Recurrent vomiting in a baby – could it be FPIES?

The Pediatric Insider

© 2019 Roy Benaroch, MD

Not every diagnosis is easy, and not every diagnosis can be made correctly from a first impression. FPIES is one of those tricky ones, and parents and docs can get it right by paying attention to clues and keeping an open mind. Let’s start with a story, and then we’ll talk about FPIES (hint: these are not the kind of PIES you want to eat!)

5 month old Sally has had two trips to the emergency department and one to her pediatrician for vomiting episodes. Each time, she has a sudden onset of vomiting, diarrhea, and lethargy, and gets sick quickly – twice she ended up needing IV fluids. She recovers in a few days and seems to feel better. Overall she’s usually a happy baby, but her weight has been concerning. She’s not growing as fast as she should. Sally attends day care and has two older siblings.

What do you think? Vomiting illnesses are very common, and they’re usually caused by viruses (like Norovirus, especially this time of year.) If there had been one or two episodes like this, and Sally otherwise seemed OK, the story wouldn’t necessarily seem unusual. After all, she’s in day care, and probably is exposed to a lot of yuck.

But, still, there are some clues that there’s more to this story. Most vomiting illnesses do not require IV fluids – Sally’s needed that twice. And overall her weight isn’t great. Could there be a connection?

Making a medical diagnosis is like detective work. First collect the clues (which are almost always in the story), then find a diagnosis that fits. But keep in mind that every diagnosis is a “work in progress” that may have to change as new facts come it. Sally seemed like she had a viral gastroenteritis (a “tummy bug”), until the story continued to unfold. I warn medical students and residents: don’t lock yourself into a diagnosis. Stay curious!

Sally’s “mystery” diagnosis turned out to be “FPIES”, or “Food Protein Induced Enterocolitis Syndrome.” It’s a rare-ish allergic condition usually affecting young babies and toddlers, who react to certain foods with episodes of intense vomiting, often with diarrhea. Sometimes FPIES can be more of a chronic presentation, including lower-grade, ongoing symptoms like poor growth. Common triggers include cow’s milk and soy, but also grains like oats and rice. There’s no test for FPIES – ordinary ‘allergy testing’ is often misleading – so the diagnosis rests on the story.

The prognosis for PFIES is very good. Children usually outgrow it. The trick is making the diagnosis early, so parents can avoid the trigger food(s). And the key to making the diagnosis is paying attention to the clues your patients and their parents are trying to tell you.  I tell my medical students and residents: stay curious and pay attention!

More about FPIES

Interested in learning more about how doctors think, and how the best diagnosticians work through the clues to figure out the answer? I’ve made three courses about this, available from The Great Courses, in audio or video formats. They can be watched or listened to in any order. You can buy ‘em (money back guarantee!), or stream them from TheGreatCoursesPlus.

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One Comment on “Recurrent vomiting in a baby – could it be FPIES?”

  1. lynnawiensmd Says:

    Thanks for the article. You are correct in that food allergy sometimes is very distracting with FPIES. People are in the office all the time wanting to be tested for a #food allergy and have never looked at the elimination/challenge aspect. IgG is rarely helpful, And anything that’s easy to get, sent to your own home, is usually too good to be true.

    Like


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