Update Management of cow’s milk protein allergy in infants

Update Management of cow’s milk protein allergy in infants

Cow’s milk is a leading cause of food allergy especially in infants and children. ‘Diagnosis and Rationale for Action against Cow’s Milk Allergy’ published by the World Allergy Organization has underlined that there is not enough information concerning geographical trends in cow’s milk allergy (CMA) in children or adults. CMA is a global challenge and collaboration of the national and international scientific communities is essential to produce and update practical guidelines for CMA.

Symptoms of cow’s milk allergy are non-specific; as a result, suspected cow’s milk allergy is far more common than proven allergy to cow’s milk. Cow’s milk allergy in infants is therefore most probably a fairly uncommon clinical picture; cow’s milk allergy is estimated to occur in less than one per cent of infants. The only valuable additional diagnostic tool is food challenge, preferably double blind. Therapy consists of a formula free of cow’s milk (preferably containing extensively hydrolysed whey protein) from the moment the mother ceases nursing her child until the age of 6-12 months. Solids can be introduced in the usual fashion; there is no scientific basis for introducing them in a step by step fashion. Prevention of cow’s milk allergy by using hypoallergenic formula (partially hydrolysed cow milk protein) in the first year of life has been shown to be unsuccessful, and can no longer be recommended. In the future, oral immunotherapy may be a promising new treatment for cow’s milk allergy.

Between 5% and 15% of infants show symptoms suggesting adverse reactions to cow’s milk protein (CMP),1 while estimates of the prevalence of cow’s milk protein allergy (CMPA) vary from 2% to 7.5%.2 Differences in diagnostic criteria and study design contribute to the wide range of prevalence estimates and underline the importance of an accurate diagnosis, which will reduce the number of infants on inappropriate elimination diets. CMPA is easily missed in primary care settings and needs to be considered as a cause of infant distress and diverse clinical symptoms. Accurate diagnosis and management will reassure parents. CMPA can develop in exclusively and partially breast-fed infants, and when CMP is introduced into the feeding regimen. Early diagnosis and adequate treatment decrease the risk of impaired growth

There are guidelines for the use of dietary products for the prevention and treatment of CMPA. However, there are currently no guidelines that specifically assist primary care physicians and general paediatricians in the accurate diagnosis and management of CMPA. This document aims to meet this need. However, these recommendations may need adaptation to reflect local situations and, because they are not evidence based, need to be prospectively validated and revised in the future. Despite these caveats, the authors believe application of these recommendations will improve the diagnostic and therapeutic skills of physicians in primary care.

Cow’s milk protein (CMP) is usually one of the first complementary foods to be introduced into the infant’s diet and is commonly consumed throughout childhood as part of a balanced diet. CMP is capable of inducing a multitude of adverse reactions in children, which may involve organs like the skin, gastrointestinal (GI) tract or respiratory system. The diagnosis of CMP-induced adverse reactions requires an understanding of their classification and immunological basis as well as the strengths and limitations of diagnostic modalities. In addition to the well-recognised, immediate-onset IgE-mediated allergies, there is increasing evidence to support the role of CMP-induced allergy in a spectrum of delayed-onset disorders ranging from GI symptoms to chronic eczema. The mainstay of treatment is avoidance of CMP; this requires dietetic input to ensure that this does not lead to any nutritional compromise.


A comprehensive history (including a family history of atopy) and careful physical examination form the foundation of both algorithms. The risk of atopy increases if a parent or sibling has atopic disease (20–40% and 25–35%, respectively), and is higher still if both parents are atopic (40–60%). In comparison to cow’s milk formula-fed infants, exclusive breast feeding during the first 4–6 months of life reduces the risk for CMPA and most severe allergic manifestations during early infancy. The distinction between breast-fed and formula-fed infants  reflects the importance of ensuring an adequate duration of breast feeding. Management principles also differ. The management of breast-fed infants depends on reducing the maternal allergen load and strict avoidance of CMP in supplementary feeding. It is recommended that exclusive or partial breast feeding is continued, unless alarm symptoms  require a different management.The earlier CMPA develops, the greater the risk of growth retardation

