Food protein-induced enterocolitis syndrome


  • Non-IgE mediated immune reaction to food protein
  • Peak incidence in infants 0-9 months
  • Cow's milk and soy (in patient's diet or maternal diet if breast fed) are most common culprits

Clinical Features

  • Acute reactions can cause life-threatening volume depletion
    • Onset of symptoms ~1-6 hours after ingesting culprit (possibly reintroduced after period of not consuming)
    • Profuse, repetitive vomiting and voluminous diarrhea
    • Can lead to profound dehydration, shock, severe electrolyte abnormalities
    • 75% of infants with FPIES appear seriously ill, with ~15% requiring hospitalization for hypotension[1]
  • Symptoms may be mild-moderate if chronically exposed to offending food

Differential Diagnosis

Nausea and vomiting (newborn)

Newborn '
Obstructive intestinal anomalies Esophageal stenosis/atresia, pyloric stenosis, intestinal stenosis/atresia, malrotation ± volvulus, incarcerated hernia, meconium ileus/plug, Hirschsprung disease, imperforate anus, enteric duplications, duodenal atresia
Neurologic Intracranial bleed/mass, hydrocephalus, cerebral edema, kernicterus
Renal Urinary tract infection, obstructive uropathy, renal insufficiency
Infectious Viral illness, gastroenteritis, meningitis, sepsis
Metabolic/endocrine Inborn errors of metabolism (urea cycle, amino/organic acid, carbohydrate), congenital adrenal hyperplasia
Miscellaneous Ileus, gastroesophageal reflux, necrotizing enterocolitis, milk allergy, GI perforation

Nausea and vomiting infant (<12 mo)

Obstructive intestinal anomalies Pyloric stenosis, malrotation ± volvulus, incarcerated hernia, Hirschsprung disease, enteric duplications, intussusception, foreign body, bezoars, Meckel diverticulum
Neurologic Intracranial bleed/mass, hydrocephalus, cerebral edema
Renal Urinary tract infection, obstructive uropathy, renal insufficiency
Infectious Viral illness, acute gastroenteritis, meningitis, sepsis, otitis media, pneumonia, pertussis, hepatitis
Metabolic/endocrine Inborn errors of metabolism, adrenal insufficiency, renal tubular acidosis
Miscellaneous Ileus, gastroesophageal reflux, post-tussive, peritonitis, drug overdose


  • Clinical diagnosis
  • Labs to assess for consequences of GI losses (e.g. BMP, Mg/Phos, VBG) +/- workup to exclude alternative diagnoses



  • Admit if requires IV rehydration, electrolyte abnormalities, or intractable symptoms

See Also

External Links


  1. Nowak-wegrzyn A, Muraro A. Food protein-induced enterocolitis syndrome. Curr Opin Allergy Clin Immunol. 2009;9(4):371-7.
  2. Current Treatment Options in Allergy. Jarock-Cyrta E, Valverde-Monge M, Nowak-Wegrzyn A. Management of Food Protein-Induced Enterocolitis Syndrome (FPIES): Current Approach and Future Needs. Current Treatment Options in Allergy 2017; 4:383