In this lecture, we’ll be discussing the
intolerance of milk protein in formula.
So here’s an example.
A three-week old infant
comes in with vomiting.
This three-week old is brought
into her pediatrician
and her mother says she’s been vomiting and
her diapers have had blood in the stool.
When asked about the feedings,
her mom says she’s been giving
a cow’s milk based formula.
So, vomiting, diapers with some blood in
the stool and a cow’s milk based formula,
what do you suspect?
The answer is milk protein allergy
or milk protein intolerance.
But this isn’t really about milk.
This is about the intolerance
of proteins found in milk.
So this in infants who are drinking milk.
That usually causes
problems but not this one.
This is about the proteins that are found
in milk and cow’s milk based formulas.
These proteins are basically prevalent
in most basic formulas, and in fact,
also prevalent in soy formulas,
and that children who are allergic
to cow’s milk based formulas
may also be allergic to soy formulas.
So, let’s look at the different types of
cow’s milk protein intolerance
that exist in kids.
The first that we can talk about
is usually after a year of age
and is more commonly an IgE-mediated
type 1 hypersensitivity reaction.
These children present with hives and wheeze
as a result of exposure to milk proteins.
Another type is eosinophilic esophagitis
and eosinophilic gastroenteritis.
This is an eosinophilic
response to the milk protein
that is occurring in the wall of the
intestine, the wall of the stomach,
and the wall of the esophagus.
This also happens usually
a little bit later on.
In infants, the most common is the
classic milk protein allergy,
and this is a result of a cellular immune
mediated type 4 hypersensitivity reaction.
I’m putting three and four together because
there is a classic syndrome called
food protein induced enterocolitis syndrome,
which is given the initials FPIES.
And FPIES is this responds
typically in small bowel,
whereas, the milk protein allergy
classically is in large bowel,
but this is the same two entities;
the FPIES is much more severe.
To remind you, the first type, which is
the type 1 hypersensitivity reaction,
is IgE mediated with rash and
wheeze rather than bloody stools.
The second type is typically later in trial
and presents with dysphagia and vomiting
and abdominal pain rather
than bloody stools.
And it’s this third and fourth type
that will present as a classic process
with blood in the stool and it
is a cellular mediated process
like a type 4
So let’s talk a little bit about
classic milk protein allergy.
This is that last third and fourth
group that we see in infants.
These infants present with
blood in their stool.
They are usually otherwise healthy.
They may be a little bit fussy
but they’re otherwise doing well,
and this usually happens in
the first few months of life.
FPIES is the very severe form that
more often involves the small bowel.
These children present very early
after they’re fed cow’s milk formula.
They have vomiting, bloody diarrhea,
and abdominal distension.
And these children may have
failure to gain weight.
They may have dehydration or they
may rarely present in frank shock.
If we suspect milk protein induced
enterocolitis, generally labs aren’t necessary.
This is mostly a historical and
a physical exam diagnosis.
But on labs if you get them,
you may see hypoalbuminemia
from a decreased
absorption of proteins.
You may see a leukocytosis, a
general inflammatory reaction.
And of course, you will
see heme-positive stools.
The diagnosis is typically
made not based on labs
but based on an empirical elimination
diet followed by a food challenge.
So, let’s go through this.
A baby comes in with
some blood in the stool,
is otherwise well appearing.
First, we will eliminate
milk protein from the diet.
Now, this seems pretty obvious for
child with a milk protein allergy
who is taking a milk
protein based formula.
These infants will typically turn them
and put them on an elemental formula
such as Nutramigen, or Alimentum,
which is very, very small
groups of amino acids
that are so small that in fact,
they cannot form an allergen.
We will not put them onto soy
formula because as you recall,
about half of kids are
also allergic to soy.
Then once they’re on this elimination
diet, we’ll see if the symptoms resolve,
and this typically takes a
few days to a few weeks,
and you should see the
blood leave the stool.
One caveat I would add is that
if the child is breastfed,
it is effective to remove
milk from the mother’s diet,
and now the breast milk
amazingly will reduce
its likelihood of causing
So we don’t have to switch
empirically breastfed children
over to the Alimentum
or the Nutramigen.
They may continue to breastfeed if the mother
can be compliant with a milk-free diet.
At about a year of age, we will
generally re-administer milk protein
because this is a short-lived
event of infancy.
And at that point, we’ll continue
to see if symptoms follow.
If the child does well after that, that was
classic for a simple milk protein allergy.
Formula-fed infants on a protein
hydrolysate or amino-acid formula.
We are not going to
switch them to soy milk.
I cannot emphasize that enough
because the cross allergy is high.
This is especially too in FPIES.
In FPIES, a reintroduction of
milk protein or soy protein
which they may also be allergic
to could be frankly dangerous.
In the treatment of FPIES in particular,
remember that’s the very severe kind
with the small bowel involvement,
we will eliminate milk
protein from the diet.
And infants with enterocolitis
may need to be NPO with fluids
because of the severity of
their intestinal involvement
before we reintroduce a
more elemental formula.
So, blood in the stool in a baby.
In older children, this will
present as wheeze and a rash.
In infants under one,
this is a classic presentation of
a simple milk protein allergy.
Most infants outgrow a simple milk
protein allergy by the age of one,
and milk proteins, cheese,
yogurt, et cetera,
may now be reintroduced into the diet.
FPIES or food protein induced
is a severe cellular-mediated allergy
involving more of the small bowel
that must be handled
And remember, elimination of
milk protein from the diet,
either through mother’s diet
if she’s breastfeeding,
or through introduction of an elemental
formula is key to managing this problem.
Thanks for your attention.