Management of Cow Milk Allergy in Infants

By - Danone Nutricia Academy

Danone Nutricia Academy

Around 5 to 15% of infants show allergy to cow’s milk protein. Early identification and adequate treatment with the right infant feed may prevent the risk of impaired growth.1 In this regard, this article discusses the different types of feeds for managing IgE and non-IgE mediated cow’s milk allergy (CMA).

Cow’s-milk allergy (CMA) is the most common food allergy in infants and young children. It can be either can be immunoglobulin (Ig)E mediated, non-IgE mediated, or mixed.2

IgE mediated CMA:2

Immediate onset – adverse effects appear immediately after ingestion
External factors determine the reaction severity
Anaphylaxis is the most severe reaction

Non-IgE mediated CMA:2

Delayed onset – adverse effects appear after >2 hours
Broad spectrum of symptoms ranging from mild rectal bleeding (proctocolitis) to severe vomiting and collapse (as in case of food protein induced enterocholitis syndrome)

Challenges of CMA

Most common presentation of food allergy in infants1
Complex diagnosis1
Diverse manifestations of IgE and non-IgE mediated allergy1

Infant feeds in non-exclusively breastfed infants

eHF2

AAF2,3

SF2,3

Whey or casein-based eHF considered as the first option

Roles of hydrolysates:

Manipulation of pathogen recognition receptors
Influence on cytokine production
Modulation of the immune response in at-risk CMA patients

Considered depending on the severity of allergic reaction

Second option due to high cost3

Recommended in infants:2

With the rare condition of anaphylaxis
With eosinophilic esophagitis
Intolerant to eHF
Severe enteropathy
Multiple food allergies

Long-term nutritional effects, such as hypophosphatemia and bone disease, which may be caused by impaired bioavailability of phosphorus, as assessed by Ballesteros et al.3,5

Considered as the second choice of feed after eHF2

Though nutritionally adequate, limited to infants >6 months and restricted use due to some discrepancies about isoflavones.3

Preferred due to cost-effectiveness4

Management of IgE and non-IgE mediated CMA: iMAP Guidelines6

Key take away

CMA poses challenges in diagnosis due to different clinical presentations.1
Early identification and referral may result in better health outcomes.1
eHF remains the first choice after breastfeeding in infants with CMA.2

Abbreviations:

AAF: Amino acid formula; CMP: Cow’s milk protein; CVS: Cyclic vomiting syndrome; GI: Gastrointestinal; eHF: Extensively hydrolyzed formula; IgE: Immunoglobulin E; SF: Soy formula

Infographic references

Venter C, Brown T, Meyer R, Walsh J, Shah N, Nowak-Węgrzyn A, Chen TX, Fleischer DM, Heine RG, Levin M, Vieira MC. Better recognition, diagnosis and management of non-IgE-mediated cow’s milk allergy in infancy: iMAP—an international interpretation of the MAP (Milk Allergy in Primary Care) guideline. Clin Transl Allergy. 2017 Dec;7(1):1-9.
Vandenplas Y. Prevention and management of cow’s milk allergy in non-exclusively breastfed infants. Nutrients. 2017 Jul;9(7):731.
Vandenplas Y, Nutten S. Specialty Infant Formulas for Milk Allergy: Current Choices and Unmet Needs. Curr Treat Options Allergy. 2018 Dec 1;5(4):487-99.
Bhatia J, Greer F. Use of soy protein-based formulas in infant feeding. Pediatrics. 2008 May 1;121(5):1062-8.
Ballesteros LF, Ma NS, Gordon RJ, Ward L, Backeljauw P, Wasserman H, Weber DR, DiMeglio LA, Gagne J, Stein R, Cody D. Unexpected widespread hypophosphatemia and bone disease associated with elemental formula use in infants and children. Bone. 2017 Apr 1;97:287-92.
Vandenplas Y, Brueton M, Dupont C, Hill D, Isolauri E, Koletzko S, Oranje AP, Staiano A. Guidelines for the diagnosis and management of cow’s milk protein allergy in infants. Arch Dis Child. 2007 Oct 1;92(10):902-8.