What is the treatment for allergic protocolitis?

Treatment of Allergic Proctocolitis

The treatment of allergic proctocolitis (FPIAP) is elimination of the offending food protein from the infant's diet, which resolves symptoms within 72-96 hours in most cases. 1

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis based on:

• Rectal bleeding (hematochezia) with or without mucus in an otherwise healthy, thriving infant, typically presenting in the first few weeks to months of life 1, 2
• Resolution of bleeding within days to weeks after elimination diet, followed by recurrence when the food is reintroduced 1
• No specific biomarker exists; investigations are reserved only for severe or atypical cases 2

Treatment Algorithm

For Exclusively Breastfed Infants (60% of cases)

Implement maternal elimination diet removing cow's milk and soy proteins, as these are the most common triggers 1, 3. Additional allergens may include egg, corn, and wheat 1.

• Symptoms should resolve within 72-96 hours of starting the elimination diet 1
• If bleeding persists beyond 2-4 weeks, consider eliminating additional allergens sequentially 2
• Continue maternal elimination diet until the infant is 9-12 months of age 2, 3

For Formula-Fed Infants

Switch to extensively hydrolyzed formula (eHF) or amino acid-based formula (AAF) 2, 3.

• eHF is typically sufficient for most cases
• AAF is reserved for severe cases or those not responding to eHF 2

Duration of Elimination Diet

The elimination diet should be continued until 9-12 months of age, as most children develop tolerance to the trigger food by one year of life 1, 3.

• FPIAP is a self-limiting condition with excellent long-term prognosis 1
• Approximately 25% of infants may not experience relapse when the food is reintroduced after a few weeks of elimination 2
• The majority of cases resolve by 12 months of age 3

Food Reintroduction

Attempt reintroduction of the offending food at 9-12 months of age under medical supervision 1, 3.

• If bleeding recurs, continue elimination and retry at 12-18 months 2
• Most children achieve tolerance by 1-3 years of age 4, 3

Critical Monitoring Considerations

Monitor for development of IgE-mediated food allergy, as approximately 25% of children with FPIAP may transition to immediate-type food allergy 3.

• Some patients develop severe IgE-mediated reactions including anaphylaxis to cow's milk or other foods 4
• IgE-mediated allergy may persist beyond preschool years in some cases 4
• Consider allergy testing if symptoms suggest IgE-mediated reactions (urticaria, angioedema, respiratory symptoms) 4

Common Pitfalls to Avoid

• Do not perform extensive investigations in typical cases, as diagnosis is clinical and investigations are reserved for severe or atypical presentations 2
• Do not discontinue breastfeeding; maternal elimination diet is preferred over switching to formula 2, 3
• Do not eliminate multiple foods simultaneously without sequential trial, as this may lead to unnecessarily restrictive diets 2
• Do not assume permanent tolerance after initial resolution; some infants develop persistent IgE-mediated allergy requiring long-term management 4