The many faces of milk problems

“There is nothing magical that happens in your gut that says, ‘oh, now you’re ready for cow’s milk.’ — Dr. Farah Khan

Milk has a special talent for creating chaos in clinic. One day it’s mucousy stools and a terrifying diaper photo, the next it’s hives after yogurt, delayed vomiting with lethargy, or a family that’s been dairy-free for years with no improvement in eczema. On this episode, Dr. Mariam Hanna is joined by pediatric allergist and clinical immunologist Dr. Farah Khan to walk through the many ways “milk problems” show up — and how allergists can avoid overdiagnosis, unnecessary testing, and prolonged elimination diets that may do more harm than good.

On this episode:

• Why allergic proctocolitis (cow’s milk protein intolerance) is often overdiagnosed
• When skin testing and IgE testing are useful 
• Understanding the difference in lactose intolerance 
• How baked milk can be used to improve quality of life in IgE-mediated milk allergy
• What makes FPIES to milk tricky, including earlier-than-expected reactions
• Why dairy elimination for eczema or EOE needs caution and frequent reassessment

Across each of these scenarios, Dr. Khan returns to the same principle: eliminating dairy should never be a one-and-done decision. Revisiting the diagnosis, retrying thoughtfully, and weighing quality of life alongside risk are essential — especially when prolonged avoidance can set the stage for the very allergy clinicians are trying to prevent.

Visit the Canadian Society of Allergy and Clinical Immunology

Find an allergist using our helpful tool

Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca

The Allergist is produced for CSACI by PodCraft Productions

Transcript

Dr. Mariam Hanna: 0:01

Hello, I'm Dr. Mariam Hanna and this is The Allergist, a show that separates myth from medicine, deciphering allergies and understanding the immune system. We have completely confused the world about our relationship with milk. We obsess over milk and bowel movements in babies, then break milk into many different formulas, fat contents, and sugar content, then enter anaphylactic allergies to milk, followed by just run-of-the-mill just bloating. Hey, it's just bloating, but that's different from those that get delayed vomiting syndromes and become lethargic. Oh, milk, you are so confusing. Milk is also a trigger for eosinophilic esophagitis in some patients and some things, honestly, to be determined. Look, we've tied it into so many different permutations that, frankly, it gets a little confusing and it's all milk. Need a confusing baby story for you? I got one. Little baby in practice the other day, mild atopic dermatitis. Mild atopic dermatitis and delayed protracted vomiting and lethargy to yogurt. I skin tested, but maybe I shouldn't have. Who knows? It's six millimeters. Big question. Now what? Ladder, strict avoidance for a year, retry in six months, and that's how it goes, right? Today, we're going to walk a windy path around the many faces of milk problems. We're not calling them all allergies because some are allergies and some are intolerances and some, who knows what you should call them, but we'll ask Dr. Khan about that too. But you need to help them navigate as they invariably come to the clinic because, hey, we deal with food allergies in our clinics every day. Allow me to introduce today's guest. Dr. Farah Khan is a pediatric allergist and clinical immunologist at Nationwide Children's Hospital. She initially worked in private practice for two years before making the dark leap back into hospital work by choice. Her clinical interests include food allergy and drug allergy. She also uses social media to provide general education around allergic conditions, which is why I thought today's topic and format would be just perfect for somebody like Dr. Khan to help us navigate through. Thank you, Dr. Khan, for joining us today and welcome to the podcast.

Dr. Farah Khan: 0:11

I feel like I'm being set up, Mariam.

Dr. Mariam Hanna: 0:13

Not at all. Let's get into it. All right, here we go. So we're going to start with the baby. Early infancy, some delayed lower GI, maybe plus or minus upper GI symptoms. So we're talking about usually a six-week-old that presents with mucusy stools, and eventually then they talk about a streak of blood in the stools. What's the diagnosis that they're asking us to exclude here, Dr. Khan?

