Cow’s Milk Protein Allergy

CMA is the most common childhood food allergy in the developed world. This chart on A4Medicine covers the management of children suspected to suffer from CMA. It provides a practical approach to addressing suspected CMA and provides guidance based on current guidelines. Differential diagnosis is cited to help clinicians consider and exclude other conditions. A guide on milk free diet can be found on the BDA website. is another useful website which can be helpful for parents.

Immune mediated allergic response to proteins in milk Ige Mediated -Reactions are acute Frequently have rapid onset From minutes- up to 2 hrs after allergen ingestion   Non-IgE mediated Generally delayed Non-acute Type 4 type delayed hypersensitivity Up to 48 hrs and up to
 1 week after consuming cow’s milk protein  Mixed IgE and Non-IgE Mixed reponses

CMA ( Cow’s milk allergy ) is a complex disorder Numerous milk proteins have been implicated in allergic response Milk contains casein and whey fractions – each of which have 5 protein components – patients can be sensitized to one or more components within either group  Most common childhood food allergy in developed world
○ second to egg allergy Highest prevalence in 1st year- seen less commonly in older children and adults ( often outgrown ) Affects 2-7.5 % children in 1st year of life ( formula fed ) Parents perceive CMA in their children far more than can be proven by oral food challenge Exclusively breast fed infants may also develop clinically significant CMA via dairy protein transfer into human breast milk

Risk factors-Difficult to predict which child will develop a food allergy Some recognized risk factors are
○ associated atopic comorbidities as asthma and eczema
○ earlier the atopic dermatitis starts and more severe it is -higher the risk of food allergy
○ frequency of severe reactions higher in children with asthma particularly if its poorly controlled Family history of atopy – allergic predisposition inherited not specific allergies Infants exclusively breast feeding in first 4-6 months are less likely to develop CMA than babies who are formula fed

Investigations-Allergy sensitization – is presence of IgE specific antibodies to a specific food allergen
 For suspected IgE mediated
♦ Skin prick test
♦ Specific immunoglobulin E in the blood (spIgE ) formerly called RAST test ( suitable in primary care )
 If allergy tests fail to confirm the history
♦ double blind placebo controlled food challenge 
( can be expensive and time consuming ) OR
♦ open oral food challenge ( easier and cheaper )
 Non IgE mediated –> strict elimination diet
♦ if symptoms do not improve within 2-8 weeks CMA is unlikely
♦ reintroduce milk if no improvement
 Breast fed –> cow’s milk protein can be excluded from mother diet ( with help from dietitian )

Differential diagnosis-Food intolerance
○ symptoms of lactose intolerance rarely develop before 6 yrs of age but acquired or 2ary lactose intolerance can happen if intestine is damaged
 Allergic reactions to other foods eg
○ hen’s egg
○ soya
○ wheat
○ animal dander
○ moulds , dust
 Anatomical abnormalities eg Meckels diverticulum
 GI conditions as
○ Crohns
○ Coeliac
○ Constipation
○ Gastroenteritis
○ Ulcerative colitis
 Pancreatic insufficiency

management – Non-IgE mediated-Consider referral to secondary care – same indications as for IgE mediated If likely delay in getting advice- contact paediatrician dietitian
○ prescribe hypoallergenic formula in interim
 Referral not indicated
○ pediatric dietitian advice
○ elimination of cow’s milk from diet for 2-6 weeks
○ reintroduction to prove its cause of symptoms 
( not sure if mum’s would agree to that )
 Exclusively breast fed
○ mother to exclude cow’s milk protein from diet
○ 1000 mg calcium and 10 mcgm Vit D for mother
 Formula fed or Mixed fed
○ replace cow’s milk with hypoallergenic infant formula or amino acid formula ( d/w dietitian )
 Weaned infants and older children
○ exclude cow’s milk from child’s diet
○ adv from dietitian and referral
○ If no improvement – refer to exclude other allergies ( eg Soya )
○ If symptoms improve – reintroduce cow milk ( to confirm diagnosis )
 Advice and information – see bottom right BDA fact-sheet milk free diet
  IgE mediated -Refer paediatrics for skin-prick or spIgE testing if

○ faltering growth in combination with one or more GI symptoms
 ( When to suspect Table in chart food allergy in under 19s )
○ one or more acute systemic reactions
○ one or more severe delayed reactions 
○ confirmed IgE mediated food allergy + asthma
○ sig atopic eczema and multiple or cross-reactive food allergies suspected
○ persistent parental suspicion despite a lack of supporting history
○ clinical suspicion multiple food allergies
 Refer all other children for skin prick and or specific IgE blood tests
( This means CMA is suspected but they do not have above mentioned features ) Provide supporting information

Referral-If referral not indicated , children with non-IgE mediated allergy can be managed in Primary care with input from paediatric dietitian In addition to above
○ nutritional counseling and regular monitoring of growth
○ re-evaluation to assess tolerance to cow’s milk protein
 ♦ every 6-12 months – to see if they have developed tolerance
 ♦ can be done at home provided there are no indications or referral to secondary care
 ♦ start with baked milk products ( eg muffins , cakes and malted biscuits ) –> less allergenic
 MAP milk ladder – available from
○ if symptoms return – elimination diet should be continued and review in 6-12 months
○ be guided by a paediatric dietitian

Extensively hydrolysed formulas (eHFs ) whey and casein based formulas that are tolerated by majority of infants with CMA
 Amimentum- from birth Althera – suitable from birth Aptamil Pepti 1 – from birth Aptamil Pepti 2 – from 6 months Cow and Gate Pepti -Junior- from birth Nutramigen Lipil 1- from birth Nutramigen Lipil 2- from 6 months Pregestimil lipil – from birth

Amino Acid formulas ( AAFs)- an alternative for children who cannot tolerate eHFs or those with severe symptoms

 Alfamino – from birth Neocate LCP from birth Neocate active – from 1 yr of age Neocate advance – from 1 yr of age who cannot eat any other food Nutraminigen Pluramino