Cows’ milk protein allergy (CMPA)

5 mins
Overview

Cows’ milk protein allergy (CMPA) is the most common type of food allergy in infants, affecting about 7% of all infants.1 It is caused by an immune reaction to protein(s) in cows’ milk.2

It is usually temporary and more than half of children with IgE-mediated cows’ milk protein allergy outgrow their milk allergy by 5 years of age. Most children with non-IgE-mediated cows’ milk allergy will be milk-tolerant by 3 years of age.1
 

Newborn baby after suffering from cows milk protein allergy
Milk allergy in infants – signs and symptoms

CMPA can cause a range of symptoms (IgE-mediated and/or non-IgE-mediated), which can occur immediately after consuming dairy or within 48 hours.2 These can be wide ranging and involve many different organ systems, mostly the skin (such as urticaria and angioedema), gastrointestinal tract (such as nausea, vomiting, and colic), and the respiratory tract (such as cough, runny nose, and wheezing)1.

CMPA versus lactose intolerance

Digestive problems may be seen with both cows’ milk protein allergy (CMPA) and lactose intolerance. However, rashes, eczema, facial swelling or breathing difficulties are not symptoms of lactose intolerance.

Advice for parents

It is very important for parents to seek medical advice if there are signs of infant milk allergy or if a baby has an adverse reaction to a food. Reassure them that if an allergy or intolerance is diagnosed, they will receive help to formulate a suitable diet to ensure their baby’s nutritional needs are met.

CMPA – diagnosis and management in primary care
  • If child CMPA is suspected, an allergy-focused clinical history tailored to the presenting symptoms should be taken. The possibility of a co-existing comorbidity (such as asthma or atopic eczema) or an alternative diagnosis (such as food intolerance or chronic constipation) should also be considered1

  • Suspected IgE-mediated CMPA is confirmed by a skin prick and/or a specific IgE antibody blood test (previously known as a RAST test). These tests may be performed in primary care if the expertise to conduct and interpret the test is available1

  • Suspected non-IgE-mediated CMPA is diagnosed by trial elimination of cows’ milk from the child's diet (or maternal diet for exclusively breastfed babies) normally for between 2–6 weeks, then reintroduction into the diet to confirm the diagnosis1

  • For suspected IgE- and non-IgE-mediated CMPA, referral to secondary care should be considered if there is:1

    • Faltering growth (when an infant grows at a rate below that which is appropriate for their age and sex) in combination with one or more gastrointestinal symptoms

    • One or more acute systemic reactions

    • One or more severe delayed reactions

    • Significant atopic eczema where multiple or cross-reactive food allergies are suspected by the parent or carer

    • Persisting parental suspicion of food allergy (especially in children with difficult or perplexing symptoms) despite a lack of supporting history

    • A clinical suspicion of multiple food allergies

  • Strict exclusion of cows’ milk protein from the child's diet (or maternal diet for exclusively breastfed babies) is currently the safest strategy for managing confirmed cows’ milk protein allergy1

CMPA – dietary management
  • In exclusively breastfed infants, a strict exclusion of cows’ milk protein from the diet of the lactating mother should be trialled2

  • Infants with cows’ milk protein allergy who are not exclusively breastfed, should receive a hypoallergenic formula based on extensively hydrolysed protein first line 3

  • In cases where extensively hydrolysed formula (eHF) is ineffective, or where the infant has severe/multiple food allergy, or if the infant is sensitive to cows’ milk in maternal breast milk, an amino acid-based formula (AAF) should be used3

  • In cases of moderate-to-severe atopic eczema, bottle-fed babies who are suspected of having a food allergy should be offered a 6–8 week trial of an eHF or an AAF1

  • Soy protein formulae can be recommended for infants with CMPA after 6 months however, tolerance to soy protein should first be established by clinical challenge1

  • Infants and children with CMPA may also react to goats milk4

Extra support: HCPs

National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summary (CKS): cows’ milk protein allergy in children. (2014) https://cks.nice.org.uk/cows-milk-protein-allergy-in-children#!topicsummary

NICE Clinical Guideline 116: Food allergy in children and young people. February 2011 https://www.nice.org.uk/guidance/cg116

References Show all Hide all
  1. National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summary (CKS): cows' milk protein allergy in children. 2014 Available here.

  2. Hill DJ et al. J Pediatr 1986; 109: 270–276.

  3. Vandenplas Y et al. Arch Dis Child 2007; 92: 902–908.

  4. Caffarelli, C. et al. (2010). Cow’s milk protein allergy in children: a practical guide. Italian Journal of Paediatrics, 36, 5.

