What is a suitable alternative nutrition source for a 3-month-old infant with a milk allergy?

Management of Milk Allergy in a 3-Month-Old Infant

For a 3-month-old infant with confirmed cow's milk allergy, continue exclusive breastfeeding with complete maternal elimination of all dairy products from the mother's diet, or if formula-feeding is necessary, use an extensively hydrolyzed formula (eHF) as first-line treatment. 1, 2

Breastfed Infants: Maternal Elimination Diet Approach

The preferred management strategy is to maintain breastfeeding while the mother eliminates all cow's milk protein from her diet. 1, 2

Implementation of Maternal Diet Modification

• The mother must eliminate all sources of cow's milk protein including milk, cheese, yogurt, butter, and hidden sources in processed foods 1, 2
• Improvement in infant symptoms typically occurs within 72-96 hours to 2 weeks of strict maternal dietary elimination 2
• Consultation with a registered dietitian is essential to ensure nutritional adequacy of the maternal diet, with particular attention to calcium and vitamin D supplementation 3, 1, 2

Monitoring and Confirmation

• If symptoms persist despite strict maternal elimination for 2 weeks, consultation with an allergy specialist is warranted 1, 2
• A rechallenge after 1-2 weeks of elimination should be performed to confirm the diagnosis before implementing longer periods of dietary restriction 2

Nutritional Considerations for Mother

• Children with milk allergy or multiple food allergies are more likely to consume inadequate calcium and vitamin D compared to children without milk allergy 3
• The possibility of consuming less-than-recommended intake of calcium and vitamin D is reduced if the child receives nutrition counseling or consumes appropriate commercial formula 3

Formula-Fed Infants: Hypoallergenic Formula Selection

If breastfeeding is not possible or if the infant fails to improve despite strict maternal dietary elimination, extensively hydrolyzed formula (eHF) is the first-line treatment. 1, 2, 4

Formula Hierarchy

• Extensively hydrolyzed formula (eHF) demonstrates 80-90% efficacy and should be the initial choice for formula-fed infants 2
• Amino acid-based formula (AAF) should be used if symptoms are life-threatening, severe, or do not resolve after 2-4 weeks of eHF treatment 1, 2
• For high-risk infants who cannot be exclusively breast-fed, hydrolyzed formula offers advantages to prevent allergic disease and cow's milk allergy 4

Formulas to AVOID

• Soy formula is NOT recommended as a first-line alternative due to cross-reactivity affecting 20-40% of infants with cow's milk protein allergy 2
• Soy formula may only be considered for infants >6 months after establishing tolerance by clinical challenge 2
• Goat's milk and sheep's milk are unsuitable alternatives due to high protein homology with cow's milk 1, 2
• Partially hydrolyzed formulas are inadequate for treatment of confirmed cow's milk protein allergy 2

Critical Pitfalls to Avoid

• Do not implement unnecessarily restrictive maternal diets beyond elimination of confirmed allergens, as this may compromise maternal nutrition and breastfeeding ability 1, 2
• Do not discontinue breastfeeding prematurely when maternal elimination diet can effectively manage symptoms 1, 2
• Do not delay switching to amino acid formula if the infant has failure to thrive or severe symptoms that persist despite eHF 2
• Avoid irregular cow's milk exposure (infrequent formula supplementation), as emerging evidence suggests this might increase the risk of cow's milk allergy 5

Nutritional Monitoring Requirements

All children with food allergy require nutritional counseling and regular growth monitoring. 3

• Children with 2 or more food allergies are at higher risk for growth impairment compared to those with 1 food allergy 3
• Height-for-age percentiles may be lower in children with milk allergy compared to healthy children 3
• Regular monitoring helps identify inadequate nutritional intake early, particularly for calcium, vitamin D, and protein 3

When Breastfeeding with Maternal Elimination is Not Feasible

If the mother is unable to maintain the elimination diet or if symptoms persist despite strict adherence, transition to hypoallergenic formula is appropriate 1, 2. The choice between eHF and AAF depends on symptom severity, with AAF reserved for severe cases or eHF failure 1, 2.