World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines update - X - Breastfeeding a baby with cow's milk allergy

Vicki McWilliam^{1

2

3}, Merryn J Netting^{4

5

6}, Evelyn Volders⁷, Debra J Palmer^{8

9}; WAO DRACMA Guideline Group

Collaborators, Affiliations

Collaborators

WAO DRACMA Guideline Group:
Ignacio Ansotegui¹⁰, Stefania Arasi¹¹, Amal H Assa'ad¹², Sami L Bahna¹³, Roberto Berni Canani¹⁴, Antonio Bognanni¹⁵, Martin Bozzola¹⁶, Jan Brozek¹⁷, Derek Chu¹⁵, Lamia Dahdah¹¹, Christophe Dupont¹⁷, Piotr Dziechciarz¹, Motohiro Ebisawa¹⁸, Ramon T Firmino¹⁹, Alessandro Fiocchi¹¹, Elena Galli²⁰, Rose Kamenwa²¹, Gideon Lack^{22

23}, Haiqi Li²⁴, Alberto Martelli²⁵, Anna Nowak-Węgrzyn^{26

27}, Nikolas G Papadopoulos^{28

29}, Ruby Pawankar³⁰, Maria Said³¹, Mario Sánchez-Borges³², Holger Schunemann^{17

33}, Raanan Shamir³⁴, Jonathan Spergel³⁵, Hania Szajewska³⁶, Luigi Terracciano³⁷, Yvan Vandenplas³⁸, Susan Waserman³⁹, Carina Venter^{40

41}, Amena Warner⁴², Gary Wk Wong⁴³

Affiliations

¹ Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia.
² Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, VIC, Australia.
³ Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia.
⁴ Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia.
⁵ School of Medicine, University of Adelaide, Adelaide, SA, Australia.
⁶ Nutrition Department, Women's and Children's Health Network, North Adelaide, SA, Australia.
⁷ Nutrition, Dietetics & Food, Monash University, Clayton, Vic, Australia.
⁸ Telethon Kids Institute, University of Western Australia, Nedlands, WA, Australia.
⁹ School of Medicine, University of Western Australia, Crawley, WA, Australia.
¹⁰ Department of Allergy & Immunology, Hospital Quironsalud Bizkaia, Bilbao, Spain.
¹¹ Translational Research in Pediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, Rome, 00165, Italy.
¹² Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
¹³ Allergy & Immunology Section, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA.
¹⁴ Department of Translational Medical Science, University of Naples Federico II, Naples, Italy.
¹⁵ Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Ontario, Canada.
¹⁶ Department of Pediatrics, Section of Pediatric Allergy and Immunology. British Hospital. Buenos Aires, Argentina.
¹⁷ Paris Descartes University, Pediatric Gastroenterology, Necker Hospital, Paris, Clinique Marcel Sembat, Boulogne-Billancourt, France.
¹⁸ Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan.
¹⁹ Faculty of Medical Sciences of Campina Grande, UNIFACISA University Centre, Campina Grande, Paraiba, Brazil.
²⁰ Pediatric Allergy Unit, San Pietro Hospital - Fatebenefratelli, Rome, Italy.
²¹ Department of Paediatrics and Child Health, Aga Khan University Hospital, Nairobi, Kenya.
²² Department of Woman and Childrens' Health/Peter Gorer Department of Immunobiology, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, UK.
²³ Evelina London Children's Hospital, Guy's St Thomas' Hospital, NHS Foundation Trust, London, UK.
²⁴ Department of Primary Child Care, Children's Hospital, Chongqing Medical University, China.
²⁵ Allergist, Edmondo de Amicis School, Milan, Italy.
²⁶ Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Childrens' Hospital, New York, NY, USA.
²⁷ Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland.
²⁸ Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.
²⁹ Allergy Unit, 2nd Paediatric Clinic, University of Athens, Athens, Greece.
³⁰ Department of Pediatrics, Nippon Medical School, Tokyo, Japan.
³¹ Allergy & Anaphylaxis Australia (AAA), Castle Hill, New South Wales, Australia.
³² Allergy and Clinical Immunology Department, Centro Médico - Docente La Trinidad and Clínica El Avila, Caracas, Venezuela.
³³ Cochrane Canada and McMaster University GRADE Center, Hamilton, Ontario, Canada.
³⁴ Institute for Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Lea and Arieh Pickel Chair for Pediatric Research, Sackler Faculty of Medicine, Tel Aviv University, Petach Tikva, Israel.
³⁵ Division of Allergy-Immunology, Dept of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA.
³⁶ Pediatric Primary Care, National Pediatric Health Care System, Milan, Italy.
³⁷ Institute for Quality and Efficiency in Health Care, Cologne, Germany.
³⁸ KidZ Health Castle, Dept of Pediatrics UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium.
³⁹ Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON, Canada.
⁴⁰ Section of Allergy and Immunology, University of Colorado Denver School of Medicine, Children's Hospital Colorado, Aurora, CO, USA.
⁴¹ The David Hide Asthma and Allergy Research Centre, Newport, Isle of Wight, UK.
⁴² Allergy UK, London, England, UK.
⁴³ Department of Paediatrics, Faculty of Medicine, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong.