Clinical manifestations of CMA

I. Gastrointestinal reactions
• Oral allergy syndrome (rare in pediatric patients) • Lip swelling is a commonly observed manifestation during food challenge procedures.
Immediate gastrointestinal allergy
• Vomiting (described in children both isolated and as part of allergic/anaphylactic reactions) • Diarrhea (usually in, but not limited to, delayed reactions)
CMA in short bowel syndrome
• Greater than 50% of these patients are also allergic to cow’s milk, according to 1 case study.
II. IgE-mediated respiratory reactions
• Rhinitis occurs in ±70% of patients during oral cow’s milk challenge, and asthma occurs in less than 8%. • Reactions rarely occur in isolation. • Reactions correlate with severe CMA. • Asthma makes for the worst prognosis in children with anaphylaxis. • Asthma in patients with CMA is of particular severity. • Respiratory symptoms in patients with CMA can progress to respiratory allergy. • Inhalation of milk vapor has been associated with severe respiratory tract reactions.
III. IgE-mediated skin reactions
Acute urticaria or angioedema
• Urticaria is a feature of most anaphylactic reactions to cow’s milk. • Urticaria with inhalation or accidental skin contact  is often severe.
Contact urticaria
• Pattern varies from irritant to allergic contact dermatitis. • Generalized eczematous rash (systemic contact dermatitis) is present. • Contact reactions are frequent in patients with AD.
IV. Late-onset reactions
• Symptoms not IgE mediated • Mostly localized in the gastrointestinal tract • Typically develop 1 to several hours or even days after ingestion • No reliable laboratory tests to diagnose late-onset CMA: IgE test results are negative
Skin • AD
Gastrointestinal tract • Gastroesophageal reflux disease
• Allergic eosinophilic esophagitis
• Food protein–induced enterocolitis syndrome
• Cow’s milk protein–induced enteropathy
• Constipation
• Severe irritability (colic)
• Food protein–induced gastroenteritis and proctocolitis
Respiratory system • Milk-induced chronic pulmonary disease
• Heiner syndrome
• AD is most often present as an eczematous lesion (after ingestion or contact). • AD can involve both IgE-mediated and non–IgE-mediated skin responses. • Less than 30% of children with moderate-to-severe AD have food allergy, and CMA is the second most common food allergy in this population. • The earlier the age of onset, the greater the severity and frequency of high of cow’s milk sIgE levels.67 • Appropriate diagnosis and elimination diets frequently lead to symptom improvement.
VI. Gastrointestinal syndromes
Symptoms frequently include nausea, vomiting, abdominal pain, diarrhea, and, with chronic disease, malabsorption and failure to thrive or weight loss.
• Food protein–induced enterocolitis syndrome, the primary cause of which is CMA • Cow’s milk–induced enteropathy syndrome and secondary lactose malabsorption • Cow’s milk–induced proctocolitis syndrome (relatively benign disorder) • Gastroesophageal reflux disease–like symptoms • Eosinophilic esophagitis • Constipation • Irritable bowel syndrom
VII. Milk-induced chronic pulmonary disease
• Heiner syndrome is a very rare form of pulmonary hemosiderosis caused by CMA. • Young children typically present with recurrent pulmonary infiltrates associated with chronic cough, tachypnea, wheezing, rales, recurrent fevers, and failure to thrive. • Milk-precipitating antibodies are found in the serum. • Symptoms generally resolve after an elimination diet.
Organ involvement Symptoms
Gastrointestinal tract Frequent regurgitation
Constipation (with/without perianal rash)
Blood in stool
Iron deficiency anaemia
Skin Atopic dermatitis
Swelling of lips or eye lids (angio-oedema)
Urticaria unrelated to acute infections, drug intake or other causes
Respiratory tract Runny nose (otitis media)20 21
(unrelated to infection) Chronic cough
General Persistent distress or colic (wailing/irritable for ⩾3 h per day) at least 3 days/week over a period of >3 weeks
  • *Infants with CMPA in general show one or more of the listed symptoms.

Alarm symptoms and findings  indicating severe CMPA as the possible cause

Organ involvement Symptoms and findings
Gastrointestinal tract Failure to thrive due to chronic diarrhoea and/or refusal to feed and/or vomiting
Iron deficiency anaemia due to occult or macroscopic blood loss
Endoscopic/histologically confirmed enteropathy or severe colitis
Skin Exudative or severe atopic dermatitis with hypoalbuminaemia or failure to thrive or iron deficiency anaemia
Respiratory tract Acute laryngoedema or bronchial
(unrelated to infection) obstruction with difficulty breathing
General Anaphylaxis



Patients with life-threatening, particularly respiratory symptoms or anaphylaxis, conditions need to be referred immediately to an emergency department experienced in the treatment of this condition. In all the other situations, the initial step in the diagnostic work-up for CMPA is clinical assessment accompanied by history taking, including establishing whether there is a family history of atopic disease .

The algorithm differs according to the severity of symptoms. If the infant does not present alarm symptoms , the case is considered as mild-to-moderate suspected CMPA, and a diagnostic elimination diet should be initiated. Infants presenting with symptoms such as angio-oedema of lips and/or eyes, urticaria and immediate vomiting are likely to have IgE-mediated allergy. In the case of IgE-mediated allergy, improvement (and normalisation) offers a safety net before challenge. A positive SPT increases the likelihood of a positive food challenge but not the severity of the reaction. In the study from Celik-Bilgili and coworkers, 60% of the patients with a RAST class 1, 50% in class 2, 30% in class 3 and even 20% in class 4 had a negative food challenge


