What is the treatment for food-induced gastroenterocolitis?

Treatment of Food Protein-Induced Enterocolitis Syndrome (FPIES)

The primary treatment for food-induced gastroenterocolitis syndrome (FPIES) is complete dietary elimination of trigger foods, along with aggressive fluid resuscitation for acute episodes and consideration of ondansetron for symptom control. 1, 2

Acute FPIES Management

Severity-Based Treatment Algorithm

Severe Reactions

• First-line: Aggressive isotonic fluid resuscitation with 10-20 mL/kg boluses of normal saline, repeated as needed 1
• Second-line: Continuous intravenous dextrose saline maintenance infusion 1
• Adjunctive therapies:
  • IV methylprednisolone (1 mg/kg; maximum 60-80 mg) to decrease inflammation 1
  • Supplemental oxygen or ventilatory support for respiratory insufficiency 1
  • Vasopressors for persistent hypotension 1
  • Bicarbonate for acidemia 1
  • Methylene blue for methemoglobinemia 1

Moderate Reactions

• First-line: Ondansetron intramuscular 0.15 mg/kg/dose (maximum 16 mg) if age >6 months 1, 2
• Second-line: Peripheral IV line for normal saline bolus 20 mL/kg, repeated as needed 1
• Monitoring: Transfer to emergency department or intensive care if persistent hypotension, shock, extreme lethargy, or respiratory distress develops 1

Mild Reactions

• First-line: Oral rehydration (breast-feeding or clear fluids) 1, 3
• Second-line: Consider ondansetron intramuscular 0.15 mg/kg/dose if age >6 months 1
• Monitoring: Observe for resolution approximately 4-6 hours from onset 1

Long-Term Management

Dietary Management

• Complete elimination of identified trigger food(s) 1, 2
• Avoid all forms of trigger foods, including baked and processed forms 1
• Nutritional consultation is strongly recommended for all patients to ensure:
  • Proper adherence to dietary avoidance 1
  • Adequate nutritional intake 2
  • Prevention of nutritional deficiencies from overly restrictive diets 2

Monitoring and Follow-up

• Regular assessment of growth and nutritional status 2
• Periodic re-evaluation of trigger foods, typically every 12-18 months 2, 4
• Most children outgrow FPIES by school age 4

Emergency Preparedness

• Written emergency management plan for all caregivers including:
  • Recognition of symptoms 2
  • Instructions for home management of mild reactions 2
  • When to seek medical attention 2
  • List of trigger foods to avoid 2

Special Considerations

• Epinephrine autoinjectors are not routinely recommended for FPIES 1

  • Exception: Patients with concomitant IgE-mediated food allergies should be prescribed epinephrine autoinjectors if deemed at risk for food-induced anaphylaxis 1, 2

• Ondansetron use:

  • Promising for stopping emesis during FPIES reactions 1
  • Use with caution in children with heart disease due to potential QT interval prolongation 1
  • More rigorous trials needed to determine efficacy 1

Common Pitfalls to Avoid

• Misdiagnosis as viral gastroenteritis, leading to delayed treatment 2, 5
• Inadequate fluid resuscitation in severe cases 1, 2
• Overly restrictive diets without nutritional guidance 2
• Failure to recognize that natural history varies for different trigger foods 4
• Unnecessary testing when diagnosis can be made clinically 1, 2

By following this treatment approach, most children with FPIES can be effectively managed, with the majority outgrowing the condition by school age.