What are the current guidelines for managing cow milk allergy in children?

Current Guidelines for Managing Cow's Milk Allergy in Children

For breastfed infants with cow's milk allergy, continue breastfeeding while the mother eliminates all cow's milk and dairy products from her diet; for formula-fed infants, use extensively hydrolyzed formula (eHF) as first-line treatment, reserving amino acid-based formula (AAF) for severe reactions or eHF failure. 1, 2

Diagnosis

Clinical Presentation by Mechanism

IgE-mediated reactions occur within minutes to 2 hours after milk ingestion and present with: 2

• Hives, angioedema
• Wheezing, respiratory symptoms
• Vomiting
• Anaphylaxis

Non-IgE-mediated reactions present with chronic symptoms: 2

• Chronic diarrhea with blood-streaked stools
• Failure to thrive
• Enteropathy
• Allergic proctocolitis (mucoid, blood-streaked stools in otherwise healthy infants)

Diagnostic Testing Strategy

Test children under 5 years with moderate-to-severe atopic dermatitis for cow's milk allergy ONLY if: 3, 2

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

For suspected IgE-mediated allergy: 2

• Perform skin prick testing (SPT) or serum-specific IgE (sIgE)
• Positive tests indicate sensitization but do NOT confirm clinical allergy
• Negative tests have high negative predictive value and help rule out IgE-mediated allergy
• Oral food challenge remains the gold standard when diagnosis is uncertain

Critical caveat: 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. 3, 2 False-positive tests are common—ensure children are clinically allergic, not just sensitized, before dietary removal. 3

Management Based on Feeding Method

Breastfed Infants

The mother should eliminate all cow's milk and dairy products from her diet, including milk, cheese, yogurt, butter, and hidden sources in processed foods. 1

• Improvement typically occurs within 1-2 weeks 1
• Consultation with a registered dietitian is mandatory to ensure nutritional adequacy 1, 2
• The mother requires calcium supplementation and nutritional monitoring 1
• If symptoms persist after 2 weeks of strict maternal elimination, consult an allergy specialist 1

Do NOT discontinue breastfeeding prematurely when maternal elimination diet can effectively manage symptoms. 1, 4 Exclusive breastfeeding should continue for at least 4-6 months when possible. 2

Formula-Fed Infants

First-line treatment is extensively hydrolyzed formula (eHF) of cow's milk protein, which has an 80-90% success rate. 1, 2, 4

For severe reactions or life-threatening symptoms, use amino acid-based formula (AAF) as first-line treatment. 1

If the infant fails to improve on eHF or has severe symptoms, switch to AAF. 1

What NOT to Use

Soy formula is NOT recommended: 2, 4

• 20-40% cross-reactivity risk
• NOT used as preventive or therapeutic strategy, particularly in infants under 6 months
• Can be considered for infants >6 months after establishing tolerance by clinical challenge

Goat's milk and sheep's milk are NOT suitable alternatives due to high protein homology with cow's milk. 1, 2, 4

Partially hydrolyzed formulas are insufficient for treatment of diagnosed cow's milk allergy. 2

Emergency Preparedness

For IgE-mediated allergy, prescribe: 2

• Epinephrine autoinjector for severe reactions
• Antihistamines for mild reactions
• Written emergency action plans detailing symptoms and treatment steps

Asthma is a critical risk factor for severe reactions and fatal anaphylaxis in children with IgE-mediated cow's milk allergy. 3, 2 Uncontrolled asthma is an absolute contraindication to oral immunotherapy. 2

Nutritional Monitoring

Mandatory nutritional consultation is required when implementing cow's milk elimination, especially in children requiring multiple food avoidances. 2

• Monitor for nutritional deficits: 15.1% of infants with suspected cow's milk allergy present with low weight-for-age, and 23.9% with low height-for-age 5
• Train parents to read food labels meticulously, as cow's milk protein appears in many forms 2
• Coordinate with schools and childcare centers for safe environment and emergency preparedness 2

Oral Food Challenge and Reintroduction

Before the challenge: 3

• Eliminate suspected foods from the diet for 2-8 weeks depending on reaction type
• In infants, diet can be limited to hypoallergenic formula
• For exclusively breastfed infants, eliminate suspected food from mother's diet
• Document significant improvements from dietary elimination

Reintroduction timing: 1, 4

• Attempt reintroduction under medical supervision typically after 6-12 months of elimination
• Perform oral food challenge at 9-12 months of age in a hospital setting to assess tolerance development
• Most children develop tolerance by 2-3 years for non-IgE-mediated disease 2
• Majority regain tolerance within first 5 years for IgE-mediated disease 2

Predictors of tolerance development: 3

• Decrease in food-specific IgE levels is often a marker for onset of tolerance
• Reduction in wheal size after skin-prick test may indicate tolerance development
• However, skin-prick test can remain positive long after food is safely consumed

Oral Immunotherapy (OIT)

Oral immunotherapy is NOT recommended for routine clinical practice for cow's milk allergy at this time, due to safety concerns and high rates of adverse reactions. 2 The 2014 NIAID guidelines recommend absolute avoidance and emergency preparedness as standard care. 2

Prevention Strategies

For at-risk infants (biological parent or sibling with allergic rhinitis, asthma, atopic dermatitis, or food allergy): 3

• Exclusive breastfeeding for at least 4-6 months is recommended 3, 2
• Maternal dietary restriction during pregnancy or lactation is NOT recommended and provides no benefit 3, 2
• For at-risk infants not exclusively breastfed, hydrolyzed infant formulas (versus cow's milk formula) may prevent or delay atopic disease, particularly atopic dermatitis 3
• There is insufficient evidence to recommend routine food allergy testing before introducing highly allergenic foods 3
• Delaying introduction of complementary foods beyond 4-6 months does NOT prevent atopic disease 3

Common Pitfalls to Avoid

Do NOT: 1, 2, 4

• Perform unnecessary maternal dietary restrictions beyond confirmed allergens, as this compromises maternal nutrition
• Use soy formula as first-line alternative in infants under 6 months
• Discontinue breastfeeding when maternal elimination diet can manage symptoms
• Restrict maternal diet during pregnancy for allergy prevention
• Remove foods from diet based solely on positive skin test or IgE without clinical symptoms