In a case of suspected mild-to-moderate CMPA, CMP elimination should start with a therapeutic formula for CMPA. The guidelines define a therapeutic formula as one that is tolerated by at least 90% (with 95% confidence) of CMPA infants.31 These criteria are met by some eHFs based on whey, casein or another protein source, and by amino acid-based formulae (AAF). Preferentially, all supplementary food should be stopped during the diagnostic elimination diet. If this is not possible in infants beyond 6 months, only a few supplementary foods should be allowed with dietary counselling. Nevertheless, the diet should not contain CMP or hen’s eggs, soy protein or peanut. Referral to a paediatric specialist and dietary counselling may be needed for patients who do not improve. In such cases, further elimination of other allergenic proteins such as fish and wheat may be appropriate. In most cases, the therapeutic elimination diet should be given for at least 2 weeks, although this may need to be increased to up to 4 weeks in gastrointestinal manifestations and atopic dermatitis before deciding that the intervention has failed.

eHFs that meet the definition of a therapeutic formula are the first choice. An AAF is indicated: if the child refuses to drink the eHF, but accepts the AAF (eHF has a more bitter taste than AAF), if the symptoms do not improve on the eHF after 2–4 weeks, or if the cost–benefit ratio favours the AAF over the eHF. The cost–benefit ratio of AAF versus eHF is difficult to elaborate in this global overview since health care cost differs substantially from country to country, as does the cost of the eHF and the AAF, which in some countries is (partially) reimbursed by national or private health insurance. The risk of failure of eHF is up to 10% of children with CMPA.4 In the latter case, clinicians should refer to a specialist for further diagnostic work-up.

Children may react to residual allergens in eHF, which may be one reason for the failure. The residual allergens in eHFs seem to be more likely to produce gastrointestinal and other non-IgE-associated manifestations compared to AAFs.4 6 32 However, IgE-related reactions have also been reported with eHF. In such cases, clinicians should consider an AAF which has been proven to be safe and nutritionally adequate to promote weight gain and growth. In some situations, the infant may be initially switched to an AAF, especially if they experience multiple food allergies, specific gastrointestinal manifestations or both. In these instances, the potential benefits of an AAF may outweigh its higher cost. If symptoms do not disappear on the AAF, another diagnosis should be considered.


