it all together and increase the chances of success
  • Consequences for naughty or dangerous behaviour – Time Out or Logical Consequences for over 2.5-3 years
  • Bring them in close, examples of this are read a book to them whilst feeding the baby
  • Get them involved in helping you prepare meals, use a learning tower, housework, washing and putting the washing out, helping change the baby etc.
  • Once they feel helpful and valued things will change in a positive direction, it will take approx. 7-10 days to turn things around.
  • Read books about emotions to help him navigate these new feelings e.g. The Brothers Quibble by Aaron Blabey, My Book of Feelings by Trace Moroney

Teaching Your Toddler About Empathy

Empty praise vs. labelled praise and effects on resilience in kids

The child’s game (part 2) relationship building with your child

Defiance And The Toddler
5 Things Your New Baby Nursery Can Do Without

5 Things Your New Baby Nursery Can Do Without

New parents will always want the best for their new child, this is a given. And the baby shops are bursting to the seams with products they make you think you cannot do without. Well, I’m here to help your purse strings and give you 5 things you definitely DO NOT NEED. As a midwife of over 30 years, I’ve visited countless homes. These are the items parents have told me they wished they hadn’t spent their well-earned cash on.

Baby Sleep Gadgets

These items promise to get your new baby to sleep but they are nothing more than a quick fix. And what I call an Elastoplast method! These include the Lulla Doll (it sounds like an alien and chews up batteries like no tomorrow). The Glow Dreaming (a red night light) – night lights damage the retina and interfere with melatonin production. Next up is the Shusher is a white noise machine that plays the shush sound constantly. You’d be better off using white noise on an app if you have noisy floorboards. and and


This is a very expensive cot devised by a paediatrician, Dr Harvey Karp. And based on his 5 S’s techniques. Basically, the baby is placed on a very hard and thin mattress and strapped into a swaddle/straight jacket. With their arms down by their side and firmly swaddled in position. This is so they cannot move, roll or get themselves comfortable. You then press a button and it rocks the baby in a swishing motion and emits white noise. Basically it takes you the parents and your loving, nurturing touch out of the equation. And lets the SNOO do it all for you. I’ve been to many homes where the parents have purchased an SNOO hoping for a peaceful night in exchange for $1303 USD OR $1871 AUD. And all they’ve got is a costly ornament gathering dust. You control everything via an app on your phone.

The problem starts with the 4 – 6-month stage when babies want to roll. Well in the SNOO the baby can’t move and it’s too snug to be used past 4-5 months with most normal sized babies. I recently did an overnight visit where I helped a mum wean her baby off the SNOO. This was because the wean off button on the device didn’t help her baby. It took one night and a lot of protest crying to get her self-settling. You may recall a previous article on similar lights, camera, action cot I reviewed in the Huffington Post

Swaddle Suit

An expensive swaddle suit such as love to dream, ergo pouch cocoon, merino kids swaddle is not needed. Swaddling is a very Australian parenting pre-occupation. The UK does not allow swaddling at all because of the risk from SIDS. Most babies prefer to have their hands free and this is how they are in utero. True self-soothing is being able to put their hand or thumb or fingers in their mouth and put themselves off to sleep from being fully awake. Once fabric interferes with this which swaddling does then it is not self-soothing. Tucking babies in firmly with sheets and blankets manages the startle reflex and allows the baby to calm themself. You may have heard of the weighted blanket which is used with ADHD? Well, using layers of blankets of natural fibres (merino wool, cotton and bamboo) achieve the same thing a calm and unstressed baby.

A purpose-built changing table

This can take up a lot of room and doesn’t add anything to a room other than unnecessary clutter. Instead, try using a foam changing mat placed on top of a chest of drawers or change your baby on the floor. Nappy changing is something you will be doing 7-10 x a day for 6-9 months so you want to choose an option that works best for you. Changing tables retail at $200-600 whereas a simple foam change mat retails at $29 AUD, a bargain.

Bassinet vs a cot

There is no reason why your baby has to sleep in a bassinet for the first 3-4 months. A cot is a perfectly good option and again saves on unnecessary clutter in the house. If you’re wanting to create a snug environment for the 4th-trimester use layers of natural fibre blankets to create the snug and cosy feel of the uterus.

I hope you enjoyed reading my top 5 things a baby nursery can do without and I hope it saved you a whole motza of cash along the way.

The Fourth Trimester

The Fourth Trimester

There is little adjustment time for a newborn baby from living and being in the womb to suddenly entering the world; one minute they’re contentedly snuggled in the sanctuary of mum’s tummy, and the next they arrive into an overwhelming reality of lights, cameras and action.

There are a few ways to make transitioning easier for your brand new baby. From the first few moments after birth, through to the next few hours, and even after you’ve gone home, there are things you can do to help your baby be comfortable in the world around them. 

There are a theory babies should be in the womb till 3 months postnatal. But if this was the case, they wouldn’t get out of the birth canal because they’d be too big they are born before they are able to cope with the outside world. Humans are the only mammals who cannot walk and move unaided at birth. Relying on their parent/caregiver for all their essential needs. The first 3 months are a time of more than normal crying and we recognize this as the 4th trimester. It needs special and sensitive management to get a smooth transition to life. 

Babies benefit from lots of love and cuddles and love to be swaddled, almost like being back in the womb. Helping them feel secure and adapt to this new crazy world. Think of this as helping the baby adapt and not as spoiling them. I’ve never seen a baby spoilt with too much love. They’re only little for such a short period of time. Babies who are held and cuddled in a positive way grow to make secure attachments and healthy emotions as adults. Try and ignore, in a polite way, any well-meaning relation who says you are spoiling your baby with too much love! 

