A vomiting child: fluff or not fluff

30-06-2022 -

by Kors Jan van Alphen – acting general practitioner

Recently, as a directing physician, I was confronted with the story of a 7-month-old boy who had vomited 3 hours after taking a bite of pears with peanut butter and then vomited a number of times. In the ABCD he was safe and stable according to the triage, although mother thought he was lethargic; No indications of allergic symptoms (shortness of breath/mucous membrane swelling/skin symptoms, etc.), no diarrhoea.  According to NTS, the contact advice BRAKEN was given: small sips of water/herbal tea and contact again as soon as possible.

Three weeks later I received a complaint from the mother of this patient that we had trivialized the complaints and had not taken them seriously. There would have been a heavy vomiting child, pale, dazed and very weak and with this image there would be an FPIES (Food Protein-Induced Enterocolitis Syndrome). The triage nurse and I had not recognized this image, which can be potentially life-threatening due to the occurrence of dehydration and hypovolemic shock. Hospitalization is then necessary as well as treatment by the pediatrician. Fortunately for the patient in question, he had fully recovered with the advice given!

I did not know the picture of FPIES (a rare disorder, often under-)diagnosed or misdiagnosed) and when reading the description, a number of alarm symptoms were missing in this case (alarm symptoms that would certainly have led to an assessment. The picture arises because food protein causes enterocolitis in babies and young children. The main symptoms are recurrent severe vomiting AND diarrhea 1-4 hours after ingestion of the triggering food : cow’s milk , soy proteins ,oats rice, eggs peanuts, banana ,sweet potato but also other foods can cause it. It is a non-IgE mediated immune system response to food that affects the gastrointestinal tract: a cell-mediated reaction hence the delay in its occurrence.  The classic IgE mediated skin abnormalities and respiratory complaints are completely absent.  Any child could potentially be affected, but some babies are at greater risk: for example, 20% of children with FPIES have relatives with food allergies and 40-80% of affected children have relatives with allergic diseases such as hay fever, asthma, eczema. There may be one food protein, but there may also be several involved.
Characteristic: severe and repeated vomiting followed by severe watery diarrhoea in which the child may also have a blue or pale complexion, lethargy (limp/lethargic) there may be hypothermia or fever as well as dehydration symptoms and shock-like symptoms.

The diagnosis is not easy to make because the symptoms do not appear immediately, the clinical presentation is variable and there are many other diseases that can resemble this picture such as stomach flu, for example. Most children who vomit will not show these symptoms and have been helped with the vomit contact advice, but if there are alarm signals as described above, then prompt assessment is recommended.

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