Food protein-induced proctocolitis

Food protein-induced proctocolitis (previously known as Cow's Milk Protein Intolerance)

• Blood-tinged stools in an otherwise healthy infant
  • Ddx
    • Food protein-induced enterocolitis syndrome (FPIES) or Food protein-induced enteropathy
      • Consider if sicker (vomiting, diarrhea, weight loss)
    • Meckel's diverticulum
    • Necrotizing enterocolitis (NEC)
    • Intussusception
    • Anal fissure
• Triggered by proteins from cow's milk, or occasionally soy or other foods, which are ingested through breast milk or standard infant formulas
  • Cow's milk – 76%
  • Egg – 16%
  • Soy – 6%
  • Corn – 2% (all in infants with multiple protein allergies).
  • Multiple (two of the above) – 8%.
  • No response to maternal dietary restriction – 8%; these infants improved after weaning to an extensively hydrolyzed or amino acid-based formula
• Management:
  • Complete elimination of cow's milk (or other suspected antigen) from the diet, most will improve within a few days up to two weeks.
    • For breastfed infant, eliminate all milk protein (all dairy including butter) from the mother's diet, followed by egg and soy if still symptomatic
    • For formula-fed infants, an extensively hydrolyzed formula is used (eg. Enfamil Nutramigen, Similac Alimentum)
      • 5-10% may not respond - consider amino acid-based formula (eg. Neocate, PurAmino)
  • Resolves by one year of age in almost all infants