Dr. Farah Khan: 0:17

So cow's milk protein intolerance or allergic proctocolitis or food protein-induced allergic proctocolitis, whatever you want to call it, yes.

Dr. Mariam Hanna: 0:19

Perfect. So that's the first thing is that it comes with three different titles, all referring to the same overall condition, which is inflammatory. How do we make this diagnosis?

Dr. Farah Khan: 0:21

So it is with what you said, like mucusy but blood-tinged, blood-streaked stools, right? But I think we're over-diagnosing this, to be quite frank and honest, because there's not like a lab test that you do, right, that's, oh, this is the diagnosis, and then the family can walk away with that. But then it starts to be other things, like my baby is spitting up more, and they're so fussy. We're dealing with colic, right? And it's other things that the baby is also dealing with, and then we package it up. So sometimes, I would say half the time, the baby never even had blood-tinged, blood-streaked blood in their stool, but they get stuck with this diagnosis.

Dr. Mariam Hanna: 0:24

To what end does a streak of blood indicate that we need to go down this? Does every blood streak mean that we should cast this diagnosis, if that's what we're looking for? Because I've looked at a lot of poop pictures in my career.

Dr. Farah Khan: 0:26

Yes, both in clinic and then also like family and like friends, right, that are like having babies and navigating this. So we've seen a lot of poop pictures, and I will say the disclaimer is I am also married to a pediatric GI doctor, so we have seen a lot of poop pictures. And it's just interesting, even from a GI perspective, when I talk to him or his colleagues and friends and things like that, I think we are over diagnosing it, right? So there was a blood-tinged streak. As long as the baby is healthy, growing, gaining weight, meeting milestones, like do we need to be aggressive in terms of like completely cutting it out the first couple of times that we saw blood-streaked, right? And I think it's very scary to see blood in the diaper, yes. I'm not discounting that, but I think giving, like what I end up telling parents that come to clinic and we talk about this is like, I have a little bit of a higher threshold. Like your baby is the cutest little thing I've seen. He's growing. He's doing really well. He's gaining weight. Like how aggressive do we need to be? And then those families, we can absolutely reintroduce cow's milk much sooner than most people think.

Dr. Mariam Hanna: 0:31

So I've heard about like happy and growing and gaining weight. You mentioned that initially as reasons as to why you maybe don't need to be strict in your removal of milk from the diet. Is that the same markers that we're using for not extending or expanding the things that we are removing from the diet?

Dr. Farah Khan: 0:33

Yeah, absolutely. I mean, people will go down like soy and corn and the data doesn't support it, right? Like the data is like after dairy, like you're going to get very small money back by eliminating like soy and corn and all these other things. But the thing that I always try to balance it with, which I think most of us are trying to do is quality of life, right? Unless you're a vegan, eliminating something like dairy is incredibly difficult. And you have a mom who's postpartum and going through physical, emotional, mental changes and trying to keep this tiny human alive. Like because moms, I don't know, something changes. Something happens in our brain when we have babies. And we're like, even if there is a like 0.1% chance that this is going to make my baby better, I'm going to do it. I'm going to do it. I'm going to be the mother. And we'll do it. And I think it's like balancing a bunch of that stuff. And I think sometimes I wish I was the primary person that people came into clinic and I was their primary encounter with this diagnosis and with these set of symptoms because the conversation that I would set up is, okay, like I wouldn't stress out about it. Yes, there was some blood tinged poops or maybe there was one diaper that was really bloody and stuff. But I don't know in your experience, but I've only had two babies in the almost, how long have I been doing this? I don't know, eight years since fellowship that have had like massive GI bleeding due to cow's milk protein intolerance. Most of them, the vast majority do beautifully.

Dr. Mariam Hanna: 0:39

Right. Right. So a lot of overdiagnosis. Let me just throw in skin testing and IGE testing for this just because it's our specialty. Would you do it or is there ever a role for it?

