Debate: Current Challenges in the Management of Food Allergies

In a 3-month-old infant with eczema, when should a hypoallergenic formula either empirically or stepwise be introduced? Basically, breast-feeding is recommended in infants up to the age of 6 months. As an alternative to breast milk, a hypoallergenic formula can be safely offered to infants with eczema. Amino acid–based formula should be reserved for infants with persistent symptoms who fail to respond to an extensively hydrolyzed formula (eHF) or in the case of the exclusively breast-fed infant whose mother has eliminated all potential allergens from her diet and the infant continues to display significant eczema with gastrointestinal (GI) symptoms and associated failure to thrive. What management is recommended in infants with eosinophilic oesophagitis (EO) who are on a milk-restricted diet who display significant symptom improvement but demonstrate minimal change, according to biopsy results? Even with complete disappearance of symptoms of EO numerous eosinophils may be found in the biopsies from the oesophagus, so reduction in eosinophil number is not mandatory for treatment success. Allergy tests are rarely helpful in this scenario and hence the timing of milk reintroduction and subsequent monitoring of symptoms should be done by a specialist gastroenterologist or allergist. For how long should an infant diagnosed at 2 to 3 months of age with delayed reactions to cow's milk and who has displayed symptomatic improvement on either hydrolysed or amino acid–based formula continue ingesting such formulas? Delayed cow's milk allergy (CMA) disappears in 50% of infants within the first year of life. Most infants will continue consuming a hypoallergenic formula during this time. After 12 months, a challenge dose should be given and repeated at 6 monthly intervals for the first 3 years of age and yearly thereafter to determine development of tolerance. For infants with persistent symptoms beyond the first year of age when there are ongoing nutritional concerns, a hypoallergenic formula should be continued. For older infants (>12–15 months) in whom there are no nutritional concerns, consideration can be given to starting the child on calcium-enriched rice milk or calcium supplementation as an alternative to continuing the hypoallergenic formula. In infants with delayed milk allergy who present with GI symptoms, clinicians must ask about the complete infant's nutrition. Soy milk formula is not an option in these infants because a considerable proportion will be similarly allergic to soya. At what point should clinicians refer infants with CMA to a gastroenterologist? The diagnostic strategy should depend on the intensity of the symptoms, and the strategy may vary from country to country. GI approaches are invasive and may be difficult to interpret. In general, allergen avoidance should be implemented first. Then endoscopies and pH studies can be carried out. What is the recommended approach in patients with CMA? Should they receive eHF or amino acid–based formula? A conservative approach should be adopted, starting with eHF before amino acid–based formula is given. If there is GI involvement, then no invasive measures should be taken for infants without severe symptoms. Clinicians should first investigate the infant's diet and use a challenge test; referral to a gastroenterologist should be a secondary option.