Cow's milk protein allergy

Symptoms of mild to moderate CMPA

• Gastrointestinal: frequent regurgitation, vomiting, diarrhea, constipation (with/without perianal rash), blood in stool, iron deficiency anemia.
• Dermatological: atopic dermatitis.
• Gastric: persistent distress or colic (≥3h per day wailing/irritable) at least 3 days/week over a period of >3 weeks.

Symptoms of severe CMPA

• Gastrointestinal: failure to thrive due to diarrhea or regurgitation/vomiting, refusal to feed, moderate to large amounts of blood in stool with decreased hemoglobin, protein-losing enteropathy.
• Dermatological: failure to thrive and severe atopic dermatitis.
  
  

For Mild to Moderate CMPA

Two-week trial of Extensively Hydrolyzed Formula (EHF)

• First line: SMA Althera.
• Second line: Nutramigen 1 (age <6 months) or Nutramigen 2 (age >6 months).

Evaluation

• Improvement:
  • Reintroduce CMP (restart usual formula).
    • If symptoms recur:
      • Continue EHF prescription.
      • Trial reintroduction of CMP at regular intervals.
    • If no symptoms:
      • Continue normal diet (formula).
      • Consider other diagnoses.
• No Improvement:
  • Two-week trial of Amino Acid Formula (AAF):
    • First line: SMA Alfamino.
    • Second line: Neocate LCP.
  • Improvement:
    • Reintroduce CMP (restart usual formula).
    • If symptoms recur:
      • Continue AAF prescription.
      • Trial reintroduction of CMP at regular intervals.
    • If no symptoms:
      • Continue normal diet (formula).
      • Consider other diagnoses.
  • No Improvement:
    • Consider other diagnoses.

For severe CMPA

• Immediate referral to paediatric dietician for diagnosis and treatment.
  
  

For Mild to Moderate CMPA

Continue breastfeeding

• Mother should follow an elimination diet, excluding CMP for 2 weeks (up to 4 weeks in case of atopic eczema or allergic colitis), plus calcium supplement, and no egg.

Evaluation

• Improvement:
  • Reintroduce CMP into mother's diet.
    • If symptoms recur:
      • Maintain elimination diet in mother (plus calcium supplement).
      • Use eHF after breastfeeding finished and solid foods free of CMP at weaning until 9-12 months of age, and for at least 6 months.
    • If no symptoms:
      • Re-introduce egg and monitor.
• No Improvement:
  • Breast feeding can continue, topical treatment in case of atopic dermatitis
  • Resume normal diet in mother and/or consider other (allergic) diagnoses.

For severe CMPA

• Referral to paediatric dietician for diagnosis and treatment.
• In the meantime, mother should follow an elimination diet (no CMP) plus calcium supplement.
  
  

Refer to paediatric dietician

• Infants with severe CMPA symptoms:
  • Gastrointestinal: failure to thrive because of diarrhea or regurgitation/vomiting, refusal to feed, moderate to large amounts of blood in stool with decreased hemoglobin, protein-losing enteropathy.
  • Dermatological: failure to thrive and severe atopic dermatitis.
• Infants with mild to moderate CMPA who show no improvement after trials of EHF and AAF (for formula-fed infants) or after elimination diet in mother (for breastfed infants).

Do not refer:

• Infants with mild to moderate CMPA who show improvement with EHF or AAF (for formula-fed infants).
• Infants who show improvement with maternal elimination diet (for breastfed infants).

Continue to manage these infants in primary care with periodic reintroduction trials of CMP and regular monitoring.

Consider other diagnoses if symptoms persist without improvement on EHF, AAF, or maternal elimination diet.