  • Brand PL, Rijk-van Gent H.Cow’s milk allergy in infants: new insights. Ned Tijdschr Geneeskd. 2011;155(27):A3508.
  • Yvan Vandenplas1. Martin Brueton. Christophe. Dupont. David Hill. ErikaIsolauri. Sibylle Koletzko. Arnold P Oranje. Annamaria Staiano.  Guidelines for the diagnosis and management of cow’s milk protein allergy in infants. Arch Dis Child2007;92:902-908    
  • American College of Allergy, Asthma, & Immunology. Food allergy: a practice parameter. Ann Allergy Asthma Immunol. 2006;96(Suppl 2):S1–S68.
  • Mukoyama T, Nishima S, Arita M, Ito S, Urisu A, et al. Guidelines for diagnosis and management of pediatric food allergy in Japan. Allergol Int. 2007;56:349–361.
  • Cow’s milk allergy in infancy. Heine RG, Elsayed S, Hosking CS, Hill DJ. Curr Opin Allergy Clin Immunol. 2002 Jun;2(3):217-25. Review.PMID: 12045418 [PubMed – indexed for MEDLINE]Related citations
  • Gastrointestinal allergy to food: a review. Ahmed T, Fuchs GJ. J Diarrhoeal Dis Res. 1997 Dec;15(4):211-23. Review.PMID: 9661317
  • The effect of hypo-allergenic formulas in infants at risk of allergic disease. Halken S, Jacobsen HP, Høst A, Holmenlund D. Eur J Clin Nutr. 1995 Sep;49 Suppl 1:S77-83. Review.
  • Allergy to cow’s milk protein hydrolysates: apropos of 8 cases] Sotto D, Tounian P, Baudon JJ, Pauliat S, Challier P, Fontaine JL, Girardet JP. Arch Pediatr. 1999 Dec;6(12):1279-85.
  • Children who are allergic to cow’s milk. Nutritional treatment] Casado Dones MJ, Cruz Martín RM, Moreno González C, Oya Luis I, Martin Rodríguez M. Rev Enferm. 2008 Sep;31(9):51-8.
  • Incidence of allergy to cow’s milk protein in the first year of life and its effect on consumption of hydrolyzed formulae] García Ara MC, Boyano Martínez MT, Díaz Pena JM, Martín Muñoz F, Pascual Marcos C, García Sánchez G, Martín Esteban M.  An Pediatr (Barc). 2003 Feb;58(2):100-5.
  • Atopy patch test in the diagnosis of food allergy in children with atopic eczema dermatitis syndrome.  Cudowska B, Kaczmarski M.  Rocz Akad Med Bialymst. 2005;50:261-7.
  • Cow’s milk challenge through human milk evokes immune responses in infants with cow’s milk allergy. Järvinen KM, Mäkinen-Kiljunen S, Suomalainen H.  J Pediatr. 1999 Oct;135(4):506-12.
  • Gastroesophageal reflux associated with cow’s milk allergy in infants: which diagnostic examinations are useful? Cavataio F, Iacono G, Montalto G, Soresi M, Tumminello M, Campagna P, Notarbartolo A, Carroccio A. Am J Gastroenterol. 1996 Jun;91(6):1215-20.
  • Clinical course and prognosis of cow’s milk allergy are dependent on milk-specific IgE status. Saarinen KM, Pelkonen AS, Mäkelä MJ, Savilahti E. J Allergy Clin Immunol. 2005 Oct;116(4):869-75.
  • Cow’s milk allergy: guidelines for the diagnostic evaluation] Kirchlechner V, Dehlink E, Szepfalusi Z. Klin Padiatr. 2007 Jul-Aug;219(4):201-5. Epub 2006 Mar 15.
  • The natural history of IgE-mediated cow’s milk allergy. Skripak JM, Matsui EC, Mudd K, Wood RA. J Allergy Clin Immunol. 2007 Nov;120(5):1172-7.
  • Use of goat’s milk in patients with cow’s milk allergy] Infante Pina D, Tormo Carnice R, Conde Zandueta M. An Pediatr (Barc). 2003 Aug;59(2):138-42.
  • Fractional exhaled nitric oxide in infants during cow’s milk food challenge. Gabriele C, Hol J, Kerkhof E, Elink Schuurman BE, Samsom JN, Hop W, Nieuwenhuis EE, de Jongste JC. Pediatr Allergy Immunol. 2008 Aug;19(5):420-5.
  • WITHDRAWN: Cow’s milk protein avoidance and development of childhood wheeze in children with a family history of atopy. Ram FS, Ducharme FM, Scarlett J.  Cochrane Database Syst Rev. 2007 Jul 18;(2):CD003795. Review.
  • [Prognoses of food allergy in infancy] Wang NR, Li HQ. Zhonghua Er Ke Za Zhi. 2005 Oct;43(10):777-81.
  • Accidental allergic reactions in children allergic to cow’s milk proteins. Boyano-Martínez T, García-Ara C, Pedrosa M, Díaz-Pena JM, Quirce S. J Allergy Clin Immunol. 2009 Apr;123(4):883-8.
  • The spectrum of cow’s milk allergy in childhood. Clinical, gastroenterological and immunological studies. Hill DJ, Davidson GP, Cameron DJ, Barnes GL. Acta Paediatr Scand. 1979 Nov;68(6):847-52.
  • Milk allergy and vitamin D deficiency rickets: a common disorder associated with an uncommon disease. Yu JW, Pekeles G, Legault L, McCusker CT. Ann Allergy Asthma Immunol. 2006 Apr;96(4):615-9
  • Cow’s milk protein avoidance and development of childhood wheeze in children with a family history of atopy. Ram FS, Ducharme FM, Scarlett J. Cochrane Database Syst Rev. 2002;(3):CD003795. Review. Update in: Cochrane Database Syst Rev. 2007;(2):CD003795.
  • Lymphocyte response to cow’s milk proteins in patients with cow’s milk allergy: relationship to antigen exposure. Suomalainen H, Soppi E, Isolauri E. Pediatr Allergy Immunol. 1994 Feb;5(1):20-6.
  • The spectrum of cow’s milk allergy. Eigenmann PA. Pediatr Allergy Immunol. 2007 May;18(3):265-71.
  • Clinical practice. Diagnosis and treatment of cow’s milk allergy. Kneepkens CM, Meijer Y. Eur J Pediatr. 2009 Aug;168(8):891-6. Epub 2009 Mar 7.
  • Growth in infants with cow’s milk allergy] Moreno Villares JM, Oliveros Leal L, Torres Peral R, Luna Paredes C, Martínez-Gimeno A, García-Hernández G. An Pediatr (Barc). 2006 Mar;64(3):244-7. Spanish.
  • Diagnosis of food allergy in children] Dupont C, Barau E. Ann Pediatr (Paris). 1992 Jan;39(1):5-12.
  • Cow’s milk formula as a cause of infantile colic: a double-blind study. Lothe L, Lindberg T, Jakobsson I. Pediatrics. 1982 Jul;70(1):7-10.