Dr. Farah Khan: 0:41

No, please. Even when parents ask, I'm like, that's not like everybody thinks like you're going to get referred to the allergist and have this magical testing. But I promise our testing is okay on a good day. Like it's a tool and it can be helpful, but it has to be interpreted so carefully. And the language that I use with parents is it's not even looking for the thing that I'm trying to diagnose. Like you're coming to me with an allergic proctocolitis diagnosis and the testing picks up on a completely different mechanism. You don't need it.

Dr. Mariam Hanna: 0:45

Don't do the testing. And then, so if they came to you, Dr. Kha n, would you tell them straight up, do the latter? Reintroduce it in mom's diet because cheese pizza and creamers and coffee are essential nutrition? Or like when it's time, give the baby yogurt and hope for the best?

Dr. Farah Khan: 0:48

Yeah. So every family is a little bit different. Every mom is a little bit different. And so I center that decision based off of what they feel the most comfortable with. I don't wait until they're a year of age. There is nothing magical that happens in your gut that says, oh, now you're ready for gal's milk. I think that is really old, outdated advice that I'm not even sure was entirely based in evidence. It's just something that we started doing and then it just stuck for decades. One, you don't need to eliminate until they're one year of age, right? So you can often introduce or attempt to reintroduce just after like a month, month and a half, month or two, like really short, short period of time for an elimination for their gut to maybe heal, get it together. And knock on wood, but most of the babies that I have, the moms reintroduce within a couple of months, they've done fabulous. So there's no reason to extend the misery unless they want to be dairy-free, right? But then also formula is really expensive, which I'm not going to get into with your like, you know, partially hydrolyzed or completely hydrolyzed formulas and balancing the financial cost of a diagnosis like this as well. And then getting them to understand like it's not, we're not harming our babies by trying to introduce. Even if you try and then there's a little bit of blood that comes up, then we just eliminate and we try again in a few weeks. So it's that kind of revisiting the diagnosis rather than just as your diagnosis, good luck in a year because what we have realized is we're trading one problem for another, right? Especially with kids who have moderate to severe eczema, they're getting set up for full-blown IgE-mediated cow's milk allergies. And I tell parents that I don't want to trade one problem for another. So we have to revisit this and continue talking about it.

Dr. Mariam Hanna: 0:56

A hundred percent. And I love that approach of try and retry again, one month off or a couple weeks, try again because you're trying not to trade diagnoses. So let's go on to the next milk allergy diagnosis, shall we? So what about the more immediate reactions in infancy? We have babies that try formula briefly at the first week of life. We have patients with eczema who show up at eight months old, first time trying yogurt and they get some hives and vomiting within minutes. Fairly instant, fairly classic story. Does skin testing or IgE testing help us risk stratify these guys? I'm trying to smell out these days the guys that are going to get better regardless of what I do versus the guys that are going to have the more stubborn course of milk allergy.

Dr. Farah Khan: 1:00

Yeah. So definitely the testing that we have plays a huge role, right? Because that's what we're going to trend over time to see whether or not things are being outgrown. I don't know if my approach has just gotten a little bit looser, a little bit lax a days ago. I don't know. Some allergists might be listening to this like she's completely cuckoo banana pants. But I use it like I don't like a number doesn't scare me, right? So just like a five millimeter wheel on milk skin testing versus 15. If the baby especially has eczema, like what does any of that mean, right? Like we have some data that's a little bit older from Hugh Samson's group and stuff, which I use as like a rule of thumb maybe, but I never let it be the thing that like drives the way that I make the decision on whether or not to when to introduce like baked milk or is this kid outgrowing. And even on the milk IgE testing, I think on the lab testing, like the higher the number, the more likely you are to have symptoms, but also what is that ratio with total IgE. And there are some infants where they have the yogurt, but the only symptoms they ever have are like hives, right? They don't have the vomiting. They don't have the angioedema. They don't have their wheezing and coughing. And I think about those kids differently. And then it doesn't matter to me what the testing is showing, right? I use it as a loose guide over time to figure out like are these numbers going down and am I ready to challenge this baby?

