Breastfeeding Food Allergy Action Plan
You suspect your breastfed infant has a food intolerance and is reacting to proteins in your breast milk, now what? First, consult with your pediatrician and determine if referrals to an allergist or gastroenterologist is warranted. In conjunction with your medical team, the following steps can help guide your journey.
Does my baby have food intolerance/allergies?
Before jumping into a game plan, lets discuss what warrants it in the first place. The following symptoms can be indicative of an infant food intolerance or allergy: reflux, vomiting, rash, eczema, diarrhea, constipation, mucous stool, bloody stool, failure to thrive, colic, lethargy, and airway restriction . Since these range widely, it is important to consider other contributing factors such as teething, vaccines, or illness before taking action to fix a food problem that may not exist. Additionally, some symptoms which exist solely, such as reflux or colic, may not be attributed to food allergies and options should be discussed with your medical professional. Commonly, two or more symptoms occur when baby is reacting to dietary proteins in your breast milk .
This is not a one-size-fits-all medical issue. The best course of action is different for every mother, infant, and family situation. Here, we outline two courses of action: removing one food at a time and removing all common culprits at once. The reason why these two approaches are recommended are based on the pros and cons of each. When removing only one at a time, it is much easier to tell which is the offending food and it can be much easier on mom. Conversely, removing several foods at once can help baby recover faster from symptoms but it will take longer to deduce which items are the problem and such a restrictive diet can be difficult for mom.
Consideration 1: Symptomology
These decisions are often based on symptom severity. Milder symptoms can often be addressed by trialing individual protein elimination until identifying the culprit. Severe symptoms are best addressed by removing most possible culprits and slowly adding back one at a time after symptoms have subsided. For example, a family whose infant has reflux and mucousy stool may want to trial one at a time while a case of severe bloody stool, projectile vomiting, and constant colic may decide to take the second approach and remove several things at once.
Consideration 2: Dietary Ability
Everyone’s food situation is different. Mothers who plan to remove many food items at once need to consider their nutritional needs and the availability of alternative foods. We outline less-allergenic food substitutions with similar minerals and vitamins here. Maternal malnutrition is a significant concern if mom cannot access or afford different foods to bridge the nutritional gap.
Consideration 3: Mental Health
There are two opposing maternal mental health considerations. On one hand, continued infant symptoms can be frustrating, depressing, and worrisome. On the other, excessively restrictive diets can be frustrating, depressing, and worrisome. See a theme here? It is vital that moms choose a path which is feasible for their long-term mental health. Breastfeeding is wonderful, but having happy parents is wonderful too. Awareness is key.
Execution: Individual Removal
When removing an individual food item, understanding timing is vital. What to cut, how long to cut, and if/when to cut the next thing are main questions. Each answer will depend on your situation. We have outlined the top infant food intolerances/allergies below. This is in order of prevalence, so start at the top of the list and choose what to eliminate based on experience. If you are a strict vegan, skip on down to soy as you have already eliminated dairy. If you consume dairy (even lactose free) start there.
Research indicated that ingested food proteins peak in breast milk concentration in approximately 2 hours and steadily decrease from there. While there are always outliers, most ingested proteins will clear mother’s system within 24 hours.
The next part of the equation is infant symptoms. How long it will take to see improvement varies greatly depending on infant sensitivity and length and quantity of exposure (a lot of soy over a long period of time versus a little in a short period). Read our article about allergy timing to better understand how this all works. Essentially, complete healing can take several weeks. That being said, if you have indeed removed the real allergy food you should see either a plateau (same) or an improvement in symptoms within a week.
CHECK FOR HIDDEN ALLERGEN SOURCES BEFORE YOU REMOVE ANOTHER FOOD!
The biggest misstep in this process is moving on to the next food without properly removing the current target. Imagine, you have eliminated dairy and see steady increase in symptoms instead of improvement. You decide to remove soy, then egg, then wheat…on and on. Several months or weeks go by without improvement when it suddenly dawns on you that your [insert surprise here] contains dairy. Back to square one. That is why it is sooooo important to ensure heavy scrutinization of everything you ingest before removing the next item. Beverages, supplements, medications, and seasonings are common hidden allergen sources . Keeping a detailed food log during this time can help you pinpoint hidden allergens or what your next target should be.
If you are absolutely certain you haven’t consumed the elimination target and are seeing significant increases in symptoms after a week it is time to consider the next target. It is recommended to use an additive approach, meaning add the next elimination to your current diet. Infants may be sensitive to more than one item so eliminating one while adding back another can cause more confusion. For example, baby is allergic to dairy and soy. You remove dairy but still experience symptoms several weeks later and decide to cut soy and bring dairy back. Unfortunately, you will continue to see symptoms because both culprits haven’t been removed together. Once you have reached baseline (little to no symptoms) then you can determine if you’d like to trial reintroduction.
If you are unsure about if/when you should eliminate another food, feel free to email us and ask! We would love to help you work through this process as each situation is different.
Execution: Mass Removal
Removing many or all allergenic food items at once is also known as an elimination diet or total elimination diet (TED). There are two strategies that seem to work well for mothers here. One: top infant allergenic food removal altogether. Two: removal of everything aside from a few “safes”. Mothers can decide which route to take based on preference. Option one allows for many more food options while option two is much more controlled. Many nursing moms appreciate option two because it takes out a lot of the guesswork and may return baby to symptom-free faster (because there is less room for accidental allergen ingestion).
Total elimination diets are difficult at best and not recommended long-term. Once baby has reached baseline mom should start carefully adding foods back into her diet to prevent malnutrition. Choosing the “safes” can be difficult as well. Generally, ensuring there is a healthy protein, carbohydrate, and fat is absolutely essential. Please work with your medical professional when making these dietary decisions.
Top Infant Food Allergies/Intolerances
More research is needed in this area. What we know is that infant food allergies do not necessarily match the typical “top 8” recognized by the FDA (number will vary based on country). This is because the top 8 is calculated based on entire population and many infant food allergies are outgrown in later years. For example, corn is a common parent-reported infant allergy which is often outgrown . If most people are only allergic to corn in their first year of life they will not be tabulated as nearly as often and corn doesn’t make the top list.
This may also vary based on symptoms. Check out our article on different types of IgE and non-IgE allergies to see if your baby’s symptoms may help point you towards specific targets.
Cow’s Milk Protein
*It is important to know that any food can cause a reaction. This list is the most common allergies based on research  but you may find that your child doesn’t fit this list.
Breastfeeding and infant food allergies deserve more than a cookie-cutter response. Every situation is different and should be treated as such. Work with your medical team, keep a food log, and reach out to us for additional support through the process. You are doing an amazing job, mama!
Luccioli, Stefano, et al. "Maternally reported food allergies and other food-related health problems in infants: characteristics and associated factors." Pediatrics 122.Supplement 2 (2008): S105-S112.
Zurzolo, Giovanni A., et al. "Hidden allergens in foods and implications for labelling and clinical care of food allergic patients." Current allergy and asthma reports 12.4 (2012): 292-296.
Zeiger, Robert S., and Susan Heller. "The development and prediction of atopy in high-risk children: follow-up at age seven years in a prospective randomized study of combined maternal and infant food allergen avoidance." Journal of Allergy and Clinical Immunology 95.6 (1995): 1179-1190.
Check each linked Free to Feed articles for more scientific references!