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The Pediatrician Next Door - Simple Advice on Parenting and Family Health
Food Allergy, Intolerance, or Something Else? FPIES Explained
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Dr. Wendy Hunter
Something I've learned over the years is
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that parents health matters and right now
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Dr. Wendy Hunter
welcome. This is a podcast where we take the confusing, surprising and sometimes controversial topics in kids health and make sense of them. If you're the kind of parent who loves to stay up on health trends and is curious about what's really going on so you can keep your family healthy. You know, new research, debates, medical mysteries. You have come to the right place because Kids Health is full of puzzles and today's episode starts with a really good one. Okay, listen, I'm going to share a story with you, and some of the clues are in this mystery. This was a baby who seemed perfectly healthy. She was growing well, developing normally, and her parents really didn't have any concerns. But something strange kept happening. About an hour and a half after being dropped off at daycare, the daycare workers would call because the baby was vomiting and not just a little Spit up. It was like repeated vomiting. Enough that the daycare staff were worried the parents would rush to pick her up. But by the time they got home and settled in, she was fine again. At first, they wondered if it was a stomach virus. Maybe something was going around the daycare. But it kept happening. And then one day, it got really bad. The daycare called. But this time the baby wasn't just vomiting. She looked really pale, lethargic, and she really couldn't stop throwing up. So the parents rushed her to the hospital, where doctors began thinking about things that make pediatricians very nervous. Could it be a blood infection? In the emergency department, the doctors did blood work. They started IV fluids and IV antibiotics while they waited to see if bacteria was going to grow in her cultures. Because when a young infant looks that sick, doctors don't take any chances. Then something strange happened. Within hours, she looked pretty good again. Her labs were normal. She stayed overnight in the hospital. They watched her really closely. And then she went home. Maybe it was a virus. But then it happened again. Same pattern. Fine in the morning, dropped off at daycare, and then an hour or two later, vomiting starts. Was it something about the daycare? Was it something in the environment? Was it the bottle she was drinking from? At home, mom was breastfeeding, and in the hospital, she was breastfeeding. But before daycare, and while she was at daycare, she got a bottle. And that small detail turned out to be the clue to the mystery going to unravel.
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I'm Dr. Wendy Hunter and I'm the pediatrician next door. I'm that doctor friend you call for practical advice about your kid's health. I mix the science of medicine with the reality of parenting.
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Okay, what is your guess about this baby? She wasn't having an infection, and she wasn't reacting to the bottle itself. She was reacting to what was inside the bottle. Formula. Yeah. This was a type of food allergy, but not in the classic sense. We're going to talk about a condition that many parents and even many doctors really aren't familiar with. It's called fpies, which stands for Food Protein induced enterocolitis. Yeah, that's why we call it FPIs. And we're going to explore the fascinating and confusing condition with allergy specialist Dr. Christopher Parrish from Latitude Food Allergy Care. He's an allergist and a pediatrician and an adult medicine doctor. He's got more experience than most with FPIs, including this baby that I just told you about. All right, where should we start? Let's start with what is the classic way that FPIS shows up. Here's Dr. Parrish.
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Dr. Christopher Parrish
The classic presentation of FPIS is going to be what we typically refer to as acute FPIs. And that's going to typically be in an infant most of the time for their first presentation. And it is delayed, repetitive vomiting, often really bad vomiting, almost exorcist style. So typically projectile and they just keep vomiting. And when I say delayed, it's usually right around two hours after the exposure to the food. It can be anywhere from kind of one to four hours. Is sort of the window that's mentioned in the diagnostic criteria in the guidelines. But the vomiting is so bad that you end up with other signs which typically are going to be extreme lethargy and extreme pallor. So these kids look really sick when they present. And that's kind of the classic presentation of acute FPIs. Chronic FPIs is related, but it's kind of a different presentation. So that's typically going to be earlier in infancy, often within the first couple months of life. And it's usually going to be in a formula fed infant because it's usually going to be milk formula or soy formula that's triggering it. And because of the ongoing exposure, you don't really have that classic presentation where you have a nice two hour delay to fit the criteria. So they kind of tend to have chronic diarrhea, chronic vomiting. If it goes on long enough, they will have dehydration and failure to thrive. They can come in looking really, really sick.
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Dr. Wendy Hunter
So this is why this baby's case was so confusing. She was switching back and forth between breast milk and formula and she wasn't reacting to the breast milk. So chronic or ongoing, long lasting FPIs, those kids don't have time to recover before they're exposed again. So they are like always sick. And acute FPIs, not cute. It's never cute. But acute cases, that means the person has symptoms and then they don't. One of the big clues is PALLOR. You heard Dr. Parish mention that it's very remarkable. And the kid is really pale, unlike what I've ever seen in other kids. These kids are pale when they have f pies. Dr. Parrish said f pies often will appear for the first time when solid foods are being started around six to seven months of age. And that makes sense if the reaction isn't to something like formula or milk. So I wondered if parents can tell that the reactions from food from the very start. Because if the kid is vomiting and sick and it starts hours after Eating. How can a parent tell?
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Dr. Christopher Parrish
It often takes multiple reactions for them to figure it out. So it's really not uncommon at all for kids with FPIs to end up in the ER getting a sepsis workup. And that's true for both chronic FPIs and for acute FPIs. I mean, I've even seen patients who presented, they were getting fed a bottle, dropped off at daycare, and then the daycare is calling, saying, oh, your child's sick again. And then I've seen kids who got flown by helicopter from rural Texas to Dallas to get taken care of when I was working there at UT Southwestern. And these kids would get a full sepsis workup because they look like a septic infant. They look extremely ill. They're often in shock when it's a bad reaction like that. And, you know, common things being common, they get the sepsis workup, and making that connection with the food can be pretty difficult early on. I've even seen kids where it wasn't fully clear until they got discharged from the hospital and then got fed another bottle, and then they come back two hours later with the same symptoms. So it's a challenging diagnosis for sure.
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Dr. Wendy Hunter
See, that's the baby I was telling you about at the beginning. The symptoms can look like infections, it can look like a stomach virus, even poisoning, which is one of the reasons it took doctors so long to recognize it. If you've never heard of F pies before, you're not alone. In fact, for most of modern pediatrics, doctors didn't recognize it either. I mean, kids were having the symptoms, but the pattern was hard to see because it didn't behave like a typical food allergy. So for many years, these episodes were blamed on something else. It wasn't until relatively recently that FIs began to be recognized as its own medical condition. In fact, it wasn't formally given its own diagnostic code until recently, which meant doctors didn't even have a way to diagnose it. So I asked Dr. Parish to explain when medicine really started recognizing FPIs and why it took so long for us to start diagnosing it.
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Dr. Christopher Parrish
There wasn't even an ICD code for it until, I think, 2016. There weren't consensus guidelines until 2017. So we're definitely recognizing it more. But like all atopic conditions, allergic conditions, I think we are seeing more of it as well. And another reason why we might be seeing more of it is we now know for the prevention of IgE mediated food allergies, we need to be introducing common food allergens earlier. And as we've been doing that, we are starting to see decreases in peanut allergy, for example, but we are seeing more FPIS reactions to those foods, particularly peanut and egg. We're seeing more commonly as FPIs trigger foods now than we ever did before.
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Dr. Wendy Hunter
I know that parents are hypervigilant about food allergies these days. I see it in clinic. But fpies is different because the kid doesn't have hives and the reaction is delayed. So it doesn't look like a food allergy. Is it a food allergy?
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Dr. Christopher Parrish
So it is an allergy because it is a food specific, it's specific to particular foods and it is the immune system reacting. So in the food allergy world, we try and break down the umbrella term of adverse reaction to food into things that are immunologically mediated and things that are due to kind of inherent characteristics of either the food itself or the person who's eating it. When it's due to just an inherent feature of the person or the food and the immune system is not really involved. That's when we would use the term intolerance. And the classic example of that would be lactose intolerance, where you have difficulty digesting the sugars in milk and it leads to gas and bloating and sometimes diarrhea. Whereas with both classic IgE mediated food allergy and with FPIs, the immune system has a specific response to most of the time food proteins and it's reproducible and it's not a non specific or non immune mediated thing. So we would call it a food allergy. It is quite distinct though from those classic ige mediated reactions. So to think about why fpies is delayed, I think it helps to think about why classic food allergies aren't typically delayed. So with a classic food allergy, you have IGE antibodies that have formed from some sort of prior exposure to that food, whether that's through the skin or through prior ingestion. And those antibodies are sitting bound to mast cells or basophils that are found on the skin, in the respiratory tract and in the GI tract. And those antibodies are bound there. So when you eat the food, it gets absorbed, it binds those and releases all sorts of nasty things that cause the symptoms of an allergic reaction. And that process happens very quickly because those antibodies are sitting there on the surface of those cells ready to go. With FPIs, the way that I explain it to families and our understanding of the pathophysiology of FPIs is really still evolving. But the evidence we have to this point is that it's really more the innate immune system reacting. And the way that I explain it to parents, it's literally as if the body is mistaking a chunk of the food protein, as if that were a protein from a viral particle. So it's basically as if your body thinks that you have a viral infection and the symptoms really do look a lot like an acute stomach bug, as we would say. Because of that, you don't have sort of a preformed response ready to go. You're eating it and then that's stimulating your innate immune system and triggering a response that takes a little while to build up.
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Dr. Wendy Hunter
It makes sense that it would be difficult to diagnose since it looks different in different ages and the symptoms are almost like not like a 24 hour bug, but more like a 3 hour stomach virus. Your brain might need a break now.
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This is heavy stuff. So when I come back, we'll talk
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about adults with FPIs. This is totally a thing. And their symptoms are completely different from those in babies and little kids. In fact, you might know someone with F pies and we'll talk about what to look for. Okay, I'll just tell you now. It tends to be people who just don't like a food and avoid it. But I'll tell you more after this.
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Now you know about f pies and doctors know about folks pies, but it is still so hard to diagnose why.
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Here's Dr. Parrish.
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Dr. Christopher Parrish
The delay in diagnosis is often just due to the difficulty in recognizing the Pattern. And also some of the most common food triggers of f pies are not foods that people tend to be on the lookout for as food allergens. So, for example, for solid food, f pies, oat and rice are way up there as far as common triggers, and they are not common triggers of more classic types of food allergy. It typically takes a second or sometimes even a third exposure for the pattern to really become evident.
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Dr. Wendy Hunter
I mean, yes, it's also tough because oat and rice seem to be in everything as an added ingredient. So it would be really hard to identify what's causing your symptoms when they happen hours after eating. And it's an ingredient that's in lots of foods. I'm going to come back to this. In the case of our daycare baby vomiting patient, the daycare workers were seeing the symptoms but hadn't given a bottle yet. The mom gave a bottle right before drop off and she didn't see the symptoms. So neither of these parties had the information to figure out what was going on. Plus, mom was eating dairy.
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Dr. Christopher Parrish
FPI's reactions to foods passed through breast milk are actually pretty rare. There are case reports of it. My younger daughter actually had it that way, but it's uncommon. So just because a child is tolerating breast milk that may have that food in it through the mom's ingestion of that food, that doesn't mean that the diagnosis can't be BF pies at all.
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Dr. Wendy Hunter
Now, we've gotten the FPIS diagnosis, so I assume the treatment is to avoid the food. But is that the only treatment?
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Dr. Christopher Parrish
Avoidance and then emergency preparedness. Now, what emergency preparedness looks like for FPIs is quite different than for classic food allergies. So epinephrine, which is the mainstay of treatment for anaphylaxis, the only first line treatment for anaphylaxis, it's not indicated for treatment of FPIs. It doesn't reverse the FPIS reactions. The most helpful medication for f pies reactions is actually ondansetron, which goes by the brand name Zofran. When they show up in the er, if the ER doc is thinking that it's a viral gastroenteritis, they're going to get that medication anyway. So that's something in the history that, you know, when I hear, oh, they got that and they got better, you know, that actually further supports the idea of it being FPIs. That's the main thing. The other thing is just hydration. In many cases, you're going to be able to keep the child hydrated orally. But some kids will need IV rehydration, especially if they're tipping over to the point where they're hypovolemic or some kids even get hypothermic with these reactions.
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Dr. Wendy Hunter
So is there hope? A lot of people with food allergies, the anaphylaxis kind like to peanuts. Some of those people do outgrow their allergy. Do kids outgrow f pies?
