Management of Food-Induced Gastroenterocolitis (FPIES)
The primary management of food-induced gastroenterocolitis syndrome (FPIES) requires complete dietary elimination of trigger foods, aggressive fluid resuscitation for acute episodes, and consideration of ondansetron for symptom control. 1
Diagnostic Work-up
Initial Evaluation
- Rule out other gastrointestinal diseases with overlapping symptoms 1
- Stool evaluation:
- Stool cultures for pathogenic organisms
- Parasitic evaluation
- Testing for Clostridium difficile
- Blood in stool
- Note: Stool tests alone cannot diagnose FPIES 1
Laboratory Assessment
- Complete blood count
- Electrolyte profile
- Consider evaluation for:
- Carbohydrate malabsorption (reducing substances in stool)
- Metabolic acidosis
- Methemoglobinemia in severe cases 1
Management of Acute FPIES Episodes
Severity-Based Approach
Severe Reactions (Medical Emergency)
- Aggressive isotonic fluid resuscitation (10-20 mL/kg boluses of normal saline) 1
- Dextrose saline as continuous IV maintenance infusion
- Consider IV methylprednisolone (1 mg/kg; maximum 60-80 mg)
- For respiratory insufficiency: supplemental oxygen, mechanical ventilation, or non-invasive positive pressure ventilation
- For hypotension: vasopressors
- For acidemia: bicarbonate
- For methemoglobinemia: methylene blue 1
Moderate Reactions
- Ondansetron (if ≥6 months old): intramuscular, 0.15 mg/kg/dose; maximum 16 mg/dose
- IV fluid rehydration if oral rehydration fails
- Monitor for 4-6 hours from onset of reaction 1
Mild Reactions
- Oral rehydration (breast-feeding or clear fluids)
- Consider ondansetron if ≥6 months old
- Monitor for resolution (4-6 hours from onset) 1
Long-term Management
Dietary Management
- Complete elimination of trigger food(s) 1
- Educate caregivers and other care providers about avoidance strategies
- For infants with milk/soy-induced FPIES:
- Avoid all forms including baked and processed foods
- Introduction of baked forms should only be done under physician supervision 1
Nutritional Support
- Consider nutritional consultation regardless of number of food avoidances
- Ensure adequate nutrition and adherence to dietary restrictions 1
Monitoring
- Regular follow-up to assess for resolution
- Periodic re-evaluation of trigger foods (typically every 12-18 months)
- Monitor growth and nutritional status 1
Special Considerations
Epinephrine Use
- Epinephrine autoinjectors are not routinely recommended for FPIES
- Consider only for patients with concomitant IgE-mediated food allergies 1
Ondansetron
- Consider as adjunctive management for emesis
- Use with caution in children with heart disease (risk of QT prolongation) 1
Pitfalls and Caveats
- Misdiagnosis: FPIES can be mistaken for sepsis, metabolic disorders, or surgical emergencies
- Delayed recognition: Failure to recognize FPIES can lead to unnecessary testing and interventions
- Inadequate fluid resuscitation: Underestimating fluid needs can lead to prolonged symptoms and shock
- Inappropriate medication use: Avoid anticholinergics, antidiarrheals, and opioids as they may worsen symptoms 2
- Nutritional deficiencies: Overly restrictive diets without nutritional guidance can lead to malnutrition
Emergency Management Plan
All caregivers should have a written emergency management plan that includes:
- Recognition of symptoms
- When to seek medical attention
- Instructions for home management of mild reactions
- Information about trigger foods to avoid 1
By following this algorithmic approach to the diagnosis and management of food-induced gastroenterocolitis, clinicians can effectively reduce morbidity and improve quality of life for affected patients.