Keen Questioning in Urgent Care Leads to Quick Diagnosis of Rare Food Allergy

Gina Murray, MD

Case: A 7-month-old male presented to one of Children’s Hospital of Philadelphia’s After-hours Urgent Care locations with vomiting, dry heaves, and lethargy. It was his third similar episode.

His parents reported that 2 weeks ago he had vomiting and diarrhea and went to his primary care provider for a sick visit. At that time, his PCP thought the likely cause was a viral infection. A week before coming to the CHOP Urgent Care, his parents had taken him to a local urgent care with similar symptoms. The provider told his parents it was likely viral again and sent him home with instructions to follow up with his pediatrician.

At CHOP Urgent Care, a thorough medical history revealed that a couple of hours prior to the latest bout of vomiting, the baby had eaten sweet potatoes. Upon further questioning and reflection, parents recalled that the baby, who had recently begun to eat solid foods, had also eaten solid food before his 2 earlier episodes. He had lost 1 lb over the last 2 weeks.

The CHOP Urgent Care physician immediately suspected food protein-induced enterocolitis syndrome (FPIES), a rare non-IgE mediated food allergy that affects the gastrointestinal tract. Untreated, it can lead to acute dehydration and/or hypovolemic shock. She administered Zofran^®, which quelled the vomiting. He nursed briefly, and his vital signs returned to normal. His parents were told to limit his feeds to breast milk.

An expedited referral to the CHOP Allergy Program confirmed the diagnosis of FPIES. After an elimination diet narrowed his allergic triggers to milk, eggs, and sweet potatoes, he has been able to resume eating other solid foods and now, at 25 months, is thriving.

Discussion: experience matters

FPIES can be tricky to diagnose because, unlike most food allergies, symptoms do not begin immediately after eating. Instead, it can take hours before severe symptoms begin.

Because the family described above chose an Urgent Care staffed by experienced pediatricians and pediatric nurses, the child was directed to the proper subspecialist for follow-up and treatment. An urgent care physician who sees mostly adults may not be familiar with rare, pediatric-specific illnesses and diseases like FPIES. Also, at some urgent care centers, mid-level providers, rather than board-certified pediatricians, see patients, and they may not have experience with out-of-the-ordinary conditions, especially ones that involve children.

CHOP has 5 After-hours Urgent Care locations in Pennsylvania, all staffed with pediatric-trained physicians and nurses. Each location has X-ray facilities with direct access to pediatric radiologists for consults, if needed. They also provide on-site testing for urine, influenza, COVID-19, and Streptococcus. Available procedures include splinting, foreign body removal, laceration repairs, and abscess drainage.

CHOP Urgent Care patients who need follow-up with a subspecialist receive expedited appointments within the CHOP Care Network.

Urgent Care or Emergency Department?

Families are often uncertain whether to take their child to Urgent Care or the ED when an illness or injury happens outside of their primary care pediatrician’s normal hours. While any life-threatening condition requires an ED, many other conditions that can’t wait until the doctor’s office opens are appropriate for evaluation and treatment at a pediatric urgent care. Severity is the key indicator. (See Chart 2).

At CHOP’s King of Prussia Campus, the new, state-of-the-art, 15-room Urgent Care is located next to the recently opened Emergency Department, which is part of the new hospital, the Middleman Family Pavilion. If a patient in the King of Prussia Urgent Care were to need the escalated care of an Emergency Department, Urgent Care staff will accompany the child through the adjoining doorway to the ED. In emergent situations, ED staff can come and transport the child to the ED. If the child were to need to be admitted, they could be hospitalized in the Middleman Family Pavilion. Children who require the resources of the Philadelphia Campus will be transported via CHOP transport.