Cow's milk protein allergy

Cow’s milk protein allergy (CMPA) is a reaction by the immune system to the proteins found in all mammalian milks including goat, sheep, buffalo etc. CMPA is different to lactose intolerance, which does not involve the immune system.

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Poor growth is common in children with Cow's Milk Protein Allergy (CMPA) during their first year of life, so as well as an accurate diagnosis, appropriate dietary treatment is vital, including the right choice of formula, to ensure adequate nutrition is provided to support optimal weight gain and growth.
The decision as to which cow’s milk substitute to choose for CMPA will depend on whether the allergy is IgE mediated or non-IgE mediated.

The World Allergy Organization (WAO) defines any adverse reaction to food as food hypersensitivity. Food hypersensitivities can either be immune-mediated (food allergy) or non-immune-mediated reactions (food intolerance). Food allergic reactions are then further divided into IgE-mediated (immediate-onset) reactions and non-IgE-mediated (delayed-onset) reactions.
The prevalence of cows’ milk protein allergy (CMPA) has been estimated at between 2-7.5% in the first year of life. CMPA typically develops in early infancy, either following first exposure to a cows’ milk protein based formula, or at the time of weaning, when cows’ milk based products are introduced into the diet.
Symptoms for CMPA are mainly gastro-intestinal problems, such as cramps, nausea, vomiting, and diarrhoea. Skin reactions (eczema) may also occur and, to a lesser extent, respiratory tract disorders. Most children with CMPA outgrow this condition as they get older and can start to tolerate milk around the age of 3 to 5 years.
CMPA is usually diagnosed before one year of age.

Skin PRICK test
If CMPA is suspected, a skin prick test can be performed. Most allergic patients react positively to a skin prick test and specific IgE antibodies can also be found in the blood. Unfortunately, these tests may provide false results and don’t necessarily provide a conclusive explanation for the cause of the symptoms.

Exclusion diet
The only reliable way to investigate food allergy is by the exclusion and re-introduction of the suspected foods in the diet. This needs to be conducted under medical supervision.
In the first phase, all suspected foodstuffs are excluded from the diet for a number of weeks. During the second phase the suspected foodstuffs are, one by one, introduced back into the diet and any reactions closely observed. When symptoms appear after the reintroduction of cow’s milk and again disappear after having been removed, a diagnosis of CMPA can be confirmed. If there is no reaction, another cause for the allergy must be investigated.
IgE-mediated CMPA
Much research has been conducted to determine the prevalence of associated soya sensitisation in infants with IgE-mediated CMPA.
Most authorities, including the Scientific Advisory Committee on Nutrition in UK, recommend that hypoallergenic formulae (extensively hydrolysed or amino acid formula) should be used as the first line of treatment in infants with CMPA under 6 months of age.
Providing soya protein allergy has been excluded (on average between 11 and 14% of children with IgE-mediated CMPA also are sensitive to soya protein), soya formula can be used in infants over 6 months who don’t like the taste of extensively hydrolysed or hypoallergenic formulae.
After the age of one, soya-based dairy alternatives are good choices due to their availability and palatability. Soya-based dairy alternatives, enriched with calcium and vitamin D, meet the nutritional needs of these children.

non IgE-mediated CMPA
The prevalence of associated soya allergy in infants with non IgE-mediated CMPA is higher than in IgE-mediated CMPA, especially in infants with gastrointestinal symptoms (enterocolitis/enteropathy syndromes).
In this case the use of amino acid based formula or extensively hydrolyzed formulas is recommended.
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