What are the presentation and diagnosis of cow's milk (CM) allergy in neonates?

From the Guidelines

Cow milk allergy in neonates should be diagnosed through a combination of clinical history, physical examination, and elimination-challenge testing, with a trial of a maternal cow’s milk–free diet for 1-2 weeks, followed by rechallenge, as recommended by the most recent guidelines 1.

Presentation of Cow's Milk Allergy

The presentation of cow's milk allergy in neonates can vary, but common signs include:

• Skin: Hives, eczema, swelling
• Gastrointestinal: Vomiting, diarrhea, abdominal pain, bloody stools
• Respiratory: Wheezing, coughing, runny nose These symptoms typically occur within minutes to hours after ingestion of cow's milk.

Diagnosis of Cow's Milk Allergy

Diagnosis is based on:

1. Detailed history of symptoms and their relation to milk intake
2. Physical exam to assess for signs of allergy
3. Elimination diet: Remove all cow's milk from diet for 1-2 weeks, as recommended by 1
4. Challenge test: Reintroduce cow's milk under medical supervision to confirm the diagnosis Additional diagnostic tools may include:

• Skin prick tests
• Blood tests for milk-specific IgE antibodies
• Oral food challenge (gold standard, but risky in severe cases)

Management of Cow's Milk Allergy

Management involves strict avoidance of cow's milk and dairy products. For breastfed infants, mothers should eliminate dairy from their diet, as suggested by 1. Formula-fed infants should be switched to extensively hydrolyzed or amino acid-based formulas, as recommended by 1. It's crucial to ensure adequate nutrition, especially calcium and vitamin D intake. Consult a pediatric allergist or dietitian for proper guidance on diet and supplementation. This approach is recommended because cow milk allergy is an immune-mediated reaction to milk proteins, and early diagnosis and management are essential to prevent potentially severe reactions and ensure proper growth and development in neonates 1.

From the Research

Presentation of Cow's Milk Allergy in Neonates

• The signs and symptoms of cow's milk allergy (CMA) in neonates are nonspecific and may be difficult to objectify 2.
• Symptoms of CMA can be wide-ranging and depend on the mechanism involved, including immunoglobulin E (IgE)-mediated, non-IgE-mediated, and mixed mechanisms of food allergy 3.
• Common manifestations of CMA in infants include food protein-induced allergic proctocolitis (FPIAP), food protein-induced enterocolitis syndrome, food protein-induced enteropathy, and Heiner syndrome (pulmonary hemosiderosis) 3.
• FPIAP is commonly seen in healthy, full-term infants who present with rectal bleeding and are otherwise well-appearing 3.

Diagnosis of Cow's Milk Allergy in Neonates

• The diagnosis of CMA in infants and young children remains a challenge because many of the presenting symptoms are similar to those experienced in other diagnoses 4.
• A correct diagnosis of CMA is pivotal, and the only reliable way to diagnose CMA is by double-blind, placebo-controlled challenge (DBPCFC) or an oral food challenge (OFC) under medical supervision 2, 4.
• Elimination and reintroduction of cow's milk and its derivatives is essential for diagnosing CMA as well as inducing tolerance to CM 4.
• A period of reintroduction of cow's milk resulting in re-emergence of symptoms in stable asymptomatic infants is an excellent diagnostic tool to confirm a cow's milk allergy 3.
• The Cow's Milk Symptom Score (CoMiSS) is an awareness tool for health care professionals to better recognize symptoms caused by the ingestion of cow's milk, but still needs validation 5.