  • Feeding a soy formula to children with cow’s milk allergy: the development of immunoglobulin E-mediated allergy to soy and peanuts. Klemola T, Kalimo K, Poussa T, Juntunen-Backman K, Korpela R, Valovirta E, Vanto T.Pediatr Allergy Immunol. 2005 Dec;16(8):641-6.
  • Prospective, controlled, multi-center study on the effect of an amino-acid-based formula in infants with cow’s milk allergy/intolerance and atopic dermatitis. Niggemann B, Binder C, Dupont C, Hadji S, Arvola T, Isolauri E. Pediatr Allergy Immunol. 2001 Apr;12(2):78-82.
  • Persistent cow’s milk protein intolerance in infants: the changing faces of the same disease. Iacono G, Cavataio F, Montalto G, Soresi M, Notarbartolo A, Carroccio A. Clin Exp Allergy. 1998 Jul;28(7):817-23.
  • Adequacy and tolerance to ass’s milk in an Italian cohort of children with cow’s milk allergy. Tesse R, Paglialunga C, Braccio S, Armenio L.Ital J Pediatr. 2009 Jul 9;35:19.- in process]
  • Multiple food allergy: a possible diagnosis in breastfed infants. de Boissieu D, Matarazzo P, Rocchiccioli F, Dupont C. Acta Paediatr. 1997 Oct;86(10):1042-6.PMID: 9350880
  • [Could whey be responsible for the development of cow’s milk allergy in newborns and infants?]Thaller T, Mutz I, Girardi L. Klin Padiatr. 2004 Mar-Apr;216(2):87-90.
  • Oral desensitization in children with cow’s milk allergy.  Zapatero L, Alonso E, Fuentes V, Martínez MI. J Investig Allergol Clin Immunol. 2008;18(5):389-96.PMID: 18973104
  • Modified proteins in allergy prevention. von Berg A. Nestle Nutr Workshop Ser Pediatr Program. 2009;64:239-47; discussion 247-57.
  • Favorable effect of breast feeding and late introduction of cow’s milk on the prevention of suspected allergic symptoms in infancy] Arató A, Szalai K, Tausz I, Szönyi L. Orv Hetil. 1996 Sep 8;137(36):1979-82. Review.
  • Maintenance of tolerance to cow’s milk in atopic individuals is characterized by high levels of specific immunoglobulin G4. Ruiter B, Knol EF, van Neerven RJ, Garssen J, Bruijnzeel-Koomen CA, Knulst AC, van Hoffen E. Clin Exp Allergy. 2007 Jul;37(7):1103-10.
  • Use of an amino-acid-based formula in the treatment of cow’s milk protein allergy and multiple food allergy syndrome] Kanny G, Moneret-Vautrin DA, Flabbee J, Hatahet R, Virion JM, Morisset M, Guenard L. Allerg Immunol (Paris). 2002 Mar;34(3):82-4.
  • Severe and unusual clinical manifestations of intolerance to cow’s milk protein in 3 patients under 12 months of age]Pela I, Materassi D, Chiappini E, Silberhorn H, Zammarchi E. Pediatr Med Chir. 2001 Jan-Feb;23(1):65-7.
  • Supplementary feeding in maternity hospitals and the risk of cow’s milk allergy: A prospective study of 6209 infants. Saarinen KM, Juntunen-Backman K, Järvenpää AL, Kuitunen P, Lope L, Renlund M, Siivola M, Savilahti E. J Allergy Clin Immunol. 1999 Aug;104(2 Pt 1):457-61.
  • Higher serum eosinophil cationic protein levels in children with cow’s milk allergy. Hidvégi E, Cserháti E, Kereki E, Arató A. J Pediatr Gastroenterol Nutr. 2001 Apr;32(4):475-9.
  • Frequency of cow’s milk allergy in childhood. Høst A. Ann Allergy Asthma Immunol. 2002 Dec;89(6 Suppl 1):33-7. Review.
  • Cow’s milk protein allergy and intolerance in infancy. Some clinical, epidemiological and immunological aspects. Høst A. Pediatr Allergy Immunol. 1994;5(5 Suppl):1-36. Review.
  • The natural history of cow’s milk protein allergy/intolerance. Høst A, Jacobsen HP, Halken S, Holmenlund D. Eur J Clin Nutr. 1995 Sep;49 Suppl 1:S13-8. Review.
  • Clinical course of cow’s milk protein allergy/intolerance and atopic diseases in childhood. Høst A, Halken S, Jacobsen HP, Christensen AE, Herskind AM, Plesner K. Pediatr Allergy Immunol. 2002;13 Suppl 15:23-8.
  • Natural course of cow’s milk allergy in childhood atopic eczema/dermatitis syndrome. Oranje AP, Wolkerstorfer A, de Waard-van der Spek FB. Ann Allergy Asthma Immunol. 2002 Dec;89(6 Suppl 1):52-5. Review.
  • Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants. Osborn DA, Sinn J. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD003664. Review.
  • Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants. Osborn DA, Sinn J. Cochrane Database Syst Rev. 2003;(4):CD003664. Review. Update in: Cochrane Database Syst Rev. 2006;(4):CD003664.
  • Cow’s milk protein allergy. A multi-centre study: clinical and epidemiological aspects. Martorell A, Plaza AM, Boné J, Nevot S, García Ara MC, Echeverria L, Alonso E, Garde J, Vila B, Alvaro M, Tauler E, Hernando V, Fernández M. Allergol Immunopathol (Madr). 2006 Mar-Apr;34(2):46-53.
  • Prevention of allergic disease in childhood: clinical and epidemiological aspects of primary and secondary allergy prevention. Halken S. Pediatr Allergy Immunol. 2004 Jun;15 Suppl 16:4-5, 9-32. Review.
  • Anaphylaxis to cow’s milk and beef meat proteins. Eigenmann PA. Ann Allergy Asthma Immunol. 2002 Dec;89(6 Suppl 1):61-4. Review.
  • Soy formula for prevention of allergy and food intolerance in infants.  Osborn DA, Sinn J. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD003741. Review
  • A prospective study of cow milk allergy in Danish infants during the first 3 years of life. Clinical course in relation to clinical and immunological type of hypersensitivity reaction. Høst A, Halken S. Allergy. 1990 Nov;45(8):587-96.
  • Milk allergy/intolerance and atopic dermatitis in infancy and childhood. Novembre E, Vierucci A. Allergy. 2001;56 Suppl 67:105-8. Review.
  • [Cow’s milk protein allergy after neonatal intestinal surgery.] El Hassani A, Michaud L, Chartier A, Penel-Capelle D, Sfeir R, Besson R, Turck D, Gottrand F. Arch Pediatr. 2005 Feb;12(2):134-9. French.
