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

Yvan Vandenplas; Helen A Brough; Alessandro Fiocchi; Mohamad Miqdady; Zakiudin Munasir; Silvia Salvatore; Nikhil Thapar; Carina Venter; Mario C Vieira; Rosan Meyer

doi:10.2147/JAA.S276992

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

J Asthma Allergy. 2021 Oct 21:14:1243-1256. doi: 10.2147/JAA.S276992. eCollection 2021.

Authors

Yvan Vandenplas¹, Helen A Brough^{2

3

4}, Alessandro Fiocchi⁵, Mohamad Miqdady⁶, Zakiudin Munasir⁷, Silvia Salvatore⁸, Nikhil Thapar⁹, Carina Venter¹⁰, Mario C Vieira¹¹, Rosan Meyer^{12

13}

Affiliations

¹ Vrije Universiteit Brussel (VUB), UZ Brussel, KidZ Health Castle, Brussels, Belgium.
² Department Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
³ Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK.
⁴ Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas's NHS Foundation Trust, London, UK.
⁵ Translational Research in Pediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, Rome, Italy.
⁶ Department of Pediatrics, Sheikh Khalifa Medical City, College of Medicine & Health Sciences, Khalifa University, Khalifa, United Arab Emirates.
⁷ Department of Child Health, Ciptomangunkusumo Hospital-Medical Faculty Universitas Indonesia, Jakarta, Indonesia.
⁸ Pediatric Department, Hospital "F. Del Ponte", University of Insubria, Varese, Italy.
⁹ Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Queensland, Australia.
¹⁰ University of Colorado, Children's Hospital Colorado, Denver, CO, USA.
¹¹ Center for Pediatric Gastroenterology -Hospital Pequeno Príncipe, Curitiba, Brazil.
¹² Department of Paediatrics, Imperial College, London, UK.
¹³ Department Nutrition and Dietetics, University of Winchester, Winchester, UK.

Abstract

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.

Keywords: amino acid formula; challenge test; cow milk allergy; hydrolysate; plant-based drink; rice hydrolysate; soy formula.

Publication types

Review