Dr. Mariam Hanna: 1:07

Loose guide, history trumps all, and you'll try in a lot. Okay, when should they start retrying in this condition? So we covered it in CMPI or proctocolitis. Who's going to start the ladder right away and who's going to wait to start the ladder?

Dr. Farah Khan: 1:10

How would that go? So I think the way that I talk to families about it is that most kids who have an unbaked milk allergy, they will tolerate baked, right? 70, 75, 80 percent of kids will tolerate baked. So that's where I start. And whether it's like a recipe that I give them at home just to start getting the baby used to the taste and texture, coming in for a food challenge once they're able to eat a muffin with us in clinic, I generally, unless they have had a concerning reaction to a baked milk product, I'm offering that because I think it really helps with quality of life. And we know that the data supports that most of these kids will do just fine. Now some of them will come in, fail miserably, right? They'll have h ives and need epinephrine. But then we know definitively, right? So even though we're provoking the reaction, I still think it's incredibly helpful because sometimes it's also helpful for parents to see an allergic reaction happen in an allergist's office. We are allergic reaction experts and we don't panic. We recognize symptoms and then treat and give them epinephrine. And I think that ends up being a really big learning experience for parents as well.

Dr. Mariam Hanna: 1:16

Great. Pass or reaction, regardless, is education and empowering to people. Okay, so let me give you a different presentation of milk problems. All right, here we go. I'm excited. In the appeal of trying allergens early, we do get patients that get delayed vomiting and lethargy. And it's something that's, I think, been brought out by the literature with early peanut introduction that we're seeing a lot more peanut FPIs. But certainly, you can also get milk FPIs. Baked milk can do delayed reactions. But then there's milk FPIs, which is delayed vomiting and lethargy. So we're often trying to differentiate those in our minds. When, if ever, should we be IgE testing? If the story is profuse protracted vomiting with lethargy, they're ash and grain color, they have no urticaria, are you IgE testing them because it's a priority allergen?

Dr. Farah Khan: 1:22

Not at the time of diagnosis, but if they have a history of eczema or like an egg allergy or peanut allergy, right, if they're atopic, then before introducing, I talk to family about risks, benefits, pros, cons of testing to help guide how are we going to do this, right? And I think the other tricky thing, aside from atypical FPIs, is that sometimes even if you just have the GI symptoms and the behavioural change and the lethargy and things like that, sometimes it doesn't take three hours or two hours, right? It's 45 minutes to an hour and you're like, oh crap.

Dr. Mariam Hanna: 1:24

Right? And so if it's 45 minutes to an hour, is that more IgE and presenting with GI-only symptoms? And then would you test?

Dr. Farah Khan: 1:26

I know, right? So I had not too long ago, like just a few months ago, I had a little baby, I think three or four months of age. They had just tried formula for the first time because they wanted to supplement with breast milk. And it was profuse vomiting that I typically hear described with FPIs reactions, but it was within 45 minutes to an hour, but no other symptoms, right? And I was like, oh. So then I do test because I think if the testing is negative, then it's super helpful, right? And then I can say, I can hang my hat on, no, this was probably FPIs. The testing was positive and then they had an accidental exposure and ended up did having some skin manifestations along with vomiting, so I felt more secure in the diagnosis. But that can be really tricky because FPIs may not be as delayed as we think sometimes.

Dr. Mariam Hanna: 1:31

Right. And then the management of FPIs seems to also be going through its own evolution for reintroduction. Can we talk about that a little bit? In that, like, how soon do you retry?

