Cow’s

Milk Allergy

By : Vahni Samaroo
• Cow's milk allergy (CMA) is the most common food allergy in
young children but is relatively uncommon in adults 
• Cow's milk allergy (CMA) is the most common food allergy in
young children, affecting approximately 2 percent of children
under four years of age . CMA is even more prevalent in infants
 Pathogenesis

• Acute allergic responses to milk are due to IgE directed against

various allergens in milk.
• Cow's milk contains casein and whey (alpha- lactalbumin , beta-
lactoglobulin ,bovine lactoferrin, bovine serum albumin and
bovine immunoglobulins) proteins that account for
approximately 80 and 20 percent of total protein, respectively
• All milk proteins are potential allergens, and polysensitization to
several proteins occurs in most patients 
• Casein, BLG, and ALA are the major milk allergens, and
cosensitization to these three allergens is common 
• Mixed IgE and non IgE processes govern non –IgE-mediated
reactions these processes are poorly understood
Clinical Manifestations

IgE-mediated reactions — IgE-mediated food-triggered

reactions generally occur immediately, within minutes to two
hours after ingestion
Mixed IgE reactions – atopic dermatitis, allergic eosinophilic
gastrointestinal disorders
Non IgE mediated reactions
• Food protein-induced enterocolitis syndrome —the typical
presentation is that of severe vomiting and diarrhea within two to
four hours after ingestion of the offending allergen, causing
dehydration, lethargy, and sometimes shock.
• The acute phase can be the first manifestation of FPIES or can occur
when the allergen is removed from the diet and then reintroduced.
Chronic exposure to the offending allergen may present with more
subtle symptoms, such as regurgitation, diarrhea, failure to thrive,
and hypoalbuminemia.
• Food protein-induced proctitis/proctocolitis — Food protein-
induced proctitis/proctocolitis usually presents by six months of
life with bloody-streaked, mucousy, loose stools and occasionally
diarrhea in breastfed or standard formula-fed infants who are
otherwise well appearing. Cow's milk and soy are the major
causative foods.
• Food protein-induced enteropathy — Food protein-induced
enteropathy (FPE) presents with protracted diarrhea in the first
nine months of life, within weeks after the introduction of the
trigger food. The majority of affected infants have failure to
thrive, and some present with malabsorption.
• Heiner syndrome — This disorder mainly affects infants.
Symptoms include cough, recurrent fever, wheezing, nasal
congestion, recurrent otitis media, hemoptysis, failure to thrive,
dyspnea, colic, anorexia, vomiting, diarrhea, and hematochezia 
How does CMA progress ?

• Tolerance is achieved by the majority of children with cow's

milk allergy (CMA).
•  Non-IgE-mediated CMA tends to resolve more quickly than IgE-
mediated CMA 
• Good prognostic factors: lower initial level of milk-specific IgE [41
], faster rate of decline of milk-specific IgE level over time [42],
and absence of concomitant allergic rhinitis or asthma
Diagnosis of CMA

• Diagnosis is largely based on history and laboratory testing (where

available)
• The gold standard for diagnosis is a clinician-supervised, double-
blind, placebo-controlled oral food challenge
• When the history and testing are not conclusive, the diagnostic
procedure may include elimination of the suspected food for two
to eight weeks followed by challenge (if the probability is higher)
or reintroduction (if the probability is lower).
Management

• The definitive treatment of CMA is strict elimination of the offending

food from the diet.
• Eosinophilic gastroenteritis can show clinical and histologic improvement
after oral corticosteroid therapy. Topical steroids, administered as inhaled
corticosteroids, have also shown beneficial effect.
• IS THERE A DIFFERENCE BETWEEN COW’S MILK ALLERGY
AND COW’S MILK INTOLERANCE?
References

• https://www-uptodate-com.ezproxygateway.sastudents.uwi.tt/contents/clinic
al-manifestations-of-food-allergy-an-overview?search=cows%20milk%20p
rotein%20intolerance&topicRef=2386&source=see_link#H3198815
• https://emedicine.medscape.com/article/931548-medication#3
• https://www.researchgate.net/publication/
264247497_Is_This_Symptom_Even_a_Food_Allergy_Clinical_Types_of_
Food_Protein-induced_Enterocolitis_Syndrome#pf5