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Updated: Dec 28 2021

Infant Food Protein-Induced Proctocolitis

  • Snapshot
    • An infant girl is brought to the pediatrician by her parents due to finding blood in her diaper. This began approximately 2-3 days prior to presentation and has not happened before. Her stools have become loose and streaked with blood. She is exclusively breastfed every 3 hours and voids approximately 10 times a day. The mother's diet consists of fish, fruits, vegetables, nuts, and milk. On physical examination, the infant is healthy-appearing and cooing. There are no anal fissures and her stool is loose with streaks of blood mixed in.
  • Introduction
    • Clinical definition
      • infant distal colon inflammation secondary to an immune reaction to certain food proteins which results in
        • rectal bleeding
  • Epidemiology
    • Incidence
      • a common cause of rectal bleeding in infants who are breastfed and formula-fed
    • Demographics
      • almost exclusively in infants
    • Dietary triggers include
      • cow's milk
      • soy
      • egg
    • Pathogenesis
      • not an IgE-mediated immune reaction to the distal rectum
        • IgE-mediated immune reactions are seen in classical food allergies which present with
          • a rapid onset (minutes to two hours)
          • skin, respiratory, gastrointestinal, and/or cardiovascular involvement
  • Presentation
    • Symptoms
      • passing of blood-tinged stools and mucus but is otherwise healthy
      • may be fussy, have increased frequency of bowel movements, and have eczema
    • Physical exam
      • typically stools
        • are soft and loose
        • have blood specks/streaks within the stool
        • may have mucous
  • Differential
    • Anal fissures
      • stools are typically firm with streaks of blood found on the outside
    • Necrotizing enterocolitis
    • Intussusception
    • Enteric infection
    • Meckel's diverticulum
    • Diagnostic criteria
      • this is a clinical diagnosis based on
        • having an otherwise healthy infant with small amounts of rectal bleeding
        • confirmation after symptom resolution secondary to removal of the presumed food antigen
  • Treatment
    • Conservative
      • modifying the mother's diet
        • indication
          • breastfed infants in whom the mother's diet contains the suspect food
            • e.g., eliminating cow's milk from the mother's diet
        • outcomes
          • breastfed infants typically respond to this maternal dietary modification
      • hydrolyzed formula
        • indication
          • used to replace cow's milk or soy-based formula in formula-fed infants
  • Complications
    • Persistent food allergy
      • rare
    • Chronic colitis
      • rare
  • Prognosis
    • Excellent because almost all infants are able to tolerate cow's milk and soy products by the time they become one year of age
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