From the Guidelines
The management of cow's milk protein allergy (CMPA) in infants primarily involves the use of hypoallergenic formula in formula-fed infants or infants who can no longer breast-feed, as recommended by the international consensus guidelines 1.
Key Considerations
- For breastfed infants, mothers should remove all dairy products from their own diet, as milk proteins pass through breast milk.
- For formula-fed babies, switching to an extensively hydrolyzed formula (such as Nutramigen, Alimentum, or Pregestimil) where proteins are broken down into smaller, less allergenic peptides is recommended.
- In severe cases where babies don't respond to hydrolyzed formulas, amino acid-based formulas (like Neocate or EleCare) may be necessary.
Elimination Diet
- The elimination diet should be maintained for at least 2-4 weeks to observe improvement in symptoms, which typically include irritability, vomiting, diarrhea, blood in stool, eczema, or poor weight gain.
- Before the challenge, suspected foods should be eliminated from the diet for 2 to 8 weeks, depending on the type of food-induced allergic reaction being examined, as suggested by the NIAID-sponsored 2010 guidelines 1.
Reintroduction and Follow-up
- Most infants outgrow this intolerance by age 3-5, so reintroduction can be attempted gradually after 6-12 months of elimination, preferably under medical supervision.
- It's essential to ensure adequate nutrition during elimination diets, particularly calcium intake for breastfeeding mothers, and to provide comprehensive counseling regarding food allergy, including food avoidance, label reading, and recognition of the signs and symptoms of anaphylaxis 1.
Important Considerations
- Food allergy diagnosis requires documentation of a clinical history of a food allergic reaction, and testing includes a food-specific IgE test and/or skin prick tests.
- All food-allergic patients should be prescribed antihistamines (mild reactions) and an epinephrine autoinjector device (severe reactions).
From the Research
Management of Cow's Milk Protein Allergy (CMPA) in Infants
- The management of CMPA in infants typically involves the use of hypoallergenic formulas, such as extensively hydrolyzed formulas or amino acid formulas 2, 3, 4.
- The selection of a formula depends on the allergy syndrome to be treated, with extensively hydrolyzed formula recommended as first choice for infants under 6 months of age with non-anaphylactic immediate cows milk allergy 3.
- Amino acid formula is recommended as first choice in anaphylaxis and eosinophilic oesophagitis 3.
- Soy formula is recommended as first choice for infants over 6 months of age with immediate food reactions, and for those with gastrointestinal symptoms or atopic dermatitis in the absence of failure to thrive 3.
- If treatment with the initial formula is not successful, use of an alternative formula is recommended 3.
Dietary Considerations
- Infants with CMPA should be maintained on an elimination diet until they are between 9-12 months or at least for 6 months 4.
- It is essential to ensure adequate protein and calcium intake in the diet of infants with CMPA, as low calcium intake is associated with reduced bone formation 5.
- Unnecessary elimination of milk and its products, which are an important part of nutrition, should be prevented, and nutrient deficiencies and growth status should be monitored by dietitians 5.
Diagnosis and Monitoring
- A thorough history and careful clinical examination are necessary to suspect CMPA, and skin prick tests and serum specific IgE are only indicative of sensitization to CMP 4.
- A double-blind placebo-controlled challenge is considered the gold standard in diagnosis, but in practice, only an open challenge is performed 4.
- The patient with suspected pathology will follow a cow's milk free diet for 2-4 weeks, and if the allergy is present, clinical manifestations will disappear 4.