  • New guidelines for managing cow’s milk allergy in infants. Meyer R. J Fam Health Care. 2008;18(1):27-30. Review.
  • Soy formula for prevention of allergy and food intolerance in infants. Osborn DA, Sinn J. Cochrane Database Syst Rev. 2004;(3):CD003741. Review. Update in: Cochrane Database Syst Rev. 2006;(4):CD003741.
  • Rectal bleeding in infancy: clinical, allergological, and microbiological examination. Arvola T, Ruuska T, Keränen J, Hyöty H, Salminen S, Isolauri E. Pediatrics. 2006 Apr;117(4):e760-8.PMID: 16585287
  • Cow’s milk allergy: a new understanding from immunology. Walker-Smith J. Ann Allergy Asthma Immunol. 2003 Jun;90(6 Suppl 3):81-3. Review
  • Safety and efficacy of a new extensively hydrolyzed formula for infants with cow’s milk protein allergy. Niggemann B, von Berg A, Bollrath C, Berdel D, Schauer U, Rieger C, Haschke-Becher E, Wahn U. Pediatr Allergy Immunol. 2008 Jun;19(4):348-54.
  • Development of food allergies with special reference to cow’s milk allergy. Foucard T. Pediatrics. 1985 Jan;75(1 Pt 2):177-81. Review.
  • Clinical spectrum of food allergy in children in Australia and South-East Asia: identification and targets for treatment. Hill DJ, Hosking CS, Heine RG. Ann Med. 1999 Aug;31(4):272-81. Review.
  • [Double-blind, placebo-controlled cow’s milk challenge in children with alleged cow’s milk allergies, performed in a general hospital: diagnosis rejected in two-thirds of the children] Hospers IC, de Vries-Vrolijk K, Brand PL. Ned Tijdschr Geneeskd. 2006 Jun 10;150(23):1292-7. Dutch.
  • [Incidence of IgE-mediated allergy to cow’s milk proteins in the first year of life] Sanz Ortega J, Martorell Aragonés A, Michavila Gómez A, Nieto García A; Grupo de Trabajo para el Estudio de la Alergia Alimentaria. An Esp Pediatr. 2001 Jun;54(6):536-9.
  • Adverse reactions to milk in infants. Kvenshagen B, Halvorsen R, Jacobsen M. Acta Paediatr. 2008 Feb;97(2):196-200.
  • Incremental prognostic factors associated with cow’s milk allergy outcomes in infant and child referrals: the Milan Cow’s Milk Allergy Cohort study. Fiocchi A, Terracciano L, Bouygue GR, Veglia F, Sarratud T, Martelli A, Restani P. Ann Allergy Asthma Immunol. 2008 Aug;101(2):166-73.
  • Epidemiology, incidence and clinical aspects of food allergy. Businco L, Benincori N, Cantani A. Ann Allergy. 1984 Dec;53(6 Pt 2):615-22. Review.
  • Allergy to soy formula and to extensively hydrolyzed whey formula in infants with cow’s milk allergy: a prospective, randomized study with a follow-up to the age of 2 years. Klemola T, Vanto T, Juntunen-Backman K, Kalimo K, Korpela R, Varjonen E. J Pediatr. 2002 Feb;140(2):219-24.
  • Infant feeding patterns affect the subsequent immunological features in cow’s milk allergy. Saarinen KM, Savilahti E. Clin Exp Allergy. 2000 Mar;30(3):400-6.
  • Importance of the first meal on the development of cow’s milk allergy and intolerance. Høst A. Allergy Proc. 1991 Jul-Aug;12(4):227-32.
  • Concurrent cereal allergy in children with cow’s milk allergy manifested with atopic dermatitis. Järvinen KM, Turpeinen M, Suomalainen H. Clin Exp Allergy. 2003 Aug;33(8):1060-6.
  • Cow’s milk allergy in Thai children. Ngamphaiboon J, Chatchatee P, Thongkaew T. Asian Pac J Allergy Immunol. 2008 Dec;26(4):199-204.
  • Prospective estimation of IgG, IgG subclass and IgE antibodies to dietary proteins in infants with cow milk allergy. Levels of antibodies to whole milk protein, BLG and ovalbumin in relation to repeated milk challenge and clinical course of cow milk allergy. Høst A, Husby S, Gjesing B, Larsen JN, Løwenstein H. Allergy. 1992 Jun;47(3):218-29.
  • Cow’s milk allergy in the first year of life. An Italian Collaborative Study. [No authors listed] Acta Paediatr Scand Suppl. 1988;348:1-14.
  • Challenge testing in children with allergy to cow’s milk proteins. Plaza Martín AM, Martín Mateos MA, Giner Muñoz MT, Sierra Martínez JI. Allergol Immunopathol (Madr). 2001 Mar-Apr;29(2):50-4.
  • Beef allergy in children with cow’s milk allergy; cow’s milk allergy in children with beef allergy. Martelli A, De Chiara A, Corvo M, Restani P, Fiocchi A. Ann Allergy Asthma Immunol. 2002 Dec;89(6 Suppl 1):38-43. Review.
  • Management of bovine protein allergy: new perspectives and nutritional aspects. Moro GE, Warm A, Arslanoglu S, Miniello V. Ann Allergy Asthma Immunol. 2002 Dec;89(6 Suppl 1):91-6. Review.
  • [Persistent forms of cow’s milk allergy. Report of 6 cases] Ben Halima N, Krichen A, Mekki MA, Ben ML, Chabchoub I, Chaabouni M, Triki A, Karray A. Tunis Med. 2003 Sep;81(9):731-7.
  • Prevention and management of food allergy. Businco L, Bruno G, Giampietro PG. Acta Paediatr Suppl. 1999 Aug;88(430):104-9. Review.
  • A hydrolysed rice-based formula is tolerated by children with cow’s milk allergy: a multi-centre study. Fiocchi A, Restani P, Bernardini R, Lucarelli S, Lombardi G, Magazzù G, Marseglia GL, Pittschieler K, Tripodi S, Troncone R, Ranzini C. Clin Exp Allergy. 2006 Mar;36(3):311-6.
  • Markers of inflammation in the feces of infants with cow’s milk allergy. Saarinen KM, Sarnesto A, Savilahti E. Pediatr Allergy Immunol. 2002 Jun;13(3):188-94.
  • A prospective study of cow’s milk protein intolerance in Swedish infants. Jakobsson I, Lindberg T. Acta Paediatr Scand. 1979 Nov;68(6):853-9.
  • Soy formulas and nonbovine milk. Muraro MA, Giampietro PG, Galli E. Ann Allergy Asthma Immunol. 2002 Dec;89(6 Suppl 1):97-101.