Dr. Farah Khan: 1:34

Yeah, I think the magic number varies depending on who you're talking to, right? That's the frustrating part, I think, about FPIs is that we still need more research, more data. Everybody does things a little bit differently. We have different, like, case reports and small cohorts that have been published, but nothing where you're like, okay, this is exactly what I'm going to do with every single patient. So I just want to normalize that. So if you're listening to this and you're like, yeah, I manage it differently depending on the patient. Yeah, same here. Like, how do you, if you have FPIs tick to unbaked milk, do you let them have baked milk? Mmm. Right? Like, exactly. You shrugged, but that's exactly my point, right? What is the downside of trying other than symptoms? Yes, but also could help improve quality of life, right? And a lot of kids will tolerate baked milk, so then we challenge them. And then for milk, it depends. If the family's really struggling after six to nine months and they're like, oh my God, we cannot keep doing this, and the patient, the kid, is also having issues with, weight gain and malnutrition, and we're just not doing well from a nutritional standpoint, then sometimes I will challenge before a year. So within six to nine months, sometimes I'll wait until a year. It's a little bit arbitrary. It's just what we've done. We don't know exactly when your gut gets it together and you outgrow the response. And then if it's something like avocado or sweet potato or something like that, I tell families generally most kids will outgrow by the time they're three. We can challenge before if you want that. It's fairly easier to avoid in relation to something like milk or egg. And then we have that conversation and then we go from there. And then even how you challenge them, right? It's changing.

Dr. Mariam Hanna: 1:44

I like how you're prompting your own concerns. Go ahead. Yes, how would you challenge them, Dr. Kahn? Tell me more.

Dr. Farah Khan: 1:47

Yeah. So it used to be like when I was in fellowship, we would want them to eat an entire serving. And it was like an eight-hour appointment. They would come in, they would get a CBC as a baseline, they would eat an entire serving, they would hang out all day. Even if they didn't have symptoms, they would get a post-CBC. Like it was just such a process. And now it's cool, I think, for parents to be like, you know what, we might be able to challenge this at home. And depending on their comfort level and the previous reaction, sometimes I'll just challenge to a third of the serving, right? Because most kids will, a third of a serving will provoke symptoms. Do I need to make them more miserable by giving them a full serving, right? So even that conversation has changed.

Dr. Mariam Hanna: 1:52

Such a confusing time. All right, we're going to move to something less stressful, but actually more common in the general population. And that is my favorite, lactose intolerance. Now, lactose intolerance is a bit of a problem because they come in for query milk allergies, so the referral is misleading. And then in my region, we've actually stopped doing breath tests altogether because it wasn't cost effective. So it's not covered. So help or harm to be continued because we're going to ask Dr. Khan that. So how do we test? Does everybody need to test?

Dr. Farah Khan: 1:56

So sometimes they do present to us instead of GI, right? Because everybody thinks it's a milk allergy. It's not. And the IgE testing is not helpful at all. There is absolutely no reason to do that. And that's what I tell families in very black and white terms. And then if the history is suggestive, because even within lactose intolerance, it is so heterogeneous, right? Some people cannot even have the splash of coffee creamer. And some people can have half a serving of ice cream before their gut is no thank you, right? And the breath test isn't going to tell you that. There's no testing that's going to tell you that, right? It's trial and error. So then it comes back to my point of I think we've gotten to a point where everybody just wants the testing to prove the diagnosis, and it's not. And I'm not saying that in a bad way, but sometimes it's to prove that my symptoms are real, right? And they're trying to justify it and explain it to family members or what have you. I do have lactose intolerance, even though your dietary habits and symptoms have long been telling you that. So I think a little bit comes from that piece of it, is just where we are with healthcare culture. So I don't necessarily breath test if they're really having, again, nutritional problems, growth issues. And then I'm also worried about do I need to screen this kid for EOE or celiac or something like that, then I'll send them to my GI counterparts. But otherwise, I get a really detailed history from them. And if they've done fine with baked milk, I'm like, great, keep it in your diet. If you can do like half of a serving of yogurt a week and that in your gut can handle it, great, let's carry on. So again, it's centering, I think, just normalizing it. Yes, you're having symptoms. Yes, I believe that you're like cramping and gassy and uncomfortable, and it's terrible. But also, I think you have figured it out and you don't need any more testing. I'm not always successful.

