An ESPGHAN Position Paper on the Diagnosis, Management, and Prevention of Cow's Milk Allergy

Abstract

A previous guideline on cow's milk allergy (CMA) developed by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) was published in 2012. This position paper provides an update on the diagnosis, treatment, and prevention of CMA with focus on gastrointestinal manifestations. All systematic reviews and meta-analyses regarding prevalence, pathophysiology, symptoms, and diagnosis of CMA published after the previous ESPGHAN document were considered. Medline was searched from inception until May 2022 for topics that were not covered in the previous document. After reaching consensus on the manuscript, statements were formulated and voted on each of them with a score between 1 and 9. A score of ≥6 was arbitrarily considered as agreement. Available evidence on the role of dietary practice in the prevention, diagnosis and management of CMA was updated and recommendations formulated. CMA in exclusively breastfed infants exists, but is uncommon and suffers from over-diagnosis. CMA is also over-diagnosed in formula and mixed fed infants. Changes in stool characteristics, feeding aversion or occasional spots of blood in stool are common and in general should not be considered as diagnostic of CMA, irrespective of preceding consumption of cow's milk. Over-diagnosis of CMA occurs much more frequently than under-diagnosis; both have potentially harmful consequences. Therefore, the necessity of a challenge test after a short diagnostic elimination diet of 2-4 weeks is recommended as the cornerstone of the diagnosis. This position paper contains sections on nutrition, growth, cost and quality of life.

Response to Letter: Gastro‐esophageal reflux and cow's milk allergy

“…We read with great interest the “letter to the editor” by Martin and Järvinen, referring to the recommendation in the guidelines on gastro‐esophageal reflux disease (GERD), published in 2018 to start an extensively hydrolyzed cow's milk based formula in case of nonacid GERD refractory to a thickened formula 1 . Martin and Jârvinen highlight that prolonged dietary elimination has been shown to have potential negative physiologic and emotional effects on the mother, on the infant, and can interrupt or end a previously successful and desired breastfeeding relationship, 2 thereby confirming the statements in the recent ESPGHAN position paper on cow's milk allergy (CMA) 3 . Marin and Järvinen stress that elimination diets should be short (2–4 weeks), with close physician follow‐up, and reintroduction/challenge should be performed 2 .…”

“…By stating so, the authors confirm what is written the GER guideline (“A trial of extensively hydrolyzed formula or amino acid‐based formula is indicated in patients who have not responded to conventional GERD therapies. For each of these nonpharmacologic therapies, a minimum 2‐week trial is recommended to assess for symptom improvement before considering other therapeutic alternatives”) and in the CMA position paper (“In patients not responding to conventional therapies for GERD, CMA can be considered, and, patients trialed on a time limited elimination diet for 2–4 weeks which should be followed by an oral food challenge).” 1,3 We further cite from the CMA‐position paper: “Careful consideration of the mother's commitment to breastfeed should be given full attention before advising on an exclusion diet and support provided by a nutritionist is encouraged where possible. In formula fed infants, an extensively hydrolyzed formula can be beneficial regarding regurgitation and colic probably due to enhanced gastric emptying and due to the fact that most hydrolysates are lactose free, indicating that the improvement may not be related to CMA.”…”

Growth pattern of paediatric patients affected by cow milk protein allergy fed with rice hydrolyzed formula

“…29 Another important point is the cost-effectiveness of HRPF; in fact, in a recent study, hypoallergenic formulas accounted for the largest proportion of the total cost of managing CMPA, averaging 69% across all comparators, with a minimum of 58% for HRPF and a maximum of 87% for amino acid-based formulas. 30 However, according to the ESPGHAN position paper, 31 it is important to consider the arsenic content of HRPFs, as this is not stated for all commercial HRPFs. 32 Therefore, only HRPFs whose the arsenic content is known and within the recommended limits should be used.…”

“…However, according to the ESPGHAN position paper, 31 it is important to consider the arsenic content of HRPFs, as this is not stated for all commercial HRPFs 32 . Therefore, only HRPFs whose the arsenic content is known and within the recommended limits should be used 33 …”

Management of food protein‐induced allergic proctocolitis in Italy: A nationwide survey by SIGENP

“…The European Society of Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) has produced a document with recommendations relating to milk protein allergy, within which it has issued a statement also dedicated to FPIAP. 2 Addressing this gap, we, on behalf of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP), conducted a nationwide electronic survey from January to September 2022 to provide the first analysis of allergic proctocolitis management in Italy.…”