Diagnostic approach and management of cow's milk protein allergy in infants and children:A practical guideline of the GI-committee of ESPGHAN

OBJECTIVES:: This position paper provides recommendations for the diagnosis and management of suspected cow's milk protein allergy (CMPA) in Europe. It presents a practical approach with a diagnostic algorithm and is based on recently published evidence based guidelines on CMPA. DIAGNOSIS:: If CMPA is suspected by history and examination, strict allergen avoidance is initiated. In certain circumstances (e.g. a clear history of immediate symptoms or a life threatening reaction with a positive test for cow's milk protein (CMP) specific IgE) the diagnosis can be made without a milk challenge. In all other circumstances, a controlled oral food challenge (open or blind) under medical supervision is required to confirm or exclude the diagnosis CMPA. TREATMENT:: In breast-fed infants, the mother should start a strict CMP-free diet. Non-breast fed infants with confirmed CMPA should receive an extensively hydrolyzed protein based formula with proven efficacy in appropriate clinical trials; amino acids based formulae are reserved for certain situations. Soy protein formula, if tolerated, is an option beyond 6 months of age. Nutritional counseling and regular monitoring of growth is mandatory in all age groups requiring CMP exclusion. RE-EVALUATION:: Patients should be re-evaluated every 6-12 months to assess whether they have developed tolerance to CMP. This is achieved in >75% by three years and >90% by six years of age. Inappropriate or overly long dietary eliminations should be avoided. Such restrictions may impair the quality of life of both child and family, induce improper growth, and also incur unnecessary healthcare costs.