What is the management algorithm for cow milk protein allergy?

Management Algorithm for Cow's Milk Protein Allergy

Initial Diagnosis and Assessment

The cornerstone of cow's milk protein allergy (CMPA) management is strict avoidance of all cow's milk proteins, with the specific approach determined by feeding method and symptom severity. 1

Diagnostic Approach

• Clinical diagnosis is based on symptom response to elimination diet followed by oral food challenge, as skin prick testing and specific IgE levels are not useful for non-IgE mediated gastrointestinal manifestations 2
• For patients with only gastrointestinal manifestations, sigmoidoscopy and rectal biopsy may be considered as an alternative diagnostic approach 2
• A symptom-based scoring system is useful when symptoms involve multiple organ systems, as no single symptom is specific for CMPA 3

Treatment Algorithm by Feeding Method

For Breastfed Infants

Continue breastfeeding with complete maternal elimination of all cow's milk proteins from the diet. 4, 5

• The mother must eliminate all sources including milk, cheese, yogurt, butter, and hidden sources in processed foods 5
• Symptom improvement typically occurs within 1-2 weeks, though it may take up to 4 weeks depending on the type of allergic manifestation 5
• Provide calcium supplementation and nutritional counseling to maintain maternal health during dietary restriction 5
• If symptoms persist after 2 weeks of strict maternal elimination, consult an allergy specialist 5

Common pitfall: Incomplete elimination of hidden dairy sources in processed foods is the most frequent cause of treatment failure in breastfed infants 4

For Formula-Fed Infants

Use extensively hydrolyzed formula (eHF) as first-line treatment for most cases of CMPA. 5, 6, 2

Step 1: Extensively Hydrolyzed Formula (eHF)

• Cow's milk protein-based eHF (whey or casein) is the recommended first choice 7, 6
• Rice hydrolyzed formulas (rHF) are also well-tolerated alternatives 7
• Monitor for symptom resolution over 2-4 weeks 4

Step 2: Amino Acid-Based Formula (AAF)

Switch to amino acid-based formula if:

• Symptoms are life-threatening or severe at presentation 5, 6
• No improvement after 2 weeks of eHF 4, 6
• Infant has reactions to eHF 5

Step 3: Persistent Symptoms Despite AAF

If mucus and blood in stool persist despite appropriate formula:

• Ensure complete elimination of all dairy products (check for cross-contamination) 4
• Monitor weight gain closely as a critical outcome measure 4
• Consider referral to pediatric gastroenterology for endoscopy with biopsy if symptoms persist beyond 2-4 weeks 4

Formulas to AVOID

Do not use the following as alternatives:

• Soy formula is NOT recommended as first-line due to 10-15% cross-reactivity risk, though it may be considered in infants over 6 months of age 5, 2, 3
• Goat's milk and sheep's milk are unsuitable due to high protein homology with cow's milk 5
• Partially hydrolyzed formulas are insufficient for treatment (only for prevention in at-risk infants) 1

Prevention in At-Risk Infants

For infants with family history of atopy who cannot be exclusively breastfed:

• Use partially or extensively hydrolyzed formulas instead of standard cow's milk formula 1
• Breastfeeding for at least 4 months prevents or delays occurrence of atopic dermatitis, CMPA, and wheezing 1
• No evidence supports delaying complementary foods beyond 4-6 months of age 1

Emergency Preparedness

All patients with CMPA must have:

• Intramuscular epinephrine available for treatment of anaphylaxis after inadvertent exposures 1
• Emergency action plan and education on allergen avoidance 1

Reintroduction and Long-term Management

Attempt reintroduction under medical supervision after 6-12 months of elimination, as most infants outgrow CMPA 5, 2

• Timing should be individualized based on initial symptom severity 5
• Periodic re-evaluation is essential since elimination diet is only for a limited period 2

Oral Immunotherapy (OIT) Considerations

OIT is NOT recommended for routine clinical practice in CMPA management. 1

• The 2014 NIAID guidelines and 2021 global consensus recommend strict avoidance as the standard of care 1
• EAACI guidelines restrict OIT to research centers with substantial experience due to safety concerns 1
• While OIT may increase reaction threshold in children, concerns about anaphylaxis rates and long-term outcomes remain 1
• Uncontrolled asthma is an absolute contraindication to OIT 1

Monitoring for Treatment Failure

Red flags requiring further evaluation:

• Poor weight gain or growth failure 4
• Systemic illness signs (fever, lethargy) 4
• Symptoms persisting beyond 2-4 weeks of appropriate elimination 4, 5