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Table 2 Differential diagnosis of FPIES [1]

From: Food protein-induced enterocolitis syndrome: a review of the new guidelines

Condition Features that may distinguish from FPIES
Infectious gastroenteritis (e.g. viral, bacterial) Single episode of illness, fever, sick contacts
Sepsis Fluid resuscitation alone not effective
Necrotizing enterocolitis (NEC) Newborns and younger infants, rapid escalation of symptoms, bloody stools, shock, intramural gas on abdominal radiographs
Anaphylaxis Symptoms begin within minutes to 2 h of exposure, positive IgE testing, usually other manifestations (e.g. urticaria)
Food aversion Look at the familial context
Inborn errors of metabolism: Urea cycle defects, Hereditary fructose intolerance, hyperammoiniemic syndromes, propionic /methylmalonic aciduria, beta-oxydations defects, hyperinsulinism-hyperammonemia syndrome, Pyruvate dehydrogenase deficiency, mitochondrial disorders, maple syrup urine disease, ketothiolase deficiency. Developmental delay, neurologic manifestations, organomegaly, reaction to fruits
Lactose intolerance In severe form, gas, bloating, cramps, diarrhea, borborygmi and vomiting following ingestion of liquid milk and large doses of dairy products with lactose
Neurologic disorders (e.g. cyclic vomiting) No relation to specific food intake
Gastrointestinal reflux disease Emesis more chronic and not usually severe (i.e. does not lead to dehydration), only upper GI symptoms present
Hirschsprung’s disease Delay in passage of the first meconium, marked abdominal distention
Food protein-induced enteropathy Symptoms usually not temporarily associated with specific food intake, symptoms more chronic than episodic, vomiting less severe, most commonly implicated foods cow milk, soy, wheat, egg white
Eosinophilic gastroenteropathies
(e.g. eosinophilic esophagitis, eosinophilic gastroenteritis)
Usually not associated with specific food intake, symptoms more chronic than episodic, vomiting less severe, more likely to have positive IgE tests
Celiac disease No temporal relationship between symptoms and specific food intake; progressive malabsorption; celiac serology is positive
Immune enteropathies (e.g. inflammatory bowel disease, autoimmune enteropathy, immunodeficiency) Rare in infancy, not related to specific food intake
Obstructive problems (e.g. malrotation, Ladd’s bands, volvulus) Not related to specific food intake, evidence of obstruction on radiological studies
Coagulation defects No relation to specific food intake
Alpha1-antitrypsine deficiency No relation to specific food intake; hepatic involvement
Primary immunodeficiencies No relation to specific food intake; intestinal symptoms, frequent infections.