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Review
. 2021 Oct 21:14:1243-1256.
doi: 10.2147/JAA.S276992. eCollection 2021.

Current Guidelines and Future Strategies for the Management of Cow's Milk Allergy

Yvan Vandenplas  1 , Helen A Brough  2   3   4 , Alessandro Fiocchi  5 , Mohamad Miqdady  6 , Zakiudin Munasir  7 , Silvia Salvatore  8 , Nikhil Thapar  9 , Carina Venter  10 , Mario C Vieira  11 , Rosan Meyer  12   13
Affiliations
Review

Current Guidelines and Future Strategies for the Management of Cow's Milk Allergy

Yvan Vandenplas et al. J Asthma Allergy. .

Abstract

Abstract: Exclusive breast feeding is recommended in all guidelines as the first choice feeding. Cow milk allergy (CMA) can be diagnosed by a diagnostic elimination diet for 2 to 4 weeks with a hypo-allergenic formula, followed by a challenge test with intact cow milk protein. The most often used hypo-allergenic formula for the diagnostic elimination diet and the therapeutic diet is a CM based extensive hydrolysate. CM-based partial hydrolysates cannot be recommended in the management of CMA because of insufficient efficacy and possible reactions, but about half of the infants with CMA may tolerate a partial hydrolysate. The pros and cons of other dietary options are discussed in this paper. The use of an amino acid-based formula and/or rice based hydrolysate formula during the diagnostic elimination and therapeutic diet is debated. When available, there is sufficient evidence to consider rice hydrolysates as an adequate alternative to CM-based hydrolysates, since some infants will still react to the CM hydrolysate. The pros and cons of dietary options such as soy formula, buckwheat, almond, pea or other plant based dietary products are discussed. Although the majority of the plant-based beverages are nutritionally inadequate, some are nutritionally adapted for toddlers. However, accessibility and content vary by country and, thus far there is insufficient evidence on the efficacy and tolerance of these plant-based drinks (except for soy formula and rice hydrolysates) to provide an opinion on them.

Conclusion: A diagnostic elimination diet, followed by a challenge remains the diagnostic standard. The use of an awareness tool may result in a decrease of delayed diagnosis. Breastmilk remains the ideal source of nutrition and when not available a CM extensively hydrolyzed formula, rice hydrolysate or amino acid formula should be recommended. More evidence is needed regarding plant-based drinks.

Keywords: amino acid formula; challenge test; cow milk allergy; hydrolysate; plant-based drink; rice hydrolysate; soy formula.

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Conflict of interest statement

YV has participated as a clinical investigator, and/or advisory board member, and/or consultant, and/or speaker for Abbott Nutrition, Ausnutria, Biogaia, By Heart, CHR Hansen, Danone, ELSE Nutrition, Friesland Campina, Nestle Health Science, Nestle Nutrition Institute, Nutricia, Mead Johnson Nutrition, Phathom Pharmaceuticals, United Pharmaceuticals (Novalac), Yakult, Wyeth. HB reports receiving research grants from the National Institutes of Health (NIH) (U01 # AI147462), Aimmune and DBV Technologies and speaker fees from DBV Technologies and Sanofi outside of the submitted work. AF has participated as an advisory board member, consultant, and/or speaker for Abbott Nutrition, Danone, Nutricia, Ordesa, Humana, and Hipp. MM has participated as an advisory board member, and/or speaker for Abbott Nutrition, Ausnutria, Biogaia, Danone, Friesland Campina, Nestle Nutrition Institute, Nutricia, United Pharmaceuticals (Novalac), and Wyeth. SS has participated as a clinical investigator, and/or advisory board member, and/or consultant, and/or speaker for Danone-Mellin, DVA, Noos, Nestlé, United Pharmaceuticals (Novalac). NT has participated as an advisory board member, and/or consultant, and/or speaker for Danone, Nutricia and Takeda. CV reports grants from Reckitt Benckiser, Food Allergy Research and Education, National Peanut Board; personal fees from Reckitt Benckiser, Nestle Nutrition Institute, Danone, Abbott Nutrition, Else Nutrition, Before Brands. MCV reports personal fees as a consultant and/or speaker from Danone Nutricia and Nestlé Nutrition Institute, outside the submitted work. RM has participated as an advisory board member, and/or consultant, and/or speaker for Abbott Nutrition, Danone, Nestle Health Science, Nutricia and Mead Johnson Nutrition. The authors report no other conflicts of interest in this work.

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