An Infant With Acute FPIES: The New Guidelines

Stephanie A. Leonard, MD


August 09, 2017

Case Continuation

When the patient in this case initially presented to the emergency department, there was concern about abdominal obstruction, including possible intussusception, malrotation, volvulus, pyloric stenosis, and Hirschsprung or severe gastroesophageal reflux disease. Other conditions in the differential diagnosis may include meningitis, gastroenteritis, sepsis, or a metabolic disorder. Her parents felt that oat was the cause of the vomiting, but at first this was deemed unlikely because it is a food that is thought to be well tolerated. The patient's benign exam; normal imaging; overall normal laboratory studies, except neutrophilia; history of normal growth and development; and absence of chronic vomiting, constipation, watery diarrhea, sick contacts, or fever helped to rule out other conditions. Ultimately, recurrence of her symptoms during the oat oral food challenge confirmed the diagnosis.

When the patient was initially evaluated by an allergist at age 7 months, it was recommended that she avoid all grains, including oat, rice, and wheat, because of the potential for multiple grain triggers. Because she had not yet been introduced to any other foods, the family was also given the guidance to delay common FPIES triggers while introducing other foods. The foods to be avoided included cow's milk, soy, egg, poultry, fish, sweet potato, green pea (legumes), and banana. Continued breastfeeding was encouraged, with use of an extensively hydrolyzed formula for supplementation if needed.

The patient returned at age 12 months and was doing well, without any additional reactions. Mild eczema was noted on her cheeks on exam. She had negative skin testing to wheat, oat, rice, cow's milk, soy, egg, and peanut. The family was given recommendations to open up her diet while continuing to avoid grains. The patient subsequently developed delayed repetitive emesis after ingestion of goat's milk for the first time and was advised to avoid goat's milk, cow's milk, and soy, owing to the common occurrence of cow's-milk and soy FPIES together.

The patient returned at age 4 years without additional reactions. An oral food challenge to oat was performed, and the patient developed emesis after 3 hours, with mild lethargy. She was treated with ondansetron and oral rehydration, and improved within 30 minutes. A few weeks later, an oral food challenge to cow's milk was performed, which she tolerated. She was able to add cow's milk, goat's milk, and soy into her diet. The patient continues to avoid grains for now.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: