Treatment and Managing Reactions

Managing and Treatment of Adult FPIES

The first step in FPIES management is avoidance of your trigger foods. The good news is the majority of individuals react to one or two foods.1, 2

If you have an accidental exposure, fluid rehydration and potentially the administration of ondansetron is key. If you are able to tolerate fluids by mouth, small sips of fluids every few minutes can be beneficial. If you cannot, then intravenous fluids will be needed. Ondansetron, if prescribed by your doctor could be considered. This medicine has been shown to be helpful in studies of children with FPIES.3-5   In children, this medicine has been helpful, however some individuals will still need emergency care.  Contraindications to ondansetron include some types of heart disease and medications that may interact.


If you are on medicines to control your blood sugar, blood pressure or blood volume and you are having difficulty staying hydrated, you should reach out to your doctor.

If it has been a while since you have had a reaction or your reactions are not consistent and repetitive, it can be worth discussing your symptoms with your physician.

1 Gonzalez-Delgado P, Muriel J, Jimenez T, Cameo JI, Palazon-Bru A, Fernandez J. Food Protein-Induced Enterocolitis Syndrome in Adulthood: Clinical Characteristics, Prognosis, and Risk Factors. J Allergy Clin Immunol Pract. 2022.

2. Crespo J, Perez-Pallise ME, Skrabski F, et al. The Natural Course of Adult-Onset Food Protein-Induced Enterocolitis Syndrome. J Allergy Clin Immunol Pract. 2022.

3.  Miceli Sopo, S., Bersani, G., Monaco, S., Cerchiara, G., Lee, E., Campbell, D., & Mehr, S. (2017). Ondansetron in acute food protein‐induced enterocolitis syndrome, a retrospective case–control study. Allergy (Copenhagen)72(4), 545–551. https://doi.org/10.1111/all.13033

4.  Le, S., Boissieu, D., Garcelon, N., Lageix, F., Bodilis, H., Branellec, A., Karila, C., Faour, H., Delacourt, C., & Lezmi, G. (2020). Efficacy of oral ondansetron in acute FPIES: A case series of 6 patients. Allergy (Copenhagen), 75(11), 2949–2951. https://doi.org/10.1111/all.14335

5.  Leonard, S. A., Miceli Sopo, S., Baker, M. G., Fiocchi, A., Wood, R. A., & Nowak-Węgrzyn, A. (2021). Management of acute food protein-induced enterocolitis syndrome emergencies at home and in a medical facility. Annals of Allergy, Asthma, & Immunology126(5), 482–488.e1. https://doi.org/10.1016/j.anai.2021.01.020

Treatment and Managing Reactions

Prevention and Management
The only way to prevent a Food Protein-Induced Enterocolitis Syndrome (FPIES) reaction is to strictly avoid the culprit food in the diet. The same is true for the breast-feeding mother if there is a clear connection between breast milk intake and the baby’s symptoms. The preventive diet will only be implemented if, at the time of the FPIES diagnosis, the child has already eaten the food(s) in question with problems.


It could be of interest to perform Oral Food Challenge (OFC) tests with “at-risk” foods (such as cow’s milk, legumes, cereals, poultry, apple, etc.) that have not yet been introduced into the baby’s diet at the time of diagnosis. If this approach is followed, as is done regularly and with good results, it is unnecessary to eliminate at-risk foods preemptively. If the patient passes the OFC, he/she can then eat the food without giving rise to concern, even before one year of age.

In the case of cow’s milk FPIES, if breast milk is lacking, the use of an amino-acid-based formula is usually recommended. Extensively hydrolyzed cow’s milk or soy formula may be considered as a cow’s milk substitute, but only after having performed an OFC to help ensure that no adverse events will occur.

Treating an FPIES Reaction
Intravenous fluids and steroids should be administered in acute and severe episodes consisting of repetitive and profuse vomiting, severe and bloody diarrhea, pallor, lethargy, and low blood pressure.

During an acute but mild FPIES episode (mild vomiting, without lethargy or low blood pressure) after accidental ingestion of the culprit food, a “wait and see” approach could be warranted, provided that a venous line for fluids and steroids is immediately available if it becomes necessary. This type of management should not be applied in the case of infants younger than one year, because of the greater difficulty of rapidly placing a venous line.

Reactions to accidental exposure can be severe, and if ingestion is known to have occurred, the patient should present to medical attention for observation. If symptoms begin when medical assistance is unavailable, it is recommended that caregivers administer fluids and steroids orally (prescribed for this possible occurrence by a physician).

Because the clinical presentation and management of FPIES are generally unfamiliar in emergency and urgent care centers, it is helpful to provide an Emergency Letter explaining symptoms and recommending management of acute reactions. The same information should be given to the child’s general practitioner and school staff in addition to a Caregiver Action Plan.

Provided by the I-FPIES Medical Advisory Board

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