Current Guidelines and Future Strategies for the Management of Cow’s Milk Allergy

Abstract

Exclusive breast feeding is recommended in all guidelines as the first choice feeding. Cow milk allergy (CMA) can be diagnosed by a diagnostic elimination diet for 2 to 4 weeks with a hypo-allergenic formula, followed by a challenge test with intact cow milk protein. The most often used hypo-allergenic formula for the diagnostic elimination diet and the therapeutic diet is a CM based extensive hydrolysate. CM-based partial hydrolysates cannot be recommended in the management of CMA because of insufficient efficacy and possible reactions, but about half of the infants with CMA may tolerate a partial hydrolysate. The pros and cons of other dietary options are discussed in this paper. The use of an amino acid-based formula and/or rice based hydrolysate formula during the diagnostic elimination and therapeutic diet is debated. When available, there is sufficient evidence to consider rice hydrolysates as an adequate alternative to CM-based hydrolysates, since some infants will still react to the CM hydrolysate. The pros and cons of dietary options such as soy formula, buckwheat, almond, pea or other plant based dietary products are discussed. Although the majority of the plant-based beverages are nutritionally inadequate, some are nutritionally adapted for toddlers. However, accessibility and content vary by country and, thus far there is insufficient evidence on the efficacy and tolerance of these plant-based drinks (except for soy formula and rice hydrolysates) to provide an opinion on them. Conclusion: A diagnostic elimination diet, followed by a challenge remains the diagnostic standard. The use of an awareness tool may result in a decrease of delayed diagnosis. Breastmilk remains the ideal source of nutrition and when not available a CM extensively hydrolyzed formula, rice hydrolysate or amino acid formula should be recommended. More evidence is needed regarding plant-based drinks.

Cows’ Milk Allergy-Associated Constipation: When to Look for It? A Narrative Review

“…In the absence of reliable laboratory tests, an allergy-focused history and elimination with open food challenge remain the recommended diagnostic steps for dairy allergic constipation [ 143 ]. The UK NICE guidelines recommend this approach in all children with chronic GI symptoms, including constipation [ 57 ] and have used this strategy as a health care quality indicator since 2016 [ 144 ].…”

“…For infants requiring CM elimination, all guidelines on the management of CMA recommend continued breast feeding, with the mother avoiding all dairy products, as the ideal nutrition [ 44 , 61 , 63 , 121 , 123 , 124 , 125 , 143 , 158 , 159 , 160 , 161 ]. A maternal CMP elimination diet during breast feeding requires close supervision and support to protect the nutritional safety of both mother and baby, in accordance with published guidelines [ 122 ].…”

“…A maternal CMP elimination diet during breast feeding requires close supervision and support to protect the nutritional safety of both mother and baby, in accordance with published guidelines [ 122 ]. When human milk is not available or it is insufficient, extensively hydrolysed CM formula, rice hydrolysate or amino acid formula are recommended for the management of CMA [ 143 ]. Hypoallergenic formulas may vary for protein source and content, method and degree of hydrolysis and additional components, which affect tolerance and efficacy [ 143 , 162 ].…”

“…When human milk is not available or it is insufficient, extensively hydrolysed CM formula, rice hydrolysate or amino acid formula are recommended for the management of CMA [ 143 ]. Hypoallergenic formulas may vary for protein source and content, method and degree of hydrolysis and additional components, which affect tolerance and efficacy [ 143 , 162 ]. In formula-fed infants with food-allergic motility disorders, the use of extensively hydrolysed formulas has been shown to be effective [ 162 ].…”

“…Rice hydrolysate formula is also a suitable alternative to CM-based hydrolysed formulas. Other plant-based milk alternatives are not nutritionally complete, and they are contraindicated as cows’ milk substitutes in infants [ 143 , 162 ].…”