What medication can be given to a 3-month-old infant with a confirmed milk allergy?

Medication Management for 3-Month-Old Infant with Confirmed Milk Allergy

For a 3-month-old infant with confirmed milk allergy, no medication is indicated—management consists of dietary modification only: continue breastfeeding with strict maternal elimination of all cow's milk and dairy products, or switch to an extensively hydrolyzed formula (eHF) if formula-feeding. 1, 2

Breastfed Infants: Maternal Dietary Elimination (No Medication Required)

The mother must completely eliminate all sources of cow's milk protein from her diet, including milk, cheese, yogurt, butter, and hidden sources in processed foods. 1, 2

• Improvement typically occurs within 72-96 hours to 1-2 weeks of strict maternal elimination 1
• Cow's milk proteins transfer through breast milk in sufficient quantities to cause allergic reactions 1, 2
• Consultation with a registered dietitian is essential to ensure nutritional adequacy, with particular attention to calcium supplementation 1, 2
• If symptoms persist despite strict maternal elimination for 2 weeks, consultation with an allergy specialist is warranted 1, 2

Formula-Fed Infants: Specialized Formula (Not Medication)

An extensively hydrolyzed formula (eHF) of cow's milk protein is the first-line treatment, with demonstrated efficacy of 80-90%. 1, 2

• Switch to amino acid-based formula (AAF) if:

  • Symptoms are life-threatening or severe 1, 2
  • Symptoms do not resolve after 2-4 weeks of eHF treatment 1
  • The infant has failure to thrive 1

• Partially hydrolyzed formulas are inadequate for treatment of confirmed milk allergy 1

Formulas to Avoid (Critical Pitfalls)

• Soy formula is NOT recommended as a first-line alternative due to cross-reactivity affecting 20-40% of infants with milk allergy 1
• Soy may only be considered for infants >6 months after establishing tolerance by clinical challenge 1, 3
• Goat's milk and sheep's milk are unsuitable alternatives due to high protein homology with cow's milk 1, 2
• Regular cow's milk formula must be completely avoided 1

No Pharmacologic Treatment Required

There are no medications indicated for the routine management of milk allergy in a 3-month-old infant. 4

• The cornerstone of management is strict allergen avoidance through dietary modification 4
• Epinephrine is reserved only for treatment of acute anaphylaxis (not routine management), administered intramuscularly as first-line therapy if anaphylactic reaction occurs 4
• Oral immunotherapy (OIT) and biologicals like omalizumab are not appropriate for infants and are restricted to older children (typically 4-17 years) in specialized centers 4

Monitoring and Follow-Up

• All infants with milk allergy require nutritional counseling and regular growth monitoring 1
• Children with milk allergy are more likely to consume inadequate calcium and vitamin D 1
• Height-for-age percentiles may be lower in children with milk allergy compared to healthy children 1
• Reintroduction of cow's milk protein should be attempted under medical supervision, typically after 6-12 months of elimination 2

Key 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 1
• Do not use medications as a substitute for proper dietary management 4