Vomiting in Infancy: Is It FPIES?

Elizabeth Feuille, MD; Anna H. Nowak-Wegrzyn, MD, PhD


January 02, 2019

Answers: Signs and Symptoms Consistent With FPIES

Based on the infant's signs and symptoms, the second and fourth cases are possible presentations of FPIES. In the second case, the infant is exhibiting symptoms of chronic FPIES triggered by a cow's milk-based formula. In the fourth case, the infant is experiencing acute FPIES triggered by rice.

The first clinical scenario describes food protein-induced allergic proctocolitis, which typically presents with mucus and specks or streaks of blood in the stools of an otherwise healthy, often breastfed infant. The third scenario is a case of colic.

Case Presentation: What Is Going on With This Baby?

Ethan, a full-term male infant, was exclusively fed a cow's milk formula from birth. He initially tolerated the formula well and had only occasional regurgitation. However, during his third week of life, he developed progressively looser and frequent nonbloody, yellow-colored stools. He also experienced increased episodes of regurgitation following feeding.

At 16 days old, Ethan had two episodes of nonbloody, nonbilious, large-volume emesis; thereafter, his fluid intake decreased from 3 ounces of formula every 3 hours to only 1 ounce of formula every 3 hours. Two days later, because of concerns over Ethan's poor feeding and his ill appearance, his parents brought him to their local emergency department (ED) for evaluation.

At presentation, Ethan was noted to be lethargic and cachectic, with dusky skin tone, poor skin turgor, distended abdomen, and a sunken fontanelle. He was afebrile and his oxygen saturation was 91% on room air. His weight was 2.50 kg—a 17% weight loss from birth weight of 3kg. Results of an arterial blood gas revealed acidemia (pH 6.9) and methemoglobinemia (13%). The complete blood count was remarkable for leukocytosis (WBC, 43.5 × 109/L) with neutrophilia (41%) and bandemia (16%) and thrombocytosis (platelets, 566 × 109/L). Results of the chemistry panel suggested dehydration (blood urea nitrogen 17 mmol/L; creatinine 0.9 µmol/L).

Based on these findings, the emergency physician suspected sepsis and ordered urine, blood, and cerebral spinal fluid cultures, all of which were ultimately negative for bacterial growth. Chest and abdominal x-rays demonstrated normal findings.

After receiving two boluses of normal saline, he was transferred to the pediatric intensive care unit where he completed a 7-day course of ampicillin and cefotaxime. His clinical status improved with intravenous (IV) hydration. On extensively hydrolyzed formula, he had persistent abdominal distension and loose stools, which improved over several days when he transitioned to an amino acid-based formula on hospital day 3.

The baby was discharged home in the care of his parents on hospital day 10, with instructions to continue the amino acid-based formula, avoid cow's milk, and return to the ED if their son experienced any recurrence of emesis and diarrhea.

Two weeks later, Ethan's parents brought him back to the ED for evaluation of profuse vomiting and lethargy, which they stated began 2-3 hours after he ingested a cow's milk-based formula. He was given IV fluids in the ED and his condition improved over the course of a few hours.


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