PMID: 38020284
PMCID: PMC10656250
DOI: 10.1016/j.waojou.2023.100830

World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines update - X - Breastfeeding a baby with cow's milk allergy

Vicki McWilliam et al. World Allergy Organ J. 2023.

. 2023 Nov 3;16(11):100830.

doi: 10.1016/j.waojou.2023.100830. eCollection 2023 Nov.

Authors

Vicki McWilliam^{1

2

3}, Merryn J Netting^{4

5

6}, Evelyn Volders⁷, Debra J Palmer^{8

9}; WAO DRACMA Guideline Group

Collaborators

WAO DRACMA Guideline Group:
Ignacio Ansotegui¹⁰, Stefania Arasi¹¹, Amal H Assa'ad¹², Sami L Bahna¹³, Roberto Berni Canani¹⁴, Antonio Bognanni¹⁵, Martin Bozzola¹⁶, Jan Brozek¹⁷, Derek Chu¹⁵, Lamia Dahdah¹¹, Christophe Dupont¹⁷, Piotr Dziechciarz¹, Motohiro Ebisawa¹⁸, Ramon T Firmino¹⁹, Alessandro Fiocchi¹¹, Elena Galli²⁰, Rose Kamenwa²¹, Gideon Lack^{22

23}, Haiqi Li²⁴, Alberto Martelli²⁵, Anna Nowak-Węgrzyn^{26

27}, Nikolas G Papadopoulos^{28

29}, Ruby Pawankar³⁰, Maria Said³¹, Mario Sánchez-Borges³², Holger Schunemann^{17

33}, Raanan Shamir³⁴, Jonathan Spergel³⁵, Hania Szajewska³⁶, Luigi Terracciano³⁷, Yvan Vandenplas³⁸, Susan Waserman³⁹, Carina Venter^{40

