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Table 3 Diagnostic criteria for patients presenting with possible FPIES [1]

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

Acute FPIES
Major criterion:
Vomiting in the 1–4 h period after ingestion of the suspect food and the absence of classic IgE-mediated allergic skin or respiratory symptoms
Minor criteria:
1. A second (or more) episode of repetitive vomiting after
eating the same suspect food
2. Repetitive vomiting episode 1–4 h after eating a
different food
3. Extreme lethargy with any suspected reaction
4. Marked pallor with any suspected reaction
5. Need for emergency room visit with any suspected reaction
6. Need for intravenous fluid support with any suspected
reaction
7. Diarrhea in 24 h (usually 5–10 h)
8. Hypotension
9. Hypothermia
The diagnosis of FPIES requires that a patient meets the major criterion and at least 3 minor criteria. If only a single episode has occurred, a diagnostic oral food challenge should be strongly considered to confirm the diagnosis, especially since viral gastroenteritis is so common in this age group. Further, while not a criteria for diagnosis, it is important to recognize that acute FPIES reactions will typically completely resolve over a matter of hours, compared to the usual several day time course of gastroenteritis. The patient should be asymptomatic and growing normally when the offending food is eliminated from the diet.
Chronic FPIES
Severe presentation: when the offending food is ingested in on a regular basis [e.g., infant formula]. Intermittent but progressive vomiting and diarrhea (occasionally with blood) develop, sometimes with dehydration and metabolic acidosis.
Milder presentation: lower doses of the problem food (e.g. solid foods or food allergens in breast milk) lead to intermittent vomiting, and/or diarrhea, usually with poor weight gain/ failure to thrive, but without dehydration or metabolic acidosis.
The most important criterion for chronic FPIES diagnosis is resolution of the symptoms within days following elimination of the offending food(s) and acute recurrence of symptoms when the food is reintroduced, onset of vomiting in 1–4 h, diarrhea in 24 h (usually 5–10 h). Without confirmatory challenge, the diagnosis of chronic FPIES remains presumptive.