Food Allergy in the Breastfed Infant

Kirsi Järvinen-Seppo, MD, PhD


May 13, 2014

Management After Failed Oral Feeding Test

If cow's milk or enriched soy milk is not tolerated at this point, the nutritional contribution (fat and protein content) of the solid-food diet needs to be assessed before transitioning from a formula to a milk substitute. Continued use of commercially prepared complete formulas is recommended for children with multiple food allergies on very limited diets or for those avoiding both milk and soy.

Enriched alternative milk sources (usually soy- or grain-based) generally do not provide similar nutrition to whole cow's milk or formulas. For children with concomitant milk and soy allergy, enriched oat milk provides calcium and vitamin D, but is lower in protein and fat. Grain (eg, rice) and nut (eg, almond) beverages tend to be even lower in fat and protein. Other mammalian milks, such as goat's or sheep's milk, are also not suitable. Donkey's or mare's milk may be tolerated but is not readily commercially available.

Calcium-fortified juices are often recommended to meet calcium needs. Excessive intake of juice, however, can displace nutrients from other dietary sources -- resulting in subsequent deficiencies, particularly of protein, fat, and energy. Nutritional counseling and regular growth monitoring are recommended for all children with food allergy.

Most children with cow's milk allergy have a favorable course and will develop tolerance to milk protein by 7 years of age. Those with anaphylaxis, elevated peak lifetime cow's-milk serum IgE antibody levels (> 50 kIU/L), or allergic EoE may have a more protracted course.

Atopic eczema tends to improve after toddlerhood, although the tendency to eczema exacerbations related to nonspecific triggers, such as weather changes, may remain.

Key Messages

  • Food allergic reactions, although rare, may present during exclusive breastfeeding and may include either immediate reactions (such as hives or maculopapular rash) or delayed-onset reactions (such as eczema, proctocolitis, FPIES, and eosinophilic gastroenteropathies).

  • Atopic dermatitis is common in infancy and is rarely related to food allergy, especially when mild. One third of cases of moderate to severe atopic dermatitis may be related to food allergies.

  • The diagnosis of food allergy is based on the history; constellation of typical clinical symptoms with clinical improvement after withdrawal of the suspected causal protein; skin-prick and/or serum-specific IgE measurement; and, if necessary, results of an oral food challenge.

  • Initial management consists of elimination of the offending food from the diet and an emergency treatment plan for acute episodes after accidental exposures. If an infant presents with food allergy during exclusive breastfeeding, a maternal elimination diet is warranted.

  • Cow's milk is responsible for most food allergic reactions in breastfed infants.

  • The prognosis of food allergy in breastfed infants is favorable, and most of those with IgE-mediated milk and egg allergies will outgrow their condition by 7 years of age. Children with peanut, tree nut, and fish allergies are less prone to outgrow these food allergies. Most children with FPIES outgrow the condition by 4 years of age, and those with allergic proctitis/proctocolitis outgrow these conditions by 1 year of age. The prognosis of EoE is poorly understood at this point.


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