Food Allergy in the Breastfed Infant

Kirsi Järvinen-Seppo, MD, PhD


May 13, 2014

Dietary Management of Food Allergy in Infants

The cornerstone of food allergy therapy is avoidance of the offending food. Cow's milk is a common trigger for early manifestations of food allergy, regardless of clinical presentation. Strict avoidance of cow's milk from the mother's and infant's diet is needed, unless otherwise suggested on the basis of allergy testing. If there is no response to a cow's-milk elimination diet, it is possible that the avoidance diet is not complete and additional foods need to be eliminated (such as egg, peanut, or wheat), or that symptoms are not related to food allergy (as is commonly the case in atopic dermatitis). A dietitian can be helpful in identifying hidden sources of milk protein in the diet.

Although not all babies react to trace amounts of food, it is difficult to assess the individual's threshold dose. Furthermore, the threshold dose can become smaller with repeated episodes, so it is important to avoid trigger foods strictly. Some patients with milk and egg allergy can tolerate the trigger food in a cooked or baked form. This is not routinely recommended without assessment by an allergist.

Not all infants who are breastfed react to dietary food proteins present in breast milk, neither do all mothers secrete dietary food proteins in their milk. However, if an infant is symptomatic owing to the presence of dietary food triggers in breast milk, maternal avoidance of these foods is recommended.

Maternal avoidance of cow's milk necessitates calcium supplementation. The vitamin A and D content of maternal milk may be reduced if the mother's diet is deficient in these vitamins; therefore, a milk-free prenatal vitamin is recommended. Avoidance of cow's milk in a formula-fed infant's diet is a major risk factor for calorie and nutrient deficiencies in young infants unless the infant is appropriately supplemented.

Alternatives to an infant with cow's-milk allergy include hypoallergenic formulas (hydrolyzed cow's milk-based formulas and amino acid-based formulas). Partially hydrolyzed cow's milk formulas are not considered hypoallergenic. Extensively hydrolyzed formulas are tolerated by about 90% of infants with cow's-milk allergy. An amino acid-based formula is recommended over extensively hydrolyzed formulas in certain cases: infants with IgE-mediated cow's milk allergy who are at high-risk for anaphylaxis, EoE, and those who continue to exhibit symptoms on extensively hydrolyzed formulas.

Avoidance of trigger foods necessitates close reading of all food ingredient labels. There are many other dairy-free products on the market, such as soy- or coconut-based yogurt and soy- or rice-based cheese. However, not all "dairy-free" products are milk protein-free, so reading all ingredient labels is imperative. Furthermore, many foods are manufactured on shared equipment. Elimination of food from the mother's and infant's diet should be done with a dietitian to ensure the nutritional adequacy of the diet and to avoid sources of cross-contamination in the diet.


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