{"doi":"10.1093/pch/pxy042","title":"A 4-month-old girl with hematemesis, pallor, and lethargy","abstract":null,"journal":"Paediatrics & Child Health","year":2019,"id":641474,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":0,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":null,"is_data_producer":false,"deposit_databanks":null,"is_oa":false,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":null,"fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":1465240,"name":"Shafee Salloum","orcid":"0000-0002-1233-3254","position":0,"is_corresponding":false}],"reference_count":0,"raw_metadata":{"has_enrichment":true,"resolved":true,"title":"A 4-month-old girl with hematemesis, pallor, and lethargy","abstract":"A 4-month-old previously healthy girl presented to the hospital with sudden onset of hematemesis, pallor and lethargy. There was no history of fever, prior vomiting or bleeding. She was exclusively breastfeeding and her symptoms started 2 hours after introducing cow’s milk (CM)-based formula for the first time. She had no known allergies and no history of eczema. Physical examination revealed an ill-appearing, pale and lethargic infant. Temperature was 35.7°C, heart rate 159 beats/minute, blood pressure 76/53 mmHg, respiratory rate 34 breaths/minute and oxygen saturation 96% on room air. Her weight was 6.5 kg (45th percentile). Laboratory showed leukocytosis: white blood cell count 16 × 103/mm3 (4 to 12 × 103/mm3), with 13% bands, 48% neutrophils and 2% eosinophils. Platelets were 550 × 103/mm3 (140 to 440 103/mm3). Hemoglobin and hematocrit were 9.5 g/dL (10.5 to 14 g/dL) and 29.6% (32 to 42 %), respectively. Electrolytes were unremarkable except for low CO2 of 16 mmol/L (20 to 28 mmol/L). Coagulation profile and ammonia level were normal. An abdominal x-ray (Figure 1) showed gaseous distention of a loop of bowel, likely the sigmoid colon. Computed tomography of the head was normal with no intracranial pathology to explain her altered mental status and urine drug screen was negative. Abdominal ultrasonography showed no evidence of intussusception. She received total of 40 mL/kg normal saline boluses and intravenous (IV) ondansetron. Nonbloody diarrhea developed and stool samples tested positive for adenovirus by polymerase chain reaction which was thought to be responsible for her symptoms. Her condition improved significantly within hours of presentation and she was discharged home the next day. Abdominal x-ray shows gaseous distention of a loop of bowel in the med-abdomen probably sigmoid colon. Two weeks after introduction of CM-based formula again, the infant presented similarly with emesis, pallor and lethargy which helped reveal the final diagnosis. The dramatic improvement in the patient’s condition with no medical interventions other than IV fluids and ondansetron, in addition to recurrent symptoms upon repeated exposure to CM in an exclusively breastfed infant raised suspicion for an allergic reaction to CM protein, specifically, Food Protein Induced Enterocolitis Syndrome (FPIES). FPIES is a delayed non-Immunoglobulin E (IgE)-mediated food allergic reaction that can be severe in acute settings and lead to shock similar to this patient. Awareness of this condition is still low among physicians, despite the severity of symptoms, and diagnosis is usually delayed due to absence of IgE-mediated typical reactions (e.g., urticaria, wheezing, etc.), and lack of diagnostic testing. The American Academy of Allergy, Asthma & Immunology recently published guidelines for diagnosis and management of FPIES (1). Acute FPIES presents as delayed (1 to 4 hours) repetitive emesis, pallor and lethargy, typically, after intermittent ingestion of the causative food, and occasionally this can be followed by diarrhea 5 to 10 hours later. Chronic FPIES on the other hand, results from chronic exposure to the offending food and manifests as intermittent emesis, chronic diarrhea and failure to thrive. FPIES mainly presents in infancy although it has been described in adults after ingestion of shellfish. There are ethnic and geographic variations in FPIES triggers with CM and soy proteins being the most common causes of FPIES in the USA. FPIES is rare in exclusively breastfed infants suggesting a possible protective role of breastmilk in these infants. The exact mechanism is unknown, but believed to be cell mediated in nature. Diagnosis of FPIES is clinical, based on history and characteristic signs and symptoms with improvement after elimination of the offending food from the diet. Diagnostic criteria are shown in Table 1. Acute FPIES diagnostic criteria* *Adapted from ref. (1). Acute FPIES diagnostic criteria* *Adapted from ref. (1). The diagnosis of FPIES requires the patient to have the major criterion and three or more of the minor criteria. Oral food challenge test can confirm the diagnosis although it is not required in all cases. If oral food challenge test is indicated, it should be done in medically supervised settings. Acute FPIES is considered a medical emergency and should be managed with aggressive fluid resuscitation, and IV ondansetron. A single dose of methylprednisolone 1 mg/kg IV might be considered in severe cases (2). Anaphylaxis, septic shock, intussusception, inborn errors of metabolism and infectious gastroenteritis are the main differential diagnoses. Avoidance of the trigger food is the main strategy in long-term management. Infants with CM or soy-induced FPIES can be treated with extensively hydrolyzed or amino acid-based formulas. FPIES is self-limited with the majority of CM and soy cases resolving by age 3 years. FPIES due to solid foods may take longer. The patient was diagnosed with FPIES after her second presentation and an amino acid-based formula was introduced. She did well with no vomiting or any allergic reaction, and her mother was advised to continue breastfeeding. FPIES is a delayed non-IgE-mediated food allergic reaction seen mainly in infancy. Acute FPIES is a medical emergency can present similar to septic shock and should be managed with IV fluids and ondansetron. Intravenous steroids might be considered, especially in severe presentations. Awareness of this condition is essential to ensure appropriate management and avoidance of unnecessary tests. There are no conflicts of interest. The author would like to thank Dr Erica L. Taylor, MD for her final review of the manuscript.","is_dataset_classified":null,"base_score":0.0,"endowment":0.0,"datacite_reuse_total":0,"file_count":0,"downloads":0,"views":0,"has_version_chain":false,"is_dataset":false,"is_oa":false,"pmid":"30792590","pmcid":"PMC6376303","openalex_id":"https://openalex.org/W2795509327","authors":[],"funders":[],"total_grants":0,"fwci":0.0,"citation_percentile":0.07048225,"influential_citations":0,"citation_trend":[],"oa_status":"bronze","license":"https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model","oa_locations":[{"url":"https://academic.oup.com/pch/article-pdf/24/1/5/27776578/pxy042.pdf","host_type":"journal"},{"url":"https://academic.oup.com/pch/article-pdf/24/1/5/27776578/pxy042.pdf","host_type":"publisher"},{"url":"http://academic.oup.com/pch/article-pdf/24/1/5/27776578/pxy042.pdf","host_type":"publisher"},{"url":"https://doi.org/10.1093/pch/pxy042","host_type":"journal"},{"url":"https://pubmed.ncbi.nlm.nih.gov/30792590","host_type":"repository"},{"url":"https://www.ncbi.nlm.nih.gov/pmc/articles/6376303","host_type":"repository"}],"fields_of_study":["Food Allergy and Anaphylaxis Research","Poisoning and overdose treatments","Drug-Induced Adverse Reactions"],"mesh_terms":[],"keywords":["Lethargy","Pallor","Girl","Medicine","Pediatrics","Internal medicine","Psychology"],"sdg_mappings":[],"linked_datasets":[],"clinical_trials":[],"software_tools":[],"database_accessions":[],"source":"live","citation_network_status":"fetched"},"created_at":"2026-08-07T18:13:16.327123Z","pmid":null,"pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}