Dr. Mariam Hanna: 2:07

Validate and don't over-investigate. I'm going to take from that one. Okay. Can it be transient or resolve?

Dr. Farah Khan: 2:10

So in older people, it tends to be lifelong, right? It's permanent. You lose the ability to break down lactase. In younger kids, I've had a slew of kids recently where parents come in and swear up and down that the transition to cow's milk, even from cow's milk-based formula or breast milk, has just been really rough. The first three months, they have weird bowel habits, and we're all watching our babies' poops. I'm guilty of that, right? What color is this? How does it look, right? How many diapers have I changed? So I'm not blaming parents at all, but I'm shrugging a little bit here, right? It's probably more transient. And I always tell them their gut sometimes just needs a little bit of time to transition. Cow's milk is just—some people are just going to have a harder transition. And I think even normalizing that, not writing their symptoms off, right? I believe what they're saying to me, but if their kid can tolerate yogurt and cheese and sour cream and butter and have ice cream and not have the same issues, am I worried that they're harming their kid by not giving them straight-up cow's milk? No, absolutely not, right? And then that's what I say to them.

Dr. Mariam Hanna: 2:17

Fair enough. And probiotics? Any data on probiotics with lactose intolerance these days?

Dr. Farah Khan: 2:19

So maybe there have been some cohorts that have published data and have shown the probiotic has the lactase, and so if you take it, it helps to digest. But again, eat some yogurt or some fermented—

Dr. Mariam Hanna: 2:21

Yeah. Yeah. No, fair enough. Fair enough. We'll leave it be. I would be remiss if I didn't bring up the kids with query milk allergy where their eczema flares up and looks really worse when they have milk in their diet. This is their evidence for milk removal with eczema.

Dr. Farah Khan: 2:25

In a very small cohort of patients, a small number of patients will respond. And even them, like, they'll be able to tolerate heated forms or even less heated forms. Maybe it's just the straight milk, right? And I always, like, if I'm seeing them for this consultation, which I had three yesterday in clinic where they swore up and down. But thankfully, the children came in and their eczema was still wildly flaring despite being dairy-free for two years or six months. And I was like, okay, but if it was the milk, right? So sometimes just taking—because it's hard for parents too, right? Like, eczema is an insanely frustrating condition. Everybody's losing sleep over it. Their skin looks terrible. They're clawing at their skin. So sometimes they're just so in it that they forget the big picture. And so sometimes if they have eliminated for three months or six months and they're coming in to see me and their kid's eczema is flaring, I can just take a step back, right? That's easy for me to do, to be like, look, you took out dairy. You already did all the hard work. And then if they're thinking about it, sometimes that's the conversation I end up having more, right? Which is we're frustrated with the eczema. We're not getting sustained control. We're still having exacerbations. We want to eliminate dairy. I tell them very frankly, we don't want to trade one problem for another. I literally say those words to them and then talk to them about the risk of elimination, especially if the kid has moderate to severe eczema, right? You don't want to end up with a full-blown systemic allergy. For my parents that really push, I'll do like maybe a two- to four-week trial, and almost all of them come back into clinic and they're like, well, that didn't work. And I'm like, yeah, because the data is weak. But it has been the narrative in medicine for generations, right? This is not something that just came up in the last few years. This has been decades and how long does it take for change to take place in medicine? 52,000 years.

Dr. Mariam Hanna: 2:36

Yeah, good. Mine was more conservative. That's good. I'm going to cover one last one. There's more to cover, but I'm going to cover one last one. EOE, it is a condition that we as allergists are picking up a lot of these days on our screens. How often should we be counseling against about removal of milk from the diet or strict removal or like just reduction? Who benefits from it and how often should I be saying it because I'm worried about them flipping to IgE-mediated or the nutritional consequences? Or is all EOE going down that same path of stricture and needing dilatation? Yeah, okay, so in the last 30 seconds, I'll get you to review that. I think it's important because we've tied it now. I actually, funny enough, Dr. Khan, I keep wondering about the patients that are like, the kid was more mucousy and throat clearing when they had milk in their diet and I've previously dismissed that. And nowadays, I'm like, is that EOE? Anyway, okay, I'll let you tackle that a little bit.

