Management of Acute Food Protein-Induced Enterocolitis Syndrome (FPIES) Reactions

Abstract

Acute FPIES reactions are characterized by different severity degrees (mild, moderate, and severe). The clinical management will involve different approaches depending on the severity of the reactions, with rehydration being the cornerstone of FPIES treatment. Oral rehydration at home is recommended in mild reactions, whereas intravenous fluid resuscitation is mandatory in severe forms characterized by protracted emesis, lethargy, pallor, diarrhea, hypotension, and metabolic acidosis. Indeed, acute FPIES can lead to hypovolemic shock, and consequently, the priority in management is restoration of hemodynamic stability. Recently, a possible role for parenteral ondansetron in controlling acute symptoms was suggested and recommended in severe reactions. In order to reduce a presumed cell-mediated inflammation, a single dose of intravenous methylprednisolone could be administered. Epinephrine autoinjectors are not recommended, because the hypotension occurred during a severe reaction is the result of fluid loss from the gastrointestinal symptoms. Epinephrine IV may be needed in case of hypovolemic shock not responsive to rehydration. The monitoring and measurement of vital signs is useful for providing real-time data and necessary to assess the clinical situation of the patient. If a progressive clinical worsening should be highlighted, the patient must be transferred to the intensive care unit for managing extreme lethargy, respiratory distress, persistent or severe hypotension even to a hypovolemic shock condition. A possible discharge can occur only when the clinical condition is completely restored, and the patient is able to tolerate oral fluids again. The history of severe FPIES reaction makes necessary to call immediately an ambulance or go to the nearest emergency department.