From the Guidelines
Cow's milk protein allergy in paediatrics should be managed with hypoallergenic formula in formula-fed infants or infants who can no longer breast-feed, as recommended by the international consensus guidelines 1. This approach is based on the strongest and most recent evidence, which prioritizes the use of hypoallergenic formulas for infants diagnosed with food protein-induced enterocolitis syndrome (FPIES) caused by cow's milk 1. The management of cow's milk protein allergy involves eliminating cow's milk protein from the diet, and for formula-fed infants, extensively hydrolyzed formulas are often considered first-line, while amino acid formulas are reserved for severe cases or when hydrolyzed formulas fail 2. Key considerations in managing cow's milk protein allergy include:
- Eliminating cow's milk protein from the diet
- Using hypoallergenic formulas for formula-fed infants
- Considering soy formulas in infants over 6 months
- Providing calcium supplementation as necessary
- Conducting periodic challenges under medical supervision to assess tolerance development It is essential to prioritize the most recent and highest quality study, which in this case is the international consensus guidelines 1, to ensure the best possible outcomes in terms of morbidity, mortality, and quality of life for infants and young children with cow's milk protein allergy.
From the Research
Diagnosis and Symptoms of Cow's Milk Protein Allergy
- Cow's milk protein allergy (CMPA) can manifest as immediate symptoms such as acute urticaria/angioedema, wheezing, rhinitis, dry cough, vomiting, laryngeal edema, acute asthma with severe respiratory distress, and anaphylaxis 3
- Late reactions due to CMPA can include atopic dermatitis, chronic diarrhoea, blood in the stools, iron deficiency anaemia, gastroesophageal reflux disease, constipation, chronic vomiting, colic, poor growth (food refusal), enterocolitis syndrome, protein-losing enteropathy with hypoalbuminemia, and eosinophilic oesophagogastroenteropathy 3
- The diagnosis of CMPA requires an understanding of its classification and immunological basis, as well as the strengths and limitations of diagnostic modalities 4
Treatment and Management of Cow's Milk Protein Allergy
- The mainstay of treatment for CMPA is avoidance of cow's milk protein, which requires dietetic input to ensure that this does not lead to any nutritional compromise 4
- Hypoallergenic formulas, including extensively hydrolyzed formula (EHF) and amino acid formula (AAF), can be used in the management of CMPA 5, 6
- EHF is recommended as the first choice for CMPA treatment, while AAF is recommended for more severe cases or those with reactions to EHF 5
- The choice of hypoallergenic formula should be based on the infant's age, the severity, frequency and persistence of symptoms, immune phenotype, growth pattern, formula cost, and in vivo proof of tolerance and efficacy 5
Hypoallergenic Formulas and Their Effects
- Extensively hydrolyzed formulas (EHF) have been shown to be well tolerated by the majority of children allergic to cow's milk, with no concerns regarding body growth or adverse effects 5
- Amino acid formulas (AAF) may be indicated in certain cases, such as height growth faltering, multisystem involvement, and severe gastrointestinal allergies 6
- Rice hydrolysed formulas (rHF) have also become available in recent years and have been shown to be well tolerated by children allergic to cow's milk 5
- Some hydrolysates may have a pro-active effect in modulating the immune system due to the presence of small peptides and additional components, like biotics 5