Dr. Farah Khan: 2:41

I think this is also such an exciting time to be an allergist, right? We are learning so, so much and I think even with EOE, it's a baby diagnosis, right? It didn't get the ICD-10 code until, was it the 90s? So we're still learning a lot. We do know that a lot of kids who get diagnosed with EOE will respond to a cow's milk elimination diet, right? And then you can get them into histologic remission and then after the scope, you can talk about potentially getting in the latter, right? Get some heated forms in or get the straight dairy back in potentially, especially if we're having a lot of problems with nutrition and overall growth. But the way that I think about dairy elimination really sometimes depends on what my GI counterparts will find on scopes, right? So if they're like severely fibrotic and strictured and need dilutations, is the dietary elimination going to be where I start? Probably not. They probably need a little bit of help with medicine before we can try a dietary elimination, but I think quality of life ends up being really important in all of these conditions that we're managing. And when we're saying something like cut out dairy, oh my god, there are some serious ramifications for parents, family, caregivers, grandparents, and the kid itself, right? So if you're not diagnosing EOE until you're 12 and you have just had a regular North American diet and then I'm telling you to potentially eliminate dairy, like how long do you think that kid's going to do it, right? Maybe six weeks, eight weeks? And then they're going to come in and be like, I'm not doing this anymore. This is crazy. And you're crazy. And then I'm like, yeah, okay.

Dr. Mariam Hanna: 2:49

You're not crazy, Dr. Kahn. You were ambitious in taking on all these milk problems for today. All right. We're at that time where we're going to wrap up today's episode by asking Dr. Farah Kahn for her top three key messages to impart to patients and physicians and caregivers on today's topic, the many faces of milk problems is what I've dubbed it. Dr. Kahn, over to you.

Dr. Farah Khan: 2:52

Okay. Number one, if you are going to eliminate dairy, please revisit that frequently and often. It is not just you slap the diagnosis, do this and come back in a year. Come back in four weeks. Okay. Two to four weeks. Let's have a conversation again. Send me a message in MyChart. Number two, we are definitely over-diagnosing allergic proctocolitis and a lot of these babies that just have colic or fussiness, or they're just having a really hard time getting it together after coming out of mom's warm, comfortable womb. Just be mindful of not setting that baby up for another problem, which is a full-blown milk allergy. And number three, FPIs can sometimes present sooner than you think. And sometimes you do need to do skin testing. I think for primary care providers, if they're listening, if you're like, it started within an hour, I'm not really sure. Those are the kids that we definitely want to see in clinic. We will help tease that out for you. Don't just assume that it's FPIs and then actually it was IGE, and then they don't get an EpiPen and they don't have all the things that they need. So use us in your subspecialty clinic. Allergists are more than happy to see all these kids and patients.

Dr. Mariam Hanna: 2:59

Perfect. Thank you, Dr. Kahn, for joining us on today's episode of The Allergist.

Dr. Farah Khan: 3:01

Thank you for having me.

Dr. Mariam Hanna: 3:03

This podcast is brought to you by the Canadian Society of Allergy and Clinical Immunology and is produced in collaboration with PodCraft Productions. The opinions shared by our guests are their own and do not necessarily reflect the views of the CSACI. Please remember that this podcast is for informational purposes only and does not provide any individualized medical advice. For show notes and relevant links from today's discussion, visit csaci.ca. While you're there, check out the Find an Allergist tool to connect with a specialist near you. If you enjoyed this episode, we'd love your support. Subscribe wherever you get your podcasts, leave a review, and a five-star rating. It helps others find the show. And remember, when removing with any diet, break it and retry is all that we're asking. Thanks for listening. Sincerely, The Allergist.