Diagnosis of Cow’s Milk Protein Allergy (CMPA) can be often misdiagnosed as certain other illnesses of childhood have common presenting symptoms.1 In the absence of a predictive marker, a detailed allergy-focused clinical history should be ascertained to establish the diagnosis of CMPA and understand the severity of the disease.2 The following case discussion of a 6-month-old infant highlights the diagnostic and management strategy to control CMPA.
A baby’s mother reported that the baby experienced discomfort at feed times, followed by vomiting and profuse stringy diarrhea for the past two weeks.1,2 This pattern was noticed after every feed, and the baby woke up crying many times while sleeping.1,2 This 6-month-old infant was presented to the pediatric clinic with his parents with complaints of vomiting, profuse stringy diarrhea after every feed, disturbed sleep and daytime restlessness for the last two weeks.1,2 They sought treatment elsewhere earlier, where the doctor had diagnosed gastroesophageal reflux and treated the patient accordingly. However, the symptoms did not resolve, and parents decided to seek a second opinion.
The baby was born through a normal full-term delivery and was exclusively breastfed for 5.5 months. At 5.5-month, the baby’s mother decided to introduce diluted cow’s milk to his weaning diet. For the initial one week, the baby was fine and playful, and his daily feed, play, nap routine was also maintained.
- Strong family history of atopy, asthma and atopic dermatitis
- He was on the 95th percentile of weight and height.
- The appearance was anxious.
- Physical examination revealed a red, slightly excoriated nose and two angry-looking rashes; one on the abdomen and the other on the left shoulder, indicated atopic dermatitis.
- Abdomen examination revealed a soft abdomen with no bloating but slight discomfort to touch.
- The rest of the physical examination was insignificant.
When switched to cow’s milk during weaning, an exclusively breastfed infant can develop gastrointestinal and cutaneous manifestations. In this case, the baby presented with gastrointestinal symptoms and atopic dermatitis that is the characteristic feature of CMPA. Hence, the provisional diagnosis of CMPA was made. 1,2
The baby’s parents were suggested to remove all cow’s milk products from his diet to confirm the diagnosis of CMPA. The doctor has also prescribed prebiotic supplemented extensively hydrolysed feed-in age-appropriate quantity for baby.1,2
CMPA is a common food allergy affecting 35% of children below three years of age with chronic diarrhea, in India.4 It is an IgE or non-IgE mediated immunological response of the body towards the peptides in the cow’s milk. Though IgE is not a diagnostic marker of CMPA, it is established that rapid development of tolerance towards cow’s milk protein is driven by low IgE levels. 5
Presenting complaints of CMPA are non-specific, which can easily be misdiagnosed.1 Irritable infant with vomiting, diarrhea, eczema can have several differential diagnoses, including colic, gastroesophageal reflux, lactose intolerance and CMPA.1 Under, missed and delayed diagnosis of CMPA can lead to growth failure, appetite loss, frequent hospital visits, caretaker work loss and healthcare burden.6
Early diagnosis and intervention, although not easy, can be guided by diagnostic tools that assist in elucidating a strong history through prompt questions, thereby aiding diagnosis of CMPA. A study demonstrated significant improvement in timely diagnosis and treatment of CMPA when a simple training package was provided to healthcare professionals. A significant increase in the prescription of hydrolyzed infant feeds with a reduction in alternative treatments was observed during the study period.6
Management strategy in CMPA includes the elimination of cow’s milk protein-containing products. Whey or casein-based eHF is the first choice of treatment with proven clinical efficiency.7 The role of gut microbiota in food allergies of infancy is related to their influence on outcomes and rapidity of tolerance development.7 Damage to gut flora by allergies impacts the body's ability to acquire tolerance towards causative allergens.5
Infant feeds with prebiotic oligosaccharides promote the growth of bifidobacteria and maintain optimal gut health.8 Various clinical studies have demonstrated the role of prebiotics containing eHF in alleviating gastrointestinal and allergic symptoms (Table 1).9-12
Table 1: Summary of clinical studies post dietary intervention with prebiotic containing feed in infants with CMPA.
