Table 6.

Management of acute FPIES episode at the medical facility [1]

Presenting Symptoms
Mild	Moderate	Severe
Symptoms
1–2 episodes of emesis No lethargy	> 3 episodes of emesis and mild lethargy	>3 episodes of emesis, with severe lethargy, hypotonia, ashen or cyanotic appearance
Management
1. Attempt oral re-hydration (e.g., breast-feeding or clear fluids)  2. If age 6 months and older: Consider ondansetron intramuscular 0.15 mg/kg/dose, maximum 16 mg/dose  3. Monitor for resolution about 4–6 h from the onset of a reaction	1. If age older than 6 months: administer ondansetron intramuscular 0.15 mg/kg/dose, maximum 16 mg/dose 2. Consider placing a peripheral intravenous line for normal saline bolus 20 ml/kg, repeat as needed 3. Transfer the patient to the emergency department or intensive care unit in case of persistent or severe hypotension, shock, extreme lethargy, or respiratory distress 4.Monitor vital signs 5. Monitor for resolution at least 4–6 h from the onset of a reaction 6. Discharge home if patient is able to tolerate clear liquids	1. Place a peripheral intravenous line and administer normal saline bolus 20 ml/kg rapidly, repeat as needed to correct hypotension 2. If age 6 months and older: administer intravenous ondansetron 0.15 mg/kg/dose, maximum 16 mg/dose 3. If placement of intravenous line is delayed due to difficult access and age is 6 months or older administer ondansetron intramuscular 0.15 mg/kg/dose, maximum 16 mg/dose 4. Consider administering intravenous methylprednisolone 1 mg/kg, maximum 60 to 80 mg/dose 5. Monitor and correct acid base and electrolyte abnormalities 6. Correct methemoglobinemia if present 7. Monitor vital signs 8. Discharge after 4–6 h from the onset of a reaction when the patient is back to baseline and is tolerating oral fluids 9. Transfer the patient to the emergency department or intensive care unit for further management in case of persistent or severe hypotension, shock, extreme lethargy, respiratory distress

Strong consideration should be lent in performing food challenges in children with history of severe FPIES in the hospital or other monitored setting with immediate availability of intravenous resuscitation.

Oral challenges in the physician’s office can be considered in patients with no history of a severe FPIES reaction, although caution should be urged as there are no data that can predict future severity of FPIES reactions