Very early onset perinatal constipation: Can it be cow’s milk protein allergy?

Abstract

Delayed passage of meconium or constipation during the perinatal period is traditionally regarded as a signal to initiate further work up to evaluate for serious diagnoses such as Hirschsprung’s disease (HD), meconium ileus due to Cystic Fibrosis, etc. The diagnosis of HD particularly warrants invasive testing to confirm the diagnosis, such as anorectal manometry or rectal suction biopsy. What if there was another etiology of perinatal constipation, that is far lesser known? Cow’s milk protein allergy (CMPA) is often diagnosed in infants within the first few weeks of life, however, there are studies that show that the CMPA allergen can be passed from mother to an infant in-utero, therefore allowing symptoms to show as early as day one of life. The presentation is more atypical, with perinatal constipation rather than with bloody stools, diarrhea, and vomiting. The diagnosis and management would be avoidance of cow's milk protein within the diet, with results and symptom improvement in patients immediately. Therefore, we discuss whether an alternative pathway to address perinatal constipation should be further discussed and implemented to potentially avoid invasive techniques in patients. This entails first ruling out CMPA with safe, noninvasive techniques with diet modification, and if unsuccessful, then moving forward with further diagnostic modalities.

Keywords: Delayed passage of meconium; Perinatal constipation; Cow's milk protein allergy; In-utero; Alternate pathway; Hirschsprung’s disease

Core Tip: Cow’s milk protein allergy (CMPA) is a far lesser known cause of perinatal constipation compared to more frequently considered diagnoses such as Hirschsprung’s, Cystic fibrosis related meconium ileus, etc. The presentation during the perinatal period is considered atypical caused by a non-immunoglobulin E (IgE) mechanism as opposed to the typical presentation caused by an IgE-mediated mechanism. The likelihood of CMPA is significant in the perinatal period, therefore should be considered more often. Here we discuss an alternative pathway for the workup of perinatal constipation focusing on CMPA as an etiology. The use of this pathway can avoid invasive tests among patients.