Making a Diagnosis1
Although there are clinical tests available for the diagnosis of IgE mediated cows’ milk allergy, unfortunately there are currently no clinical tests to diagnose non IgE mediated allergies as the exact mechanism of the allergy is not fully understood.
For babies suffering with immediate (IgE symptoms) it is possible to perform a Skin Prick test to help confirm your diagnosis. It is important to understand that a positive SPT or specific serum IgE test merely indicates sensitisation and does not confirm clinical allergy. However, a positive test coupled with a clear history of a reaction should usually be sufficient to confirm a diagnosis. There are no validated tests for the diagnosis of non-IgE CMA, apart from the elimination of cows’ milk from the diet for 2-4 weeks, followed by reintroduction to confirm your diagnosis.
The MAP guidelines2 are a very useful tool to assist this diagnosis.
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Dietary Management of the Breastfed Infant2
Like all infants, breast milk is the gold standard nutrition for infants with cows’ milk allergy. Breastfeeding is recommended as the first line treatment with the strict exclusion of cows’ milk containing food from the maternal diet for 2-4 weeks. Maternal supplementation of 1000mg calcium and 10µg vitamin D daily as well as referral to a dietitian is usually recommended. If symptoms resolve within this period it is very important to confirm diagnosis by the reintroduction of cows’ milk. The mother should revert to her normal cows’ milk containing diet over a period of one week. If symptoms reoccur you can confirm your diagnosis of cows’ milk allergy and the mother should resort back to cows’ milk free diet until tolerance is achieved.
Dietary Management of the Formula Fed or Combination Fed Infant2
Formulas with reduced allergenicity based on extensively hydrolysed proteins are recommended for infants with cows’ milk allergy and their suitability is dependent on the degree of hydrolysis. Extensively hydrolysed formulas contain at least 80% of protein in the form of peptides and are suitable for mild to moderate allergy. Amino acid formulas contain free amino acids and are suitable for severe allergy.3
Formula fed and combination fed infants with suspected cows’ milk allergy should be placed on an extensively hydrolysed formula (EHF) for 2-4 weeks. For combined feeding the mum should also eliminate cows’ milk from her diet with referral to a dietitian. If symptoms resolve you should perform a home challenge with cows’ milk formula to confirm diagnosis. If there was no improvement in symptoms on EHF for 2-4 weeks and you still suspect that the infant may have cows’ milk allergy, you may consider the trial of an amino acid formula and referral to a paediatrician with special interest in allergy. Infants will remain on EHF or AA formula until tolerance has been achieved.2
The good news is the majority of infants will outgrow their milk allergy and reintroducing milk and milk products back into the diet once tolerance has been achieved is important. The milk ladder2 is a useful tool developed to induce tolerance and gradually reintroduce milk into an infant’s diet. The milk ladder can be used in the community and takes into account the allergenicity of milk products- starting at the least allergenic in step 1 and allowing the child to make their way up to step 12 which contains the most allergenic- cows milk.
Please note the milk ladder is only suitable for use with mild to moderate CMPA. Infants with a history of severe reactions or severe eczema may require a supervised challenge under supervision of a healthcare professional.2
- Venter et al, Diagnosis and management of non-IgE-mediated cow’s milk allergy in infancy – a UK primary care practical guide, Clin Transl Allergy. 2013; 3: 23
- Milk Allergy In Primary Care, A primary care guide to the diagnosis and management of cow’s milk allergy in the first year of life, https://cowsmilkallergyguidelines.co.uk/
- American Academy of Paediatrics, Committee on Nutrition, Hypoallergenic Infant Formulas, 2000;106;346