What is the treatment for allergic proctocolitis in infants?

Treatment of Allergic Proctocolitis in Infants

The first-line treatment for allergic proctocolitis in infants is elimination of the offending food protein, typically cow's milk protein, from the diet with resolution of symptoms usually occurring within 72-96 hours of dietary elimination. 1, 2

Management Based on Feeding Method

For Breastfed Infants:

• Continue breastfeeding with maternal elimination of suspected trigger food (most commonly cow's milk) 3, 4
• Do not recommend routine maternal dietary elimination if the infant is thriving and asymptomatic 5
• If symptoms occur after breastfeeding or the infant has failure to thrive (FTT), the mother should eliminate the suspected trigger food from her diet 5
• Consider nutritional consultation to assist the mother with the elimination diet to ensure adequate nutrition, including calcium supplementation 3, 4
• Symptoms typically resolve within 72-96 hours of starting the elimination diet 1, 2
• If symptoms persist despite strict maternal dietary elimination for 2 weeks, consultation with an allergy specialist is recommended 3

For Formula-Fed Infants:

• Switch to a hypoallergenic formula 5:
  • Extensively hydrolyzed formula (eHF) is the first choice for most infants 3, 4
  • Amino acid-based formula (AAF) for infants who don't respond to extensively hydrolyzed formula or have severe symptoms 5, 6
• Avoid soy formula due to potential cross-reactivity (20-40% of infants with cow's milk protein allergy may also react to soy) 5, 4
• Avoid goat's and sheep's milk due to high protein homology with cow's milk 5, 3

Monitoring and Follow-up

• Most infants return to their usual state of health within 3-10 days of switching to a hypoallergenic formula or maternal elimination diet 5
• In severe cases, temporary bowel rest and intravenous fluids might be necessary 5
• If resolution of symptoms is not accomplished with dietary elimination, consider:
  • For breastfed infants: discontinuation of breastfeeding and introduction of a hypoallergenic formula 5, 4
  • For formula-fed infants: switching from eHF to AAF if symptoms persist 5, 6

Reintroduction of Foods

• Reintroduce the foods triggering allergic reactions under a physician's supervision 5
• Timing of reintroduction is variable, but most children can tolerate the trigger food within one year of life 1, 2, 7
• The median time for successful reintroduction is around 8 months of age 7
• Gradual reintroduction (ladder approach) for cow's milk and hen's egg has shown good results 7
• The relapse rate is slightly higher when trigger food reintroduction is attempted after 12 months compared to before 12 months 7

Special Considerations

• In infants with multiple food allergies, atopy patch testing (APT) might be helpful to identify polysensitization 6
• For infants with multiple food allergies not responding to maternal elimination diet, an amino acid-based formula may be necessary 6
• Children with cow's milk or soy-induced food protein-induced enterocolitis syndrome (FPIES) can also have an increased likelihood of reacting to solid foods, most commonly rice or oat 5

Common Pitfalls and Caveats

• Avoid unnecessarily restrictive maternal diets beyond elimination of confirmed allergens 3, 8
• Do not delay introduction of complementary foods past 6 months of life 5
• When introducing solids at about 6 months, start with fruits and vegetables, followed by other complementary foods such as red meats and cereals 5
• Be aware that some infants may not relapse when the presumed offending food is reintroduced after a few weeks of elimination diet 8