Cow's Milk Protein Intolerance

Key Features

• Refers to nonallergic food sensitivity

• More common in males than females and in young infants

• Estimated prevalence is 0.5–1.0%

• Exposure to cow's milk protein is from formula or breast milk

• A family history of atopy is common

Clinical Findings

• Symptoms may occur while an infant is still exclusively breastfed

• Most common form is a healthy infant with flecks of blood in the stool or with loose mucoid stools with streaks of blood

Diagnosis

• Skin testing is not reliable and not indicated

• Histology, not required for diagnosis, shows mild lymphonodular hyperplasia, mucosal edema, and eosinophilia on rectal biopsy

• In older children, milk protein sensitivity may induce

  • Eosinophilic gastroenteritis with protein-losing enteropathy

  • Iron deficiency

  • Hypoalbuminemia

  • Hypogammaglobulinemia

• A celiac-like syndrome with villous atrophy, malabsorption, hypoalbuminemia, occult blood in the stool, and anemia can occur

Treatment

• When symptoms are mild and the infant is thriving, no treatment may be needed

• Otherwise, treatment consists of eliminating the source of the protein

• In breastfed infants, maternal avoidance of milk protein usually suffices

• In formula-fed infants, substituting a protein hydrolysate formula for cow's milk–based formula is indicated

• A more severe form of food protein–induced enterocolitis syndrome (FPIES) may require corticosteroids

• Allergic colitis in young infants is self-limited, usually disappearing by 8–12 months of age