Detection and management of milk allergy: Delphi consensus study

Hilary I Allen; Ursula Pendower; Miriam Santer; Marion Groetch; Mitchell Cohen; Simon H Murch; Hywel C Williams; Daniel Munblit; Yitzhak Katz; Neeraj Gupta; Sabeen Adil; Justine Baines; Eefje G P M de Bont; Matthew Ridd; Victoria L Sibson; Alison McFadden; Jennifer J Koplin; Josephine Munene; Michael R Perkin; Scott H Sicherer; Robert J Boyle

doi:10.1111/cea.14179

Detection and management of milk allergy: Delphi consensus study

Clin Exp Allergy. 2022 Jul;52(7):848-858. doi: 10.1111/cea.14179. Epub 2022 Jun 10.

Authors

Hilary I Allen¹, Ursula Pendower¹, Miriam Santer², Marion Groetch³, Mitchell Cohen⁴, Simon H Murch⁵, Hywel C Williams⁶, Daniel Munblit⁷, Yitzhak Katz⁸, Neeraj Gupta⁹, Sabeen Adil¹⁰, Justine Baines¹¹, Eefje G P M de Bont¹², Matthew Ridd¹³, Victoria L Sibson¹⁴, Alison McFadden¹⁵, Jennifer J Koplin¹⁶, Josephine Munene¹⁷, Michael R Perkin¹⁸, Scott H Sicherer⁴, Robert J Boyle¹

Affiliations

¹ National Heart and Lung Institute, Imperial College London, London, UK.
² Primary Care Research Centre, University of Southampton, Southampton, UK.
³ Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
⁴ Department of Paediatrics, University of Alabama at Birmingham & Children's of Alabama, Birmingham, Alabama, USA.
⁵ University of Warwick, Coventry, UK.
⁶ Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK.
⁷ Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
⁸ Allergy and Immunology Institute, Assaf Harofeh Medical Center, Department of Paediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
⁹ Division of Paediatric Allergy, Department of Paediatrics, Institute of Child Health, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India.
¹⁰ International Lactation Consultant Association, Raleigh, North Carolina, USA.
¹¹ Manchester Children's Community Centre, Manchester, UK.
¹² Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.
¹³ Population Health Sciences, University of Bristol, Bristol, UK.
¹⁴ First Steps Nutrition Trust, London, UK.
¹⁵ Mother and Infant Research Unit, University of Dundee, Dundee, UK.
¹⁶ Murdoch Children's Research Institute, Parkville, Victoria, Australia.
¹⁷ Certified Lactation Educator, Kenya Association for Breastfeeding and La Leche League South Africa, Nairobi, Kenya.
¹⁸ Population Health Research Institute, St George's University of London, London, UK.

PMID: 35615972
DOI: 10.1111/cea.14179

Abstract

Background: There is significant overdiagnosis of milk allergy in young children in some countries, leading to unnecessary use of specialized formula. This guidance, developed by experts without commercial ties to the formula industry, aims to reduce milk allergy overdiagnosis and support carers of children with suspected milk allergy.

Methods: Delphi study involving two rounds of anonymous consensus building and an open meeting between January and July 2021. Seventeen experts in general practice, nutrition, midwifery, health visiting, lactation support and relevant areas of paediatrics participated, located in Europe, North America, Middle East, Africa, Australia and Asia. Five authors of previous milk allergy guidelines and seven parents provided feedback.

Findings: Participants agreed on 38 essential recommendations through consensus. Recommendations highlighted the importance of reproducibility and specificity for diagnosing milk allergy in children with acute or delayed symptoms temporally related to milk protein ingestion; and distinguished between children directly consuming milk protein and exclusively breastfed infants. Consensus was reached that maternal dietary restriction is not usually necessary to manage milk allergy, and that for exclusively breastfed infants with chronic symptoms, milk allergy diagnosis should only be considered in specific, rare circumstances. Consensus was reached that milk allergy diagnosis does not need to be considered for stool changes, aversive feeding or occasional spots of blood in stool, if there is no temporal relationship with milk protein ingestion. When compared with previous guidelines, these consensus recommendations resulted in more restrictive criteria for detecting milk allergy and a more limited role for maternal dietary exclusions and specialized formula.

Interpretation: These new milk allergy recommendations from non-conflicted, multidisciplinary experts advise narrower criteria, more prominent support for breastfeeding and less use of specialized formula, compared with current guidelines.

Keywords: Cow's milk allergy; Delphi consensus; breastfeeding; overdiagnosis.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Allergens
Child
Child, Preschool
Delphi Technique
Female
Humans
Infant
Infant Formula
Milk Hypersensitivity* / diagnosis
Milk Proteins
Reproducibility of Results

Substances

Allergens
Milk Proteins