Daily Clinical Briefing · Educational reading for healthcare professionals
Timing, trigger foods and absent skin or respiratory signs help distinguish FPIES from common mimics.
In a child with repetitive vomiting, ask what was eaten one to four hours earlier before labelling the illness gastroenteritis.
A child eats, appears well for a while, then starts vomiting repeatedly. There are no hives, no facial swelling and no respiratory symptoms. By the time the child is assessed, the vomiting may even have stopped.
That pattern should make the timing of the feeding history particularly important.
Food protein-induced enterocolitis syndrome (FPIES) is a delayed, non-IgE-mediated food allergy. Acute reactions typically produce repetitive vomiting one to four hours after a trigger food, often with pallor or lethargy and sometimes later diarrhoea. Cow’s milk, soy, oat, rice and sweet potato are among the reported triggers, although patterns vary.
The absence of immediate allergic features matters. Isolated FPIES does not behave like a typical IgE-mediated reaction, and adrenaline does not treat it. Management instead follows the child’s physiology: control the vomiting, assess hydration and haemodynamic status, and use oral or intravenous rehydration according to severity. Ondansetron may be used for vomiting.
The history can be more revealing than the child’s appearance at assessment. A child who has recovered may still have had a significant reaction. Previous tolerated tastes do not exclude FPIES either; reactions may become apparent after several exposures or a larger portion.
Chronic FPIES creates a different problem. Repeated exposure can produce persistent vomiting, diarrhoea, dehydration and faltering growth, potentially resembling reflux or gastroenteritis. An otherwise thriving infant with isolated blood-streaked stools points towards a different food-protein disorder and should not automatically be grouped with severe chronic FPIES.
Testing also needs restraint. Diagnosis is primarily clinical, and broad IgE panels are not routine. Targeted testing has a role in selected situations, including concern about an IgE component or planning a food challenge.
For emergency clinicians, the useful change is small: when an infant or young child has otherwise unexplained repetitive vomiting, reconstruct what was eaten during the previous one to four hours. Recurrent episodes linked to the same food deserve more than another label of viral gastroenteritis.
Two diagnostic problems challenge pattern recognition: postoperative liver chemistry abnormalities that may originate from muscle or bone rather than liver, and febrile headache where clinical features, cerebrospinal fluid patterns and rapid enterovirus PCR help distinguish meningitis from encephalitis.
Low-dose radiotherapy is considered as an anti-inflammatory treatment for selected persistent musculoskeletal conditions, while intermediate doses target benign hyperproliferative disease, with patient selection, conservative treatment, anatomy, age, dose and irradiated tissues shaping decisions and consent.
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Food protein-induced enterocolitis syndrome causes delayed gastrointestinal reactions, typically repetitive vomiting one to four hours after a trigger without usual skin or respiratory allergy features, requiring recognition of the feeding pattern, severity-based rehydration and planned trigger avoidance and reintroduction.
Prehospital practice updates focus on safer sedation for acute behavioural disturbance, early ECG and hospital notification in suspected STEMI, and equipment governance, with particular emphasis on allowing droperidol time to work, end-tidal carbon dioxide monitoring and resisting unapproved equipment modifications.
Petrichor is a composite earthy smell produced when water moistens soil, with geosmin and methyl isoborneol major contributors; human sensitivity is striking but not unique, while reported links between geosminophilia, pica and iron deficiency remain associations rather than established causation.
Add recent food exposure to the history of infants and young children with sudden repetitive vomiting, pallor or lethargy. Check hydration, ongoing vomiting, appearance and haemodynamic status before choosing oral or intravenous rehydration. Avoid broad IgE testing when the clinical pattern is primarily non-IgE-mediated.
An infant develops repeated vomiting, pallor and marked lethargy two hours after eating oatmeal. There is no urticaria, swelling, wheeze or stridor, and a similar episode followed the same food previously. What diagnosis best fits this pattern?
Acute food protein-induced enterocolitis syndrome. The characteristic pattern is repetitive vomiting one to four hours after a trigger, often with pallor or lethargy and without typical skin or respiratory allergy features.
A patient with acute behavioural disturbance receives intramuscular droperidol. The patient remains unsettled shortly afterwards but is being safely monitored and the clinical condition permits further observation. What should happen before considering additional sedation?
Allow at least 15 minutes for the initial droperidol dose to act while continuing reassessment. End-tidal carbon dioxide monitoring should be used after parenteral sedation, with resuscitation equipment immediately available.
A patient presents with fever, headache, neck stiffness and photophobia. Cerebrospinal fluid obtained early in the illness shows neutrophil-predominant pleocytosis with preserved glucose. Does the neutrophil predominance alone establish bacterial meningitis?
No. Early viral meningitis may also produce neutrophil-predominant cerebrospinal fluid, so the absolute cell count, glucose, protein, Gram stain, clinical features and illness tempo need to be interpreted together.
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