II. Epidemiology

  1. Age: 0-10 months (usually presents 3 weeks - 3 months)

III. Pathophysiology

  1. Distal colon inflammatory reaction to Cow's Milk Protein
  2. Appears to not be IgE mediated
  3. Concomitant soy milk reaction in 30% of infants

IV. Predisposing factors

  1. Early introduction of cow's milk
    1. Especially after Gastroenteritis

V. Symptoms

  1. Loose Bowel Movements
  2. Blood and mucus streaked stools
  3. Otherwise healthy infant with normal growth
  4. Vomiting
  5. Hives

VI. Differential Diagnosis

  1. Swallowed maternal blood (during delivery, or from cracked nipples)
    1. Most common cause of infants with blood in stool
  2. Infectious Colitis causing bloody stool (Salmonella, Shigella)
  3. Enterocolitis due to Necrotizing Enterocolitis
  4. Anal Fissure
  5. Hirschsprung's Disease

VII. Labs

  1. Stool studies
    1. Leukocytes
    2. Stool Guaiac
    3. Stool Culture
    4. Wright's Stain for Eosinophils
  2. Complete Blood Count with differential
    1. Eosinophilia
  3. RAST testing not useful

VIII. Management

  1. Nursing Mothers
    1. Avoid milk and possibly soy products in maternal diet
  2. Formula fed
    1. May trial on Soy Formula first (previously not recommended)
    2. Casein Hydrolysate formula (e.g. Nutramigen)
    3. Elemental formula (Neocate) for refractory cases
  3. Re-challenge with cow's milk at 1 year

IX. Prognosis

  1. Infants outgrow in 95% cases by age 1 year

X. References

  1. Mason and Woods in Herbert (2019) EM:Rap 19(2): 7-8

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