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Review
. 2021 Jan 21;13(2):297.
doi: 10.3390/nu13020297.

Cow's Milk Allergy or Gastroesophageal Reflux Disease-Can We Solve the Dilemma in Infants?

Silvia Salvatore  1 , Massimo Agosti  1 , Maria Elisabetta Baldassarre  2 , Enza D'Auria  3 , Licia Pensabene  4 , Luana Nosetti  1 , Yvan Vandenplas  5
Affiliations
Review

Cow's Milk Allergy or Gastroesophageal Reflux Disease-Can We Solve the Dilemma in Infants?

Silvia Salvatore et al. Nutrients. .

Abstract

Cow's milk allergy (CMA) and gastro-esophageal reflux disease (GERD) may manifest with similar symptoms in infants making the diagnosis challenging. While immediate reaction to cow's milk protein indicate CMA, regurgitation, vomiting, crying, fussiness, poor appetite, sleep disturbances have been reported in both CMA and GERD and in other conditions such as functional gastrointestinal disorders, eosinophilic esophagitis, anatomic abnormalities, metabolic and neurological diseases. Gastrointestinal manifestations of CMA are often non-IgE mediated and clinical response to cow's milk free diet is not a proof of immune system involvement. Neither for non-IgE CMA nor for GERD there is a specific symptom or diagnostic test. Oral food challenge, esophageal pH impedance and endoscopy are recommended investigations for a correct clinical classification but they are not always feasible in all infants. As a consequence of the diagnostic difficulty, both over- and under- diagnosis of CMA or GERD may occur. Quite frequently acid inhibitors are empirically started. The aim of this review is to critically update the current knowledge of both conditions during infancy. A practical stepwise approach is proposed to help health care providers to manage infants presenting with persistent regurgitation, vomiting, crying or distress and to solve the clinical dilemma between GERD or CMA.

Keywords: CMA; GER; GERD; alginate; cow’s milk allergy; eosinophilic esophagitis; hydrolyzed formula; infants; reflux; thickened formula.

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Conflict of interest statement

S.S. has participated as advisory board member, and/or consultant, and/or speaker for Bioproject, Danone, D.M.G., Mellin, Nestlé, Novalac; M.E.B. has participated as consultant for Aurora Biofarma, Y.V. has participated as a clinical investigator, and/or advisory board member, and/or consultant, and/or speaker for Abbott Nutrition, Biocodex, Biogaia, CHR Hansen, Danone, Nestle Health Science, Nestle Nutrition Institute, Nutricia, Mead Johnson Nutrition, United Pharmaceuticals, Wyeth. All the above manufacturers and companies have had no input or involvement in any aspect of this study. The other authors have no conflict of interest to disclose.

Figures

Figure 1
Figure 1
Simplified stepwise approach and ACTION PLAN for infants with persistent (≥1 week) regurgitation, vomiting and crying. See text for complete explanation and further details. Legend: US = ultrasound; CM = cow’s milk protein; AR = thickened; PPI = proton pump inhibitors; GER = gastroesophageal reflux; EoE = eosinophilic esophagitis; HPF = high power field.
Figure 2
Figure 2
The challenging clinical overlap among Functional Gastrointestinal Disorder (FGID), GERD, CMA and eosinophilic esophagitis (EoE) in infants (modified from Nielsen 2006 [18].
See this image and copyright information in PMC

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