  • Natural history of cow’s milk allergy. An eight-year follow-up study in 115 atopic children. Cantani A, Micera M. Eur Rev Med Pharmacol Sci. 2004 Jul-Aug;8(4):153-64.
  • Cow’s milk protein-specific IgE concentrations in two age groups of milk-allergic children and in children achieving clinical tolerance. Sicherer SH, Sampson HA. Clin Exp Allergy. 1999 Apr;29(4):507-12.
  • Vomiting and gastric motility in infants with cow’s milk allergy. Ravelli AM, Tobanelli P, Volpi S, Ugazio AG. J Pediatr Gastroenterol Nutr. 2001 Jan;32(1):59-64.
  • Accuracy of specific IgE antibody assays for diagnosis of cow’s milk allergy. Ahlstedt S, Holmquist I, Kober A, Perborn H. Ann Allergy Asthma Immunol. 2002 Dec;89(6 Suppl 1):21-5.
  • [Prevalence of soya allergy in children with cow’s milk allergy] Szaflarska-Szczepanik A, Gasiorowska J. Med Wieku Rozwoj. 2003 Apr-Jun;7(2):241-8. Polish.
  • Hypoallergenic formulas–when, to whom and how long: after more than 15 years we know the right indication! Høst A, Halken S. Allergy. 2004 Aug;59 Suppl 78:45-52. Review.
  • [Clinical evaluation of the tolerance for a soy-based special milk formula in children with cow’s milk protein intolerance/allergy (CMPI/CMPA)] Buts JP, Di Sano C, Hansdorffer S. Minerva Pediatr. 1993 May;45(5):209-13. Italian.
  • [Double blind placebo controlled cow’s milk provocation for the diagnosis of cow’s milk allergy in infants and children] Schade RP, Meijer Y, Pasmans SG, Knulst AC, Kimpen JL, Bruijnzeel-Koomen CA. Ned Tijdschr Geneeskd. 2002 Sep 14;146(37):1739-42.
  • Educational clinical case series for pediatric allergy and immunology: allergic proctocolitis, food protein-induced enterocolitis syndrome and allergic eosinophilic gastroenteritis with protein-losing gastroenteropathy as manifestations of non-IgE-mediated cow’s milk allergy. Maloney J, Nowak-Wegrzyn A. Pediatr Allergy Immunol. 2007 Jun;18(4):360-7. Review.
  • Cow’s milk allergy, incidence and pathogenetic role of early exposure to cow’s milk formula. Stintzing G, Zetterström R. Acta Paediatr Scand. 1979 May;68(3):383-7.
  • Bahna SL. Cow’s milk allergy versus cow milk intolerance.Ann Allergy Asthma Immunol. 2002 Dec;89(6 Suppl 1):56-60. Review.
  • The predictive value of specific immunoglobulin E on the outcome of milk allergy. Rottem M, Shostak D, Foldi S. Isr Med Assoc J. 2008 Dec;10(12):862-4.
  • Evidence of very delayed clinical reactions to cow’s milk in cow’s milk-intolerant patients. Carroccio A, Montalto G, Custro N, Notarbartolo A, Cavataio F, D’Amico D, Alabrese D, Iacono G. Allergy. 2000 Jun;55(6):574-9.
  • Exposure to cow’s milk during the first 3 months of life is associated with increased levels of IgG subclass antibodies to beta-lactoglobulin to 8 years. Jenmalm MC, Björkstén B. J Allergy Clin Immunol. 1998 Oct;102(4 Pt 1):671-8.
  • The efficacy of amino acid-based formulas in relieving the symptoms of cow’s milk allergy: a systematic review. Hill DJ, Murch SH, Rafferty K, Wallis P, Green CJ. Clin Exp Allergy. 2007 Jun;37(6):808-22. Review.
  • Gastroesophageal reflux and cow’s milk allergy in infants: a prospective study. Iacono G, Carroccio A, Cavataio F, Montalto G, Kazmierska I, Lorello D, Soresi M, Notarbartolo A. J Allergy Clin Immunol. 1996 Mar;97(3):822-7.
  • Gastrointestinal manifestations of cow’s milk protein allergy during the first year of life. Yimyaem P, Chongsrisawat V, Vivatvakin B, Wisedopas N. J Med Assoc Thai. 2003 Feb;86(2):116-23.
  • Prevalence of soy protein hypersensitivity in cow’s milk protein-sensitive children in Korea.Ahn KM, Han YS, Nam SY, Park HY, Shin MY, Lee SI. J Korean Med Sci. 2003 Aug;18(4):473-7.
  • Prescott SL. The Australasian Society of Clinical Immunology and Allergy position statement: Summary of allergy prevention in children. Med J Aust. 2005;182:464–467.
  • Muraro A, Dreborg S, Halken S, Høst A, Niggemann B, et al. Dietary prevention of allergic diseases in infants and small children. Part III: Critical review of published peer-reviewed observational and interventional studies and final recommendations. Pediatr Allergy Immunol. 2004;15:291–307.
  • Muraro A, Dreborg S, Halken S, Høst A, Niggemann B, et al. Dietary prevention of allergic diseases in infants and small children. Part I: immunologic background and criteria for hypoallergenicity. Pediatr Allergy Immunol. 2004;15:103–11.
  • Muraro A, Dreborg S, Halken S, Høst A, Niggemann B, Aalberse R, et al. Dietary prevention of allergic diseases in infants and small children. Part II. Evaluation of methods in allergy prevention studies and sensitization markers. Definitions and diagnostic criteria of allergic diseases. Pediatr Allergy Immunol. 2004;15:196–205.
  • Høst A, Koletzko B, Dreborg S, Muraro A, Wahn U, et al. Dietary products used in infants for treatment and prevention of food allergy. Joint Statement of the European Society for Paediatric Allergology and Clinical Immunology (ESPACI) Committee on Hypoallergenic Formulas and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition. Arch Dis Child. 1999;81:80–84.
  • American Academy of Pediatrics Committee on Nutrition. Hypoallergenic infant formulae. Pediatrics. 2000;106:346–349.
  • Johansson SG, Hourihane JO, Bousquet J. A revised nomenclature for allergy. An EAACI position statement from the EAACI nomenclature task force. Allergy. 2001;56:813–824.
  • Johansson SG, Bieber T, Dahl R. Revised nomenclature for allergy for global use: report of the Nomenclature Review Committee of the World Allergy Organization, 2003. J Allergy Clin Immunol. 2004;113:832–836

