What is the management plan for a child diagnosed with a cow's milk allergy?

Management of Cow's Milk Allergy in Children

Strict elimination of all cow's milk protein from the child's diet is the cornerstone of management, with extensively hydrolyzed formulas (casein or whey) as the first-line substitute for infants who cannot be exclusively breastfed. 1

Immediate Dietary Management

For Formula-Fed Infants

• Replace standard cow's milk formula with extensively hydrolyzed casein or whey formulas as the first-line therapeutic option 1
• Amino acid-based formulas are reserved for severe cases or when extensively hydrolyzed formulas are not tolerated 1
• Soy formula is NOT recommended as a preventive or therapeutic strategy, particularly in infants under 6 months, due to cross-reactivity risk 2
• Partially hydrolyzed formulas are insufficient for treatment of diagnosed cow's milk allergy 2

For Breastfed Infants

• The breastfeeding mother must eliminate all cow's milk protein from her own diet while continuing to breastfeed 1, 3
• Exclusive breastfeeding should continue for at least 4-6 months when possible 2
• Maternal dietary restriction during pregnancy is NOT recommended and provides no benefit 2, 4

Emergency Preparedness Based on Reaction Type

IgE-Mediated Allergy (Immediate Reactions)

• Prescribe epinephrine autoinjector for all children with IgE-mediated cow's milk allergy due to risk of anaphylaxis 1
• Prescribe antihistamines for mild cutaneous reactions 1
• Provide written emergency action plan detailing symptoms and treatment steps 2
• Asthma is a critical risk factor for severe reactions and fatal anaphylaxis—these children require heightened vigilance 2

Non-IgE-Mediated Allergy (Delayed Reactions)

• Epinephrine is typically not required for conditions like allergic proctocolitis or food protein-induced enteropathy 1
• Management focuses on dietary elimination and monitoring for resolution of symptoms (bloody stools, chronic diarrhea, failure to thrive) 1

Nutritional Monitoring

• Mandatory nutritional consultation when implementing cow's milk elimination, especially in children requiring multiple food avoidances 2
• Monitor for calcium deficiency, vitamin D deficiency, and growth parameters at regular intervals 4
• Excessively restrictive diets without documented clinical allergy can cause serious harm including poor growth, hypovitaminosis, and kwashiorkor 4

Education and Label Reading

• Train parents to read food labels meticulously—cow's milk protein appears in many forms: casein, whey, lactalbumin, lactoglobulin 2, 5
• All eight major allergens (including milk) must be clearly labeled on food products per FALCPA guidelines 6
• Precautionary labeling ("may contain traces") is voluntary and unregulated—advise strict avoidance when present 6
• Coordinate with schools and childcare centers to ensure safe environment and emergency preparedness 2

Reintroduction Strategy and Natural History

Timeline for Tolerance Development

• Most children with non-IgE-mediated cow's milk allergy develop tolerance by 2-3 years of age 1
• The majority with IgE-mediated allergy regain tolerance within the first 5 years 1
• High initial specific IgE levels correlate with lower rates of tolerance development 6

Graded Milk Ladder Approach

• Once tolerance begins developing, introduce baked milk products first (extensively heated milk in baked goods), as these are tolerated earlier than fresh milk 7
• Progress through a structured 12-step milk ladder at home, starting with extensively baked products and gradually advancing to less-heated forms 7
• A supervised single low-dose exposure to milk at diagnosis (ED05 dose) significantly accelerates progress on the milk ladder and gives parents confidence to proceed 7
• Supervised oral food challenges should be performed when clinical history or testing suggests possible tolerance development 1, 5

Oral Immunotherapy: Current Status

• Oral immunotherapy (OIT) is NOT recommended for routine clinical practice for cow's milk allergy at this time 2, 5
• The 2014 NIAID guidelines recommend absolute avoidance and emergency preparedness as standard care 2
• European guidelines restrict immunotherapy to research centers with substantial experience due to safety concerns about local and systemic anaphylactic reactions 2
• OIT may increase the threshold of reaction in select cases but requires careful monitoring and is associated with high rates of adverse reactions 2
• Uncontrolled asthma is an absolute contraindication to OIT 2

Critical Pitfalls to Avoid

• Do NOT implement dietary restrictions based solely on positive skin prick test or specific IgE without clinical symptoms—sensitization does not equal allergy 2, 4
• Do NOT perform allergy testing in asymptomatic infants, even with family history, as tests are poorly specific and lead to unnecessary restrictions 4
• Do NOT delay introduction of solid foods beyond 4-6 months—this provides no allergy prevention benefit and can cause nutritional deficits 2
• Do NOT confuse cow's milk allergy (immune-mediated) with lactose intolerance (enzyme deficiency)—these require completely different management 6, 1
• Do NOT use partially hydrolyzed formulas for treatment of diagnosed allergy—only extensively hydrolyzed or amino acid-based formulas are appropriate 1

Testing Indications in Young Children

Test children under 5 years with moderate-to-severe atopic dermatitis for cow's milk allergy ONLY if: 2, 4

• Eczema persists despite optimized topical therapy and skin care management, OR
• There is reliable history of immediate reaction after milk ingestion

Up to 37% of children under 5 with moderate-to-severe atopic dermatitis have IgE-mediated food allergy, but optimize skin care first before attributing symptoms to food allergy 2, 4