Seven Ways To Help Your Baby To Adapt

  1. Cosy Sleep Environment – Swaddling
  2. Baby Wearing
  3. Dim Lighting
  4. Bathing
  5. Sucking & Regular Feeds
  6. Kangaroo Care is also known as Skin to Skin
  7. White Noise

A Cosy Sleep Environment

Babies love the feeling of snug. The uterus, towards term, had become very snug and there was little room for them to move. Creating this in the outside world is essential to help your baby feel safe and secure and subsequently to be able to sleep well. There are several ways you can do this. One of them is swaddling. The other is layers of heavy blankets to recreate the feeling of the snugness of the womb. However, in a very hot summer in Australia this may not be practical from heat and overheating point of view. Consequently, the swaddle and use of swaddling were created.


Dim Lighting


New babies don’t need a lot of baths as they don’t do a lot to get very dirty! You may decide to only do one bath a day and the rest of the time to do a top and tail daily or twice a day. A top and tail as the name implies consists of washing the face and neck folds and the nappy area.

Keep skincare very simple and avoid soap with perfume and essential oils in it. Suitable cleaning products to help a delicate baby’s skin include QV bath, sorbolene and Dermaveen. Bath products containing lots of ingredients and sodium laurel sulfate should be avoided. Sodium laurel sulfate is a foaming agent and can cause irritated eyes, skin and lead to eczema.,,1210215,00.html

If your baby dislikes their bath try putting a washcloth on their tummy and pouring warm water onto it. Another tip I’ve used a lot is to place the baby over your forearm and onto their front in the bath. Be careful of course to avoid putting their face into the water! Swish the baby body up and down to calm them. In 30 years this has not failed and I’ve never had a baby continue to cry once I’ve done this. Putting a baby on their front or prone reduces stress and the hormone cortisol.

To clean their eyes and face use separate cooled boiled water (especially for the eyes) and clean from the inside to the out with a damp cotton wool ball, dry with a dry cotton wool ball.

Wash their head or hair once a week to avoid the build up of oils to prevent cradle cap.

Sucking & Regular Feeds


Night breastfeeds are important and babies need at least 1-2 breastfeeds.

Prolactin is increased with night feed helping increase and maintain supply for the

following day. By following a strict routine, where baby sleeps through the night by 6 weeks, you risk diminishing your supply, sabotaging your ability to successfully breastfeed. Then baby would probably lose weight and formula creeps in.

During the day following a feed-play-sleep model. Newborn to 6-week babies do well with a feed-play-feed-sleep model. At night it’s a straightforward feed-sleep model.

Formula feeding – generally they need 6-8 formula feeds in 24 hours. The mathematical formula to work out their required amounts in each feed is 150 X weight in KG and divide this by the number of feeds in 24 hours. There is no perfect formula that agrees with ALL babies. Start with a newborn formula or stage one from 0-6 months. When preparing a feed always put the cooled boiled water, hand hot or 40 degrees centigrade, into a bottle and add the exact level scoops next, shake to combine then offer to your baby.

A young baby at 0-6 weeks can generally take 100-160 mls within 20-30 minutes at each feed. My preferred bottle and teat is a Pigeon wide necked peristaltic teat.

Burping or winding is something I generally do and recommend but only for 5 minutes.

Always clean and sterilise feeding equipment.

A useful gadget for formula feeding is Perfect Prep by Tommee Tippee –


Sucking is a primal reflex and newborn babies can soothe using one. If your baby has reflux or is premature they can be a useful addition to help your baby adapt to extra-uterine life. However, once your baby is 2-3 months of age it is a good idea to wean of them to avoid a 4 month sleep regression. At 3 months the baby has hand awareness and likes to put them into their mouth. Then at 4 months the extrusion reflex makes an appearance and the dummy or pacifier is forcefully ejected from the mouth. Hence the perfect storm of trouble has arrived.

It is better to look at soothing and sleep from a preventative approach and move your baby on at developmental milestones. By continuing to use a dummy or pacifier longterm you are preventing the baby to use their own self-soothe reflex. Preventing the self-soothe reflex being used at 3-4 months has been linked (evidence-based) with sensory processing disorders. This is something we need to be talking about, parents need to know this. When you know things like this you can then make positive parenting decisions.

Kangaroo Care or Skin to Skin

Putting your naked baby on your chest and doing skin to skin can help increase your milk supply and help breast feeding. Especially if you do this within an hour of birth. Kangaroo care, as skin to skin is called when used for premature babies, decreases cortisol and helps keep heart rate and breathing constant, helps feeding and weight gain. If you’re having problems with breast feeding doing skin to skin for half an hour before a feed will help your letdown and supply.

Mums who practised kangaroo care were more likely to breastfeed exclusively and, on average, these moms breastfed three months longer than those who didn’t practice skin-to-skin care, says one study published in Neonatal Network.

Just 10 minutes of skin-to-skin contact reduces babies’ levels of the stress hormone cortisol, and increases levels of the “cuddle hormone” oxytocin, which stimulates the parasympathetic nervous system to make babies feel calm and safe, says Ludington in the journal AACN Clinical Issues.

Less stress = better sleep. Premature babies who were cradled skin-to-skin slept more deeply and woke up less often than those who slept in incubators, reported the journal Pediatrics.

White Noise

And these are my top tips for a smooth transition to the fourth trimester.

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