How to manage cow's milk intolerance?

Management of Cow's Milk Intolerance

The cornerstone of managing cow's milk intolerance is strict dietary elimination of all cow's milk proteins, with the specific approach depending on whether the child is breastfed or formula-fed, and whether the reaction is IgE-mediated (allergy) or non-immunologic (intolerance). 1

Critical First Step: Distinguish Allergy from Intolerance

Before proceeding with management, you must differentiate between cow's milk protein allergy (CMPA) and lactose intolerance, as they require completely different approaches:

• Cow's milk protein allergy is an immune-mediated reaction to milk proteins that can be IgE-mediated (rapid onset within minutes to hours) or non-IgE-mediated (delayed, chronic gastrointestinal symptoms) 1, 2
• Lactose intolerance is a non-immunologic reaction due to inability to digest the sugar lactose, causing abdominal pain and diarrhea without immune involvement 1, 3
• These conditions present with overlapping symptoms but lactose intolerance is extremely rare in infants and young children, whereas CMPA affects 2-3% of infants 4, 5

Diagnostic Approach

For Suspected CMPA (Not Lactose Intolerance)

Eliminate cow's milk protein from the diet for 2-8 weeks and document symptom improvement; if improvement occurs, perform a supervised oral challenge to confirm the diagnosis. 1

• In breastfed infants: Implement a maternal elimination diet excluding at minimum cow's milk and egg for 2-4 weeks 1
• In formula-fed infants: Switch to extensively hydrolyzed formula or amino acid-based formula 1
• Document significant improvements during the elimination period 1
• If symptoms resolve with elimination, proceed to oral food challenge under medical supervision to confirm diagnosis 1

Challenge Protocol

The oral food challenge should follow this structure 1:

• Begin with a dose lower than expected to cause reaction
• Gradually increase dose while monitoring for allergic symptoms
• Continue until cumulative dose equals a standard age-appropriate portion
• Have treatment for anaphylaxis immediately available
• Challenge must be supervised by experienced medical personnel 1

Management by Feeding Type

Breastfed Infants

Continue breastfeeding while the mother eliminates all cow's milk and egg from her diet. 1

• Exclusive breastfeeding until 4-6 months is recommended even with family history of atopic disease 1
• Small amounts of cow's milk protein in breast milk may induce tolerance rather than sensitization 4
• Maternal diet restriction during pregnancy is NOT recommended for prevention 1
• If symptoms persist despite maternal elimination, consider switching to extensively hydrolyzed or amino acid-based formula 1

Formula-Fed Infants

Use extensively hydrolyzed formula (eHF) or amino acid-based formula as first-line replacement. 1

• Extensively hydrolyzed formulas are appropriate for most cases 1
• Amino acid-based formulas may be more efficient in severe cases or when eHF fails 1, 2
• Do NOT use soy formula as a preventive strategy or first-line substitute, as 41-54% develop reactions to other foods including soy 1, 4
• Avoid partially hydrolyzed formulas for treatment (these are for prevention only) 1

Thickened Feedings Consideration

If reflux symptoms coexist, thickened feedings may help 1:

• Add up to 1 tablespoon rice cereal per ounce of hypoallergenic formula 1
• WARNING: Do not use thickening agents in preterm infants due to necrotizing enterocolitis risk 1
• Be aware this increases caloric density from 20 to 34 kcal/oz, risking excessive energy intake 1

Nutritional Management

Ensure carefully planned allergen-free diets provide sufficient nutrients for healthy growth. 1

• Work with families to recognize and avoid all food-allergen ingredients 1
• Products with precautionary labeling ("may contain traces") should be avoided due to contamination risk 1
• Monitor growth parameters regularly to prevent malnutrition 2

Common Pitfalls to Avoid

• Do NOT order food antigen-specific IgG panels - these are not evidence-based and lead to overdiagnosis 2
• Do NOT confuse lactose intolerance with CMPA - lactose intolerance testing is only indicated if the patient consumes >280 ml milk daily and is rarely relevant in infants 6, 3
• Do NOT restrict maternal diet during pregnancy for prevention 1
• Do NOT use soy formula as a substitute without documented tolerance 1
• Do NOT continue elimination diet without confirmed diagnosis via challenge 1

Prognosis and Follow-Up

Most children develop tolerance to cow's milk, with recovery rates of 45-56% at one year, 60-77% at two years, and 71-87% at three years. 4

• Decreasing food-specific IgE levels often mark onset of tolerance 1
• High initial specific IgE levels, additional atopic disease, or multiple food allergies predict persistence 1, 4
• Plan periodic challenges to assess tolerance development 1
• Monitor for development of other food allergies (egg, soy, peanut) which occur in 41-54% 4
• Up to 80% may develop environmental inhalant allergies before puberty 4

Emergency Preparedness

For IgE-mediated CMPA with risk of anaphylaxis 1:

• Prescribe epinephrine auto-injector (EpiPen Jr 0.15 mg for <25 kg, EpiPen 0.3 mg for ≥25 kg)
• Educate on recognizing anaphylaxis symptoms: mouth/throat itching and swelling, hives, vomiting, diarrhea, shortness of breath, weak pulse, dizziness 1
• Emphasize that antihistamines and asthma inhalers cannot be depended upon in anaphylaxis 1
• Allow self-carry and self-administration of epinephrine 1