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Rosan Meyer RD PhD Paediatric Allergy Dietitian Department of Gastroenterology Great Ormond Street Childrens Hospital

Carina Venter RD PhD The David Hide Asthma and Allergy Research Centre University of Portsmouth

Cow’s milk protein allergy

in children Diagnosis and management of one of the most common food allergies seen in children can be a complex process


ow’s milk protein allergy (CMPA) is one of the most common food allergies seen in infants and young children. It covers a wide spectrum of symptoms affecting the gastrointestinal tract, the skin and the respiratory tract.1

The fi rst food allergen to which most children are exposed is cow’s

milk (CM), which explains why this is also one of the most prevalent food allergies in early infancy. It is thought that between 1.9-4.9% of young children have a CMPA.2,3

Symptoms typically occur after

their fi rst or second known exposure to CM, which is often in the form of infant formula containing a casein/whey mixture or within complementary foods (ie, milk based baby cereals, yoghurt), but it may also occur in breast fed infants.4 According to the European Academy for Allergy and Clinical Immunology (EAACI) and World Health Organisation (WHO),5


adverse reaction to cow’s milk can be referred to as cow’s milk allergy if it involves the immune system. Non-allergic cow’s milk hypersensitivity (ie, lactose intolerance) on the other hand, does not involve the immune system. CMPA is divided into Immunoglobulin E (IgE) mediated (ie, immediate type allergy) and non-IgE mediated (ie, delayed type, onset typically) CMPA. Symptoms related to IgE mediated CMPA typically appear within two hours of ingesting CM, whereas symptoms related to non-IgE mediated CMPA tend to appear > 2 hours and up to a couple of days.6 More

recently, a subgroup of cow’s milk allergic children have been identifi ed with mixed IgE and non-IgE mediated food allergies, which means that some symptoms occur quite soon after ingestion of CM, but that there are delayed symptoms as well.7


Kvenshagen et al. found that the majority of infants with CMPA exhibit symptoms related to the skin (eg,

atopic dermatitis, urticaria), gastrointestinal tract (eg, diarrhoea, vomiting) and respiratory tract (ie, affected breathing).3

The recent

guidelines from the National Institute of Clinical Excellence (NICE) on the diagnosis and assessment of children with food allergies, summarise the symptoms, that should highlight the possibility of a food allergy.8

These are summarised in Table 1. The main aspects of diagnosing CMPA include clinical history,

skin prick tests and/or blood tests (when indicated) and elimination of CM followed by reintroduction of CM at home or during a food challenge in hospital. The allergy focused clinical history is the most important aspect in the diagnosis of any food allergy.8,10,11 been very well summarised by NICE guidelines and include8

This has :

Any individual and family history of atopic disease (eczema, asthma, allergic rhinitis and also food allergy) in parents or siblings. Any personal history of atopic disease, especially eczema. What the suspected allergen is. Details of any foods that are avoided and why. Presenting symptoms and other symptoms that may be associated with food allergy. Feeding history (eg, weaning). Details of any previous treatment or exclusions and the response.

After taking allergy-focused history, the choice for diagnostic procedure should be made, which can be one of the following: If the history suggests IgE-mediated, immediate type symptoms: skin prick tests (SPT) and specifi c IgE test are useful in the diagnosis of this type of CMPA, but are often diffi cult to interpret. For cow’s milk, ‘diagnostic reference levels’ have been set to aid diagnosis, but these should always be consid- ered in the context of the clinical history. The 95% predictive decision point for cow’s milk is 15 kuA/L (5 kuA/L for children under two years) based on specifi c IgE test and the 100% decision point based on skin prick test result is 8 mm (6 mm for

52 Nursing in Practice March/April 2012

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