|Randomized, double-blind, placebo-controlled trial9||To investigate the effects of GOS:FOS (9:1) supplemented feed (8 g/L) on immune response toward CMP following DTP-vaccination.||6 months|| |
|Observational, prospective trial10||To study the effect of hydrolyzed infant prebiotic containing feed on colic, regurgitation and constipation||5 months||Reduction in colic pains, regurgitation and constipation symptoms within 2 weeks.|
|Prospective, randomized, double-blind, placebo-controlled study11||To evaluate the effect of prebiotic mixture GOS/FOS (8 g/L) containing infant feed on allergic manifestations and infections.||2 years||A significant reduction (p<0.5) in the incidence of atopic dermatitis, allergic urticaria, and recurrent wheezing in the prebiotic group as compared to the placebo group.|
|Prospective, double blind, placebo-controlled study 12||To evaluate the effect of prebiotic mixture GOS/FOS (8 g/L) containing infant feed on allergic manifestations and infections.||5 years|| |
A well-informed pediatrician can make a definitive diagnosis of CMPA and suggest an early dietary intervention to reduce the disease's undesirable consequences.
- Walsh J, Venter C, Brown T, et al. A practical approach for UK primary care on the management of cow’s milk allergy in infants. Br J Gen Pract 2014;64:48–9.
- Venter C, Brown T, Shah N 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.
- Vandenplas Y, Koletzko S, Isolauri E et al. Guidelines for the diagnosis and management of cow’s milk protein allergy in infants. Arch. Dis. Child. 2007, 92, 902–908.
- Matthai J, Sathiasekharan M, Poddar U, Sibal A, Srivastava A, Waikar Y, Malik R, Ray G, Geetha S, Yachha SK. Guidelines on Diagnosis and Management of Cow’s Milk Protein Allergy. Indian Pediatrics. 2020 Aug;57(8):723-9.
- Vandenplas Y. Prevention and Management of Cow's Milk Allergy in Non-Exclusively Breastfed Infants. Nutrients. 2017 Jul 10;9(7):731.
- Wauters L, Brown T, Venter C, Dziubak R. et al. Cow's Milk Allergy Prescribing Is Influenced by Regional and National Guidance. Journal of Pediatric Gastroenterology and Nutrition. 2015;62. 1. 10.1097.
- Bunyavanich S, Shen N, Grishin A, et al. Early-life gut microbiome composition and milk allergy resolution. J Allergy Clin Immunol. 2016 Oct;138(4):1122-1130.
- Wiciński M, Sawicka E, Gębalski J, et al. Human Milk Oligosaccharides: Health Benefits, Potential Applications in Infant Formulas, and Pharmacology. Nutrients. 2020 Jan 20;12(1):266.
- Van Hoffen E, Ruiter B, Faber J, M'Rabet L, Knol EF, Stahl B, Arslanoglu S, Moro G, Boehm G, Garssen J. A specific mixture of short‐chain galacto‐oligosaccharides and long‐chain fructo‐oligosaccharides induces a beneficial immunoglobulin profile in infants at high risk for allergy. Allergy. 2009 Mar;64(3):484-7.
- Savino F, Cresi F, Maccario S, et al. “Minor” feeding problems during the first months of life: effect of a partially hydrolysed milk formula containing fructo- and galacto-oligosaccharides. Acta Paediatr 91:86–90, 2003.
- Arslanoglu S, Moro GE, Schmitt J, et al. Early dietary intervention with a mixture of prebiotic oligosaccharides reduces the incidence of allergic manifestations and infections during the first two years of life. The Journal of nutrition. 2008 Jun ;138(6):1091-5.
- Arslanoglu S, Moro GE, Boehm G, et al. Early Neutral Prebiotic Oligosaccharide Supplementation reduces the incidence of some allergic manifestations in the first 5 years of life. J. Biol. Regul. Homeost. Agents. 2012 Jul;26:49-59.
CVM code: 1617451939421