Dr. Jerin K. John, (Dr. Bhanu Vikraman Pillai Dr. Anupa AchamaThomas Dr. Neeraj Panchanadikar Ped gastro )Dr. C. Jayakumar (Pediatrics)
A 6-month-old developmentally normal female infant, the third child of non-consanguineous parents, with a history of biliary atresia status post-Kasai procedure, presented to the OPD with three episodes of dysentery
The infant also had vomiting, reduced urine output, and high-grade fever for two days. There was a history of recent introduction of cow’s milk into her diet.
On examination, the infant was found to have some dehydration.She was managed with parenteral fluids and started on antibiotics
Labs
– Hb 10.3 g/dL
– Hct 31%
– Platelet Count: 239,000/µL
– TLC 13.7 x 10^9/L
– CRP): 10.3 mg/L
Stool and urine routine examinations were normal, and cultures were negative.
Given the clinical presentation and the temporal relationship with the introduction of cow’s milk, cow’s milk protein allergy (CMPA) was suspected. The infant was switched to hydrolyzed feeds, leading to a marked improvement in symptoms, confirming the diagnosis of CMPA.
The infant was treated with antibiotics for five days and was gradually weaned off intravenous fluids as her oral intake improved. She was discharged after showing significant symptomatic improvement.
Differential Diagnosis
The differential diagnosis for this infant presenting with gastrointestinal symptoms and a history of biliary atresia includes:
1. Infectious Gastroenteritis: Common in infants, this could present with diarrhea, vomiting, and fever, but stool cultures were negative in this case.
2. Intestinal Obstruction: Could be considered given the history of previous surgery, though imaging and clinical examination did not support this.
3. Post-Kasai Complications: Complications such as cholangitis might present similarly but were ruled out based on clinical and laboratory findings.
4. Cow’s Milk Protein Allergy (CMPA): The most likely diagnosis in this case, confirmed symptomatic improvement upon switching to hydrolyzed feeds.
5. Sepsis: The fever and elevated CRP could suggest an underlying infection, but cultures were negative, and symptoms resolved with the management of CMPA.
Discussion:
Cow’s milk protein allergy (CMPA) is a common food allergy in infancy, affecting approximately 2.2% of infants.
CMPA can be either IgE-mediated or non-IgE-mediated and may persist until the child is 2 to 5 years old. While many children outgrow CMPA, some continue to experience symptoms. At the time of diagnosis, the levels of specific IgE and the age of the patient are important predictors of prognosis. Notably, infants with IgE-mediated CMPA are at higher risk of developing other atopic conditions, such as atopic dermatitis, asthma, food allergies, and allergic conjunctivitis.
Nutritional management is crucial for children with CMPA. Diets must be carefully balanced to ensure adequate nutrition. In cases where CMPA persists, supplementation with calcium is essential to prevent deficiencies. Cow’s milk protein allergy is particularly common in the first year of life, making it a well-known condition during this period.
Interestingly, CMPA can also occur in exclusively breastfed infants. This is due to the presence of proteins from foods such as egg, peanut, milk, and wheat in breast milk, which can trigger allergic reactions. Despite the benefits of breastfeeding, it is recommended that mothers of infants with CMPA continue breastfeeding while eliminating these allergens from their diet. Diagnosis of CMPA is based on clinical history and supported laboratory investigations. Treatment typically involves dietary modifications for nursing mothers and the use of hypoallergenic formulas, such as extensively hydrolyzed or amino acid-based formulas, in infants.
Understanding the underlying immunopathology of CMPA can provide insight into the infant’s prognosis. Acute gastroenteritis, which damages the small intestinal mucosa, can be a trigger for developing cow’s milk protein intolerance, especially in infants with IgA deficiency, as it increases susceptibility to foreign proteins. Allergic reactions in CMPA can occur in response to whey proteins (such as alpha-lactalbumin, beta-lactoglobulin, bovine serum albumin, and immunoglobulins) and casein proteins (alpha S1, alpha S2, beta, kappa).
Carry Home Message:
Cow’s milk protein allergy (CMPA) is not a rare condition in infancy that requires careful diagnosis and management. It can present in both formula-fed and exclusively breastfed infants due to allergenic proteins in breast milk. Early recognition and appropriate dietary adjustments, including the use of hydrolyzed or amino acid-based formulas and maternal dietary modifications, are crucial for symptom resolution and long-term health. Additionally, understanding the potential for associated atopic conditions is important for ongoing management. Regular follow-up and nutritional monitoring are essential to ensure proper growth and development while avoiding nutritional deficiencies, such as calcium.
Indian Academy of Pediatrics Kerala
Case Reports Pediatrics