Mild to moderate
non-IgE-mediated CMA
■ Mostly 2–72 hours after
ingestion of cow’s milk protein
■ Formula fed, exclusively
breastfed, or with onset of
mixed feeding
Usually several of these
symptoms will be present
■ Treatment resistance, e.g. to
atopic dermatitis or reflux,
increases likelihood of allergy
■ Gastrointestinal
—— irritability—‘colic’
—— vomiting—‘reflux’—GORD
—— food refusal or aversion
—— diarrhoea-like stools—loose
and/or more frequent
—— constipation—especially
soft stools, with excessive
straining
—— abdominal discomfort,
painful flatus
—— blood and/or mucus in stools
in an otherwise well infant
■ Skin
—— pruritus (itching), erythema
(flushing)
—— non-specific rashes
—— moderate persistent atopic
dermatitis
Cow’s milk free diet
eHF
Or—advise exclusively
breastfeeding mother to exclude
all cow’s milk protein from her own
diet and to take daily calcium and
vitamin D
See Management Algorithm
(Figure 2)
CMA=cow’s milk allergy; IgE=immunoglobulin E; GORD=gastro-oesophageal reflux disease; AAF=amino acid-based formula;
eHF=extensively hydrolysed formula; CVS=cardiovascular system.
Severe Mild to moderate
non-IgE-mediated CMA IgE-mediated CMA
■ Mostly 2–72 hours after ingestion of cow’s ■ Mostly within minutes (may be
milk protein up to 2 hours) after ingestion of
■ Formula fed, exclusively breastfed, or at cow’s milk protein
onset of mixed feeding ■ Mostly formula fed or at onset of
One or more of these severe and persisting mixed feeding
symptoms: One or more of these
■ Gastrointestinal symptoms:
—— diarrhoea, vomiting, abdominal pain, ■ Skin—one or more usually
food refusal or food aversion, significant present
blood and/or mucus in stools, irregular or —— acute pruritus, erythema,
uncomfortable stools +/- faltering growth urticaria, angioedema
■ Skin —— acute ‘flaring’ of persisting
—— severe atopic eczema +/- faltering growth atopic dermatitis
■ Gastrointestinal
—— vomiting, diarrhoea,
abdominal pain/colic
■ Respiratory
—— acute rhinitis and/or
conjunctivitis
Cow’s milk free diet Cow’s milk free diet
Severe IgE-
AAF Initial 1st choice—eHF
mediated CMA
Or advise exclusively ANAPHYLAXIS (Soy may be used in some settings
breastfeeding mother if not sensitised)
to exclude all cow’s Or—advise exclusively
milk protein from her breastfeeding mother to exclude
own diet and to take all cow’s milk protein from her own
daily supplements of diet and to take daily supplements
calcium and vitamin of calcium and vitamin D according
D according to local to local recommendations
recommendations
■ IgE testing needed
■ Ensure: Immediate
reaction with ■ If diagnosis confirmed (which
—— urgent referral may require a supervised
to local severe respiratory
and/or CVS signs challenge in a minority of cases):
paediatric
allergy service and symptoms —— follow-up with serial IgE
—— urgent dietetic (Rarely a severe testing and later planned
challenge to test for acquired
referral gastrointestinal
presentation) tolerance
■ Dietetic referral required
Emergency
If competencies to arrange and
treatment and
interpret testing are not in place
admission
early referral to local paediatric
allergy service is advised