41}, Amena Warner⁴², Gary Wk Wong⁴³

Affiliations

¹ Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia.
² Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, VIC, Australia.
³ Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia.
⁴ Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia.
⁵ School of Medicine, University of Adelaide, Adelaide, SA, Australia.
⁶ Nutrition Department, Women's and Children's Health Network, North Adelaide, SA, Australia.
⁷ Nutrition, Dietetics & Food, Monash University, Clayton, Vic, Australia.
⁸ Telethon Kids Institute, University of Western Australia, Nedlands, WA, Australia.
⁹ School of Medicine, University of Western Australia, Crawley, WA, Australia.
¹⁰ Department of Allergy & Immunology, Hospital Quironsalud Bizkaia, Bilbao, Spain.
¹¹ Translational Research in Pediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, Rome, 00165, Italy.
¹² Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
¹³ Allergy & Immunology Section, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA.
¹⁴ Department of Translational Medical Science, University of Naples Federico II, Naples, Italy.
¹⁵ Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Ontario, Canada.
¹⁶ Department of Pediatrics, Section of Pediatric Allergy and Immunology. British Hospital. Buenos Aires, Argentina.
¹⁷ Paris Descartes University, Pediatric Gastroenterology, Necker Hospital, Paris, Clinique Marcel Sembat, Boulogne-Billancourt, France.
¹⁸ Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan.
¹⁹ Faculty of Medical Sciences of Campina Grande, UNIFACISA University Centre, Campina Grande, Paraiba, Brazil.
²⁰ Pediatric Allergy Unit, San Pietro Hospital - Fatebenefratelli, Rome, Italy.
²¹ Department of Paediatrics and Child Health, Aga Khan University Hospital, Nairobi, Kenya.
²² Department of Woman and Childrens' Health/Peter Gorer Department of Immunobiology, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, UK.
²³ Evelina London Children's Hospital, Guy's St Thomas' Hospital, NHS Foundation Trust, London, UK.
²⁴ Department of Primary Child Care, Children's Hospital, Chongqing Medical University, China.
²⁵ Allergist, Edmondo de Amicis School, Milan, Italy.
²⁶ Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Childrens' Hospital, New York, NY, USA.
²⁷ Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland.
²⁸ Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.
²⁹ Allergy Unit, 2nd Paediatric Clinic, University of Athens, Athens, Greece.
³⁰ Department of Pediatrics, Nippon Medical School, Tokyo, Japan.
³¹ Allergy & Anaphylaxis Australia (AAA), Castle Hill, New South Wales, Australia.
³² Allergy and Clinical Immunology Department, Centro Médico - Docente La Trinidad and Clínica El Avila, Caracas, Venezuela.
³³ Cochrane Canada and McMaster University GRADE Center, Hamilton, Ontario, Canada.
³⁴ Institute for Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Lea and Arieh Pickel Chair for Pediatric Research, Sackler Faculty of Medicine, Tel Aviv University, Petach Tikva, Israel.
³⁵ Division of Allergy-Immunology, Dept of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA.
³⁶ Pediatric Primary Care, National Pediatric Health Care System, Milan, Italy.
³⁷ Institute for Quality and Efficiency in Health Care, Cologne, Germany.
³⁸ KidZ Health Castle, Dept of Pediatrics UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium.
³⁹ Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON, Canada.
⁴⁰ Section of Allergy and Immunology, University of Colorado Denver School of Medicine, Children's Hospital Colorado, Aurora, CO, USA.
⁴¹ The David Hide Asthma and Allergy Research Centre, Newport, Isle of Wight, UK.
⁴² Allergy UK, London, England, UK.
⁴³ Department of Paediatrics, Faculty of Medicine, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong.

PMID: 38020284
PMCID: PMC10656250
DOI: 10.1016/j.waojou.2023.100830

Abstract

Cow's milk allergy is rare in exclusively breastfed infants. To support the continuation of breastfeeding an infant after diagnosis with a cow's milk allergy, it is critical to examine the evidence for and against any form of cow's milk elimination diet for lactating mothers. In this narrative review, we highlight the lack of high-quality evidence, hence subsequent controversy, regarding whether the minuscule quantities of cow's milk proteins detectable in human milk cause infant cow's milk allergy symptoms. Current clinical practice recommendations advise a 2-4 week trial of maternal cow's milk dietary elimination for: a) IgE-mediated cow's milk allergy only if the infant is symptomatic on breastfeeding alone; b) non-IgE-mediated associated symptoms only if the history and examination strongly suggest cow's milk allergy; and c) infants with moderate to severe eczema/atopic dermatitis, unresponsive to topical steroids and sensitized to cow's milk protein. There should be a clear plan for home reintroduction of cow's milk into the maternal diet for a period of 1 week to determine that the cow's milk elimination is responsible for resolution of symptoms, and then subsequent reoccurrence of infant symptoms upon maternal cow's milk reintroduction. The evidence base to support the use of maternal cow's milk avoidance for the treatment of a breastfed infant with cow's milk allergy is of limited strength due to a lack of high-quality, adequately powered, randomised controlled trials. It is important to consider the consequences of maternal cow's milk avoidance on reducing immune enhancing factors in breast milk, as well as the potential nutritional and quality of life impacts on the mother. Referral to a dietitian is advised for dietary education, along with calcium and vitamin D supplementation according to local recommendations, and a maternal substitute milk should be advised. However, for most breastfed infants with cow's milk allergy maternal cow's milk dietary elimination will not be required, and active support of the mother to continue breastfeeding is essential.