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Dr. Christopher Parrish
Most kids do outgrow f pies. If you look at the data, you have probably three quarters of kids outgrowing it by the time they're kindergarten age and probably half of them outgrowing it by the time they're kind of two or three. So kind of during those toddler years. Another thing that's fascinating about it is if you look at what foods are common f pies triggers, it does vary around the world based on when the foods are introduced. So in the Mediterranean, seafood is a very common trigger for FPIs, even in babies because they'll often give them a fish soup or things like that as part of their early diet. In the US we don't really see that just because people don't feed their kids seafood at the same frequency. Avocado has emerged as a really big FPI's trigger in recent years. Initially it had been categorized as a low risk food, but it's, you know, I think as people become aware of it's generally a pretty healthy food and it's kind of trendy and everything. So more people are feeding it to their babies early. It's nice and mushy. It's kind of a good food for babies to eat. And so we're seeing more FPIs to it. The other thing to remember about f pies is it's a syndrome. So it's really just a collection of symptoms that we've decided to label as f pies. I really think there is kind of a spectrum of f pies ish symptoms as well. So you might have a patient who has some vomiting or gets really fussy after a particular food but doesn't meet the full criteria. Those kits could still be managed basically the same as FPIs. You could still say, okay, we're going to avoid that food and then we'll try it again six months or a year later and see if that issue is resolved. It's something that, though, if you don't think about it, you're never going to make the diagnosis like with, with everything else in medicine. But it's something that as an allergist When I see a kid with an issue with vomiting, you know, it's at the top of my mind. But for other clinicians where, you know, FPIs isn't a big part of what they do, it's not going to be top of mind for them.
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Dr. Wendy Hunter
FPIs can mimic other conditions, and the reaction isn't immediate. So what is the best way to diagnose FPIs? If you are a parent, Dr. Parish's answer is not going to surprise you.
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Dr. Christopher Parrish
Parents are good detectives, and moms have really good instincts. So if a mom is asking, could this be the food, Take it seriously. Because mom's instincts are almost always really, really accurate. So that would be my advice, would be, basically, if a mom is questioning if weird GI symptoms could be due to a food, take it seriously and then start thinking about it. Because I would say most of the patients that I see with FPIs, the mom is the one who suspects the diagnosis first and then seeks out the allergist.
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Dr. Wendy Hunter
I'm a mom and a pediatrician, and I'm going to tell you a real fun story. I am a good detective. I have always had an aversion to brunch and fried rice. There were lots of foods that I just wouldn't eat. And in my 40s, I started to get horrific stomach pains.
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Starting about an hour after eating, I
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would double over in pain and then two or three hours later be completely fine. So I avoided weird things like orange juice and bananas. And then one day, I ate an egg white salad all by itself, and I had the worst symptoms ever. And that's when I realized I have f pies to egg white, not egg yolk. I can eat mayonnaise and carbonara, but a pisco sour with egg white foam? Ugh, I want to die. Does this sound familiar? Do you know someone like this, a food avoider? Dr. Parish does.
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Dr. Christopher Parrish
I bet most people know somebody in their family who says, oh, I don't eat shellfish. It doesn't sit well with me. Or they have some food that they avoid because of some vague GI symptoms. I think a lot of those actually have FPIs to that food, and it never gets labeled because it's as an adult. In particular, once you've recognized it, a lot of times they end up with an aversion to it.
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Dr. Wendy Hunter
Fpies is a good reminder that the immune system does not always follow the rules. When most people think of food allergies, they picture hives, swelling, or trouble breathing that happens within minutes of eating something. But Elfpies is different. The symptoms are delayed and instead of looking like a typical allergy, it looks like something completely different, like a stomach virus or food poisoning or even a bacterial infection. Once the pattern is recognized, though, it is incredibly reassuring for families. Knowing what's going on means you can avoid the trigger food. You can have a plan when a reaction happens and understand that most children might grow out of it. As awareness grows, we are likely to learn more about this unusual immune response and how to better diagnose and manage it. I want to thank My guest today, Dr. Christopher Parish, for helping us unpack this fascinating and confusing condition.
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Dr. Parrish practices at Latitude Food Allergy
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Care, where he specializes in diagnosing and treating complex food allergy conditions. And as always, thank you for listening. If you've enjoyed this or you just feel a little smarter, I really would appreciate it if we would follow the show or share it with a friend. I can only do this because I have you as a great audience.
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For more from the Pediatrician Next Door, find me on the web@ pediatriciannextdoorpodcast.com if you've got a question about the weird things kids do, send an email to hellopediatriciannextdoorpodcast.com for a chance to hear your voice on the show. I'm Dr. Wendy Hunter and I'm the Pediatrician Next Door. This show is produced by Red Rock Music. Make sure to subscribe and leave a review wherever it is you're listening. I'll be back next time with more.