Links Article Cow’s Milk Allergy

Provided by


Yudhasmara Foundation htpp://www.allergyclinic.wordpress.com/

WORKING TOGETHER FOR STRONGER, SMARTER AND HEALTHIER CHILDREN BY EDUCATION, CLINICAL INTERVENTION, RESEARCH AND INFORMATION NETWORKING. Advancing of the future pediatric and future parenting to optimalized physical, mental and social health and well being for fetal, newborn, infant, children, adolescents and young adult



  • Dr Narulita Dewi SpKFR, Physical Medicine & Rehabilitation
  • Dr Widodo Judarwanto SpA, Pediatrician
  • Fisioterapis

Clinical and Editor in Chief :

Dr Widodo Judarwanto, pediatrician email : judarwanto@gmail.com, Curiculum Vitae

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider.

Copyright © 2012, Children Allergy Clinic Online Information Education Network. All rights reserved


2 responses to “Update Management of cow’s milk protein allergy in infants

Tinggalkan Balasan

Isikan data di bawah atau klik salah satu ikon untuk log in:

Logo WordPress.com

You are commenting using your WordPress.com account. Logout / Ubah )

Gambar Twitter

You are commenting using your Twitter account. Logout / Ubah )

Foto Facebook

You are commenting using your Facebook account. Logout / Ubah )

Foto Google+

You are commenting using your Google+ account. Logout / Ubah )

Connecting to %s