Vomiting in Infancy: Is It FPIES?

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

Disclosures

January 02, 2019

Answers: FPIES Management

Families of children with FPIES should be provided with a written emergency treatment plan for acute reactions with recommendations on how to perform oral rehydration at home, and to present to an ED for IV fluids if oral rehydration fails. Epinephrine and antihistamines have no role in the management of FPIES. Corticosteroids are not prescribed for FPIES. Calling 911 or advising patients to go straight to the ED with any reaction may not be necessary in all cases.

The 2017 consensus guidelines recommend conducting an interval food challenge in the hospital or ED every 12 to 18 months.[1] It is also appropriate for clinicians to refer patients to a specialist to determine if an OFC is appropriate.

How Are Acute Reactions Managed in FPIES?

Management of acute FPIES reactions hinges on rehydration. As previously noted, patients with mild reactions (when lethargy, pallor, or other severe symptoms are absent) may be treated at home with oral fluids.

Reactions accompanied by lethargy must be managed in a medical facility with IV fluids. Limited evidence supports the use of ondansetron to reduce vomiting in acute reactions.[11] Due to presumed T cell-mediated mechanism, a single dose of methylprednisone at 1 mg/kg is typically given to patients for FPIES reactions managed in the medical setting; there is, however, no evidence to support its efficacy.[1,12]

Intramuscular epinephrine and antihistamines have no role in the management of FPIES reactions.

How Is FPIES Managed Over Time?

Once an acute reaction has been addressed and a diagnosis of FPIES is suspected, guidelines recommend strict avoidance of the trigger food. To prepare families in case of future reactions, it is helpful to provide a written emergency plan outlining plan of care. The website for the International FPIES Association provides a sample emergency letter.

An allergist can be helpful in managing children with FPIES over time. International consensus guidelines advise that the offending food be offered in a supervised OFC every 12 to 18 months to assess for acquisition of tolerance.[1] Skin testing to assess for IgE sensitization preceding challenges may be useful. Though tests for IgE sensitization are not diagnostic of FPIES, development of IgE sensitization, referred to as atypical FPIES, predicts a more protracted course and carries risk for development of IgE-mediated allergy symptoms on trigger-food exposure.[4,13]

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