Vomiting in Infancy: Is It FPIES?

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


January 02, 2019

Answers: Clinical Manifestations of FPIES

Children with FPIES may present with a wide range of symptoms, and all of the answer options in the first question are correct.

According to diagnostic criteria from the recently published international consensus guidelines,[1] all answer options for the second and third questions are correct, with two important exceptions:

  • Respiratory symptoms and rashes are not typical of either acute or chronic FPIES; and

  • Serum and skin tests are not predictive of a diagnosis of FPIES

What Is the Typical Presentation of FPIES?

Children with FPIES typically present with vomiting that is often accompanied by diarrhea and lethargy.[1] The timing and progression of an FPIES reaction varies and depends upon frequency of exposure to the inciting protein.

In chronic cases of FPIES, repeated, frequent ingestions result in insidious onset of vomiting, watery diarrhea (with or without blood), and failure to thrive; symptoms are not timed with food ingestion.[1,6] Ethan's initial presentation is consistent with chronic FPIES, which occurs exclusively in infancy.

In cases of acute FPIES, vomiting, which may be profuse, develops 1-4 hours after an isolated ingestion of the trigger food. Diarrhea may start 5-10 hours following ingestion and persist for up to 24 hours.[1] Acute FPIES typically presents in infancy; however, the condition can develop in older children and, though rare, in adults. Ethan's second presentation to the ED is consistent with an acute FPIES reaction.

In both acute and chronic FPIES, severe manifestations such as pallor, lethargy, and hypothermia are common.[3,4] Reactions may progress to severe dehydration and shock.[1,6,7,8]

Regarding laboratory findings, neutrophilia, often with bandemia, is virtually always present in both acute and chronic presentations. Other findings may include thrombocytosis, acidemia, mild eosinophilia, and methemoglobinemia.[1,6]

Although respiratory symptoms and rashes are not typical of acute or chronic FPIES, children with FPIES often have concomitant allergic conditions such as atopic dermatitis or IgE-mediated food allergy.[4,9,10]


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