Management of Milk Protein Allergy in Infants
For breastfed infants with suspected milk protein allergy, continue breastfeeding while the mother eliminates all cow's milk and dairy products from her diet; for formula-fed infants, switch to extensively hydrolyzed formula (eHF) as first-line treatment. 1
Breastfed Infants: Maternal Elimination Diet
The mother should completely eliminate all sources of cow's milk protein from her diet, including milk, cheese, yogurt, butter, and hidden sources in processed foods. 1
Symptomatic improvement typically occurs within 1-2 weeks of strict maternal dietary elimination, though allergic proctocolitis may resolve within 72-96 hours. 1, 2
The mother requires calcium supplementation and consultation with a registered dietitian to ensure nutritional adequacy while maintaining the elimination diet. 1
If symptoms persist despite strict maternal elimination for 2 weeks, consult an allergy specialist for further evaluation. 1
Do not discontinue breastfeeding prematurely—maternal elimination diet effectively manages symptoms in most cases and aligns with optimal infant feeding recommendations. 1, 3
Formula-Fed Infants: Hypoallergenic Formula Selection
Extensively hydrolyzed formula (eHF) of cow's milk protein is first-line treatment, with an 80-90% success rate. 1, 2, 3
For severe reactions, life-threatening symptoms, or failure to improve on eHF, use amino acid-based formula (AAF) as first-line treatment. 1, 3
Most infants return to their usual state of health within 3-10 days of switching to hypoallergenic formula, with median resolution time of 5 days. 2
Critical Alternatives to Avoid
Soy formula is NOT recommended as first-line alternative due to 20-40% cross-reactivity risk with cow's milk protein allergy. 1, 2, 3
Soy formula may be considered only for infants >6 months after establishing tolerance by clinical challenge. 3
Goat's milk and sheep's milk are unsuitable alternatives due to high protein homology with cow's milk. 1, 3
Monitoring and Expected Timeline
Resolution of symptoms typically occurs within 1-4 weeks depending on the type of allergic manifestation. 1
For allergic proctocolitis specifically, expect resolution within 72-96 hours of dietary elimination. 2
In severe cases requiring hospitalization, temporary bowel rest and intravenous fluids may be necessary, with 90% success rate. 2
Reintroduction Protocol
Reintroduce cow's milk protein under medical supervision, typically after 6-12 months of elimination. 1, 2, 3
Oral food challenge should be performed at 9-12 months of age in a hospital setting to assess tolerance development. 3
Timing of reintroduction varies based on severity of initial symptoms and should be individualized to the clinical presentation. 1
Common Pitfalls to Avoid
Do not implement unnecessarily restrictive maternal diets beyond cow's milk elimination unless other food allergies are confirmed—this compromises maternal nutrition and breastfeeding ability. 1, 2, 3
Do not recommend routine maternal dietary elimination if the infant is thriving and asymptomatic, even with a diagnosis of milk protein allergy. 1, 2
Be aware that children with cow's milk or soy-induced food protein-induced enterocolitis syndrome (FPIES) have a 30% likelihood of reacting to solid foods, most commonly rice or oat. 2, 3
Do not use soy formula as first-line alternative in infants under 6 months. 3
Special Considerations for Severe Presentations
If the infant has failure to thrive, severe eczema, or persistent symptoms despite appropriate dietary intervention, refer to a pediatric gastroenterologist or allergist for further evaluation. 2
Amino acid-based formula should be used immediately for life-threatening symptoms rather than attempting eHF first. 1