What is the plan of care for a 4-month-old infant with hives that occur during breastfeeding and resolve shortly after?

Management of Infant Hives During Breastfeeding

The mother should immediately eliminate all cow's milk protein from her diet while continuing to breastfeed, and the infant should be prescribed an epinephrine autoinjector, as any food allergy presenting with hives can progress to anaphylaxis on subsequent exposures. 1, 2

Immediate Actions

Prescribe Emergency Medication

• An epinephrine autoinjector must be prescribed immediately, even though the current presentation involves only isolated hives, because food allergies can escalate to severe reactions with future exposures. 1
• Antihistamines (H1 and H2 blockers) can provide symptomatic relief for the urticaria but do not replace the need for epinephrine availability. 1

Initiate Maternal Dietary Elimination

• 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, as food allergens transfer through breast milk in sufficient quantities to trigger allergic reactions in sensitized infants. 1, 2, 3
• Breastfeeding should be maintained throughout this process, as it aligns with infant feeding recommendations and provides immunologic benefits. 1, 2

Timeline and Monitoring

Expected Improvement

• Symptoms typically improve within 1-2 weeks of strict maternal dietary elimination, though some manifestations may resolve within 72-96 hours. 1, 2
• Document symptom patterns carefully during the elimination period to establish causality. 1

Diagnostic Confirmation

• After 2 weeks of strict elimination with documented symptom resolution, perform a supervised rechallenge by having the mother reintroduce cow's milk protein into her diet while monitoring the infant under medical supervision. 1, 2
• This rechallenge step is imperative to confirm the diagnosis before committing to longer periods of dietary restriction. 4

Nutritional Support

• Refer the mother to a registered dietitian to ensure nutritional adequacy of the elimination diet, particularly regarding calcium supplementation and other nutritional considerations needed to maintain maternal health during breastfeeding. 1, 2

Critical Pitfalls to Avoid

Do Not Use Inappropriate Alternatives

• Never recommend soy formula as an alternative, as 20-40% of infants with cow's milk protein allergy also react to soy due to cross-reactivity. 1, 2
• Goat's milk and sheep's milk are not suitable alternatives due to high protein homology with cow's milk. 1, 2

Do Not Discontinue Breastfeeding Prematurely

• Stopping breastfeeding should be avoided when maternal elimination diet can effectively manage symptoms, as breastfeeding provides substantial benefits. 2
• However, if the infant fails to improve despite strict maternal dietary elimination for 2 weeks, or if the mother cannot maintain the elimination diet, consider amino acid-based formula for severe cases. 2

When to Escalate Care

• If symptoms persist despite strict maternal dietary elimination for 2 weeks, mandatory consultation with an allergy specialist is required. 1, 2
• All infants with documented food allergy should be referred to an allergist for longitudinal care. 1

Long-Term Management

• Reintroduction of cow's milk protein should be attempted under medical supervision, typically after 6-12 months of elimination, though timing should be individualized based on initial symptom severity. 1, 2
• Most children eventually develop tolerance to cow's milk, though this may take several years. 1
• Regular growth monitoring is mandatory for all children with food allergies. 1

Additional Considerations

Multiple Food Allergies

• If cow's milk elimination alone proves insufficient after 2 weeks, consider that the infant may be reacting to multiple foods in the maternal diet (such as egg, peanut, or fish), which would require additional eliminations based on clinical history and testing. 3, 5
• Avoid unnecessarily restrictive maternal diets beyond confirmed allergens, as this may compromise maternal nutrition and breastfeeding ability. 2

Growth Monitoring

• Monitor infant growth parameters closely, as some studies have shown that infants with atopic manifestations during breastfeeding may experience growth impairment, particularly when symptoms are prolonged. 6