Keywords: Breastfeeding; IgE-mediated cow's milk allergy; Infant; Maternal nutrition; Non-IgE-mediated cow's milk allergy.

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Conflict of interest statement

VMcW reports speaker honoraria and advisory panel consultancy outside the submitted work for Nutricia, Abbott and Nestle Nutrition Institute, MJN reports speaker honoraria from Nestle Nutrition Institute outside the submitted work, EV has nothing to disclose, DJP reports advisory panel consultancy outside the submitted work for Nestle Nutrition Institute. WAO DRACMA Guideline Group, Declaration of competing interests: S Arasi, S Bahna, Bognanni, J Brozek, D Chu, L Dahdah, Piotr Dziechciarz, E Galli, R Kamenwa, H Li, A Martelli, R Pawankar, H Schunemann, R Targino, L Terracciano, and A Warner have no conflicts to disclose. Relationships reported related to the submitted work: IJ Anstotegui – Abbott, Amgen, Astra Zeneca, Bayer, Bial, Faes Farma, Hikma, Menarini, Merck, Mundipharma, Roxall, Sanofi, Stallergenes, UCB. A Assa’ad – Aimmune Therapeutics, DBV Technologies, Astella, ABBVIE, Novartis, Sanofi, FARE, NIH and an intellectual property patent licensed to Hoth. R Berni Canani – Ch.Hansen, Danone, DVB, Humana, iHealth, Kraft Heinz, Mead Johnson, Nestlè, Novalac, Nutricia, Sanofi. M Bozzola – Danone C Dupont – Nestle Health Science, Nestle France, Nutricia, Novalac, Sodilac, Abbott, Danone, and stock ownership at DBV Technologies. M Ebisawa – DBV Technologies, Mylan, ARS Pharmaceuticals, Novartis. A Fiocchi – Abbott, Danone. G Lack – FARE, National Peanut Board (NPB), The Davis Foundation, Action Medical Research, UK Food Standards Agency, Medical Research Council, DBV Technologies, Mission Mighty Me, Novartis, Sanofi-Genyzme, Regeneron, ALK-Abello, Lurie Children’s Hospital. A Nowak-Wegrzyn – Nestle, Nutricia, Novartis, Gerber, Aimmune. N Papadopoulos – Novartis, Nutricia, HAL Allergy, Menarini/ Faes Farma, Sanofi, Mylan/Meda, Biomay, AstraZeneca, GSK, MSD, ASIT Biotech, Boehringer Ingelheim, Gerolymatos International SA, Capricare. M Said – Nestle, Nutricia, Abbott, Bayer for Anaphylaxis Australia. J Spergel – DBV Technologies, Regeneron, Sanofi, and Aimmune. H Szajewska – Ausnutria, Cargill, Danone, Else Nutrition, Hipp, Nestle, and Nestle Nutrition Institute. Y Vandenplas – Abbott Nutrition, Biogaia, Biocodex, By Heart, CHR Hansen, Danone, ELSE Nutrition, Friesland Campina, Hero, Hypocrata, Nestle Health Science, Nestle Nutrition Institute, Nutricia, Mead Johnson Nutrition, Orafti, Phacobel, Phathom Pharmaceuticals, Sari Husada, United Pharmaceuticals (Novalac), Wyeth, Yakult. C Venter – Reckitt Benckiser, Nestle Nutrition Institute, Danone, Abbott Nutrition, Else Nutrition, and Before Brands, DBV Technologies. S Waserman – Novartis-basic science work on peanut allergy, Aimmune-peanut OIT trial, Medical Advisor to Food Allergy Canada, and Pfizer, Bausch, Kaleoconsultant for epinephrine autoinjectors. GWK Wong – Nestle, Danone.

Figures

**Fig. 3**
Cow's milk protein containing dairy foods, including cow's milk, yogurt, and cheeses

See this image and copyright information in PMC

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World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines update - X - Breastfeeding a baby with cow's milk allergy

Collaborators

Affiliations

World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines update - X - Breastfeeding a baby with cow's milk allergy

Authors

Collaborators

Affiliations

Abstract

Conflict of interest statement

Figures

References

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