II. Epidemiology

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

III. Pathophysiology

  1. Cow's milk protein allergy
  2. Concomitant soy milk allergy in 30% of infants

IV. Predisposing factors

  1. Early introduction of 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. Casein Hydrolysate formula (e.g. Nutramigen)
    2. Elemental formula (Neocate) for refractory cases
    3. Do not substitute with Soy Formula (not effective)
  3. Re-challenge with milk at 1 year

IX. Prognosis

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

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