Important Notice:

The World Health Organisation (WHO) has recommended that pregnant women and new mothers be informed on the benefits and superiority of breastfeeding – in particular the fact that it provides the best nutrition and protection from illness for babies. Mothers should be given guidance on the preparation for, and maintenance of, lactation, with special emphasis on the importance of a well-balanced diet both during pregnancy and after delivery. Unnecessary introduction of partial bottle-feeding or other foods and drinks should be discouraged since it will have a negative effect on breastfeeding. Similarly, mothers should be warned of the difficulty of reversing a decision not to breastfeed. Before advising a mother to use an infant formula, she should be advised of the social and financial implications of her decision: for example, if a baby is exclusively bottle-fed, more than one can (400 g) per week will be needed, so the family circumstances and costs should be kept in mind. Mothers should be reminded that breast milk is not only the best, but also the most economical food for babies. If a decision to use an infant formula is taken, it is important to give instructions on correct preparation methods, emphasising that unboiled water, unsterilised bottles or incorrect dilution can all lead to illness.

Newborn baby after suffering from cows milk protein allergy
5 mins

Cows’ milk protein allergy (CMPA)

Overview

Cows’ milk protein allergy (CMPA) is the most common type of food allergy in infants, affecting about 7% of all infants.1 It is caused by an immune reaction to protein(s) in cows’ milk.2

It is usually temporary and more than half of children with IgE-mediated cows’ milk protein allergy outgrow their milk allergy by 5 years of age. Most children with non-IgE-mediated cows’ milk allergy will be milk-tolerant by 3 years of age.1
 

Milk allergy in infants – signs and symptoms

CMPA can cause a range of symptoms (IgE-mediated and/or non-IgE-mediated), which can occur immediately after consuming dairy or within 48 hours.2 These can be wide ranging and involve many different organ systems, mostly the skin (such as urticaria and angioedema), gastrointestinal tract (such as nausea, vomiting, and colic), and the respiratory tract (such as cough, runny nose, and wheezing)1.

CMPA versus lactose intolerance

Digestive problems may be seen with both cows’ milk protein allergy (CMPA) and lactose intolerance. However, rashes, eczema, facial swelling or breathing difficulties are not symptoms of lactose intolerance.

Advice for parents

It is very important for parents to seek medical advice if there are signs of infant milk allergy or if a baby has an adverse reaction to a food. Reassure them that if an allergy or intolerance is diagnosed, they will receive help to formulate a suitable diet to ensure their baby’s nutritional needs are met.

CMPA – diagnosis and management in primary care
  • If child CMPA is suspected, an allergy-focused clinical history tailored to the presenting symptoms should be taken. The possibility of a co-existing comorbidity (such as asthma or atopic eczema) or an alternative diagnosis (such as food intolerance or chronic constipation) should also be considered1

  • Suspected IgE-mediated CMPA is confirmed by a skin prick and/or a specific IgE antibody blood test (previously known as a RAST test). These tests may be performed in primary care if the expertise to conduct and interpret the test is available1

  • Suspected non-IgE-mediated CMPA is diagnosed by trial elimination of cows’ milk from the child's diet (or maternal diet for exclusively breastfed babies) normally for between 2–6 weeks, then reintroduction into the diet to confirm the diagnosis1

  • For suspected IgE- and non-IgE-mediated CMPA, referral to secondary care should be considered if there is:1

    • Faltering growth (when an infant grows at a rate below that which is appropriate for their age and sex) in combination with one or more gastrointestinal symptoms

    • One or more acute systemic reactions

    • One or more severe delayed reactions

    • Significant atopic eczema where multiple or cross-reactive food allergies are suspected by the parent or carer

    • Persisting parental suspicion of food allergy (especially in children with difficult or perplexing symptoms) despite a lack of supporting history

    • A clinical suspicion of multiple food allergies

  • Strict exclusion of cows’ milk protein from the child's diet (or maternal diet for exclusively breastfed babies) is currently the safest strategy for managing confirmed cows’ milk protein allergy1

CMPA – dietary management
  • In exclusively breastfed infants, a strict exclusion of cows’ milk protein from the diet of the lactating mother should be trialled2

  • Infants with cows’ milk protein allergy who are not exclusively breastfed, should receive a hypoallergenic formula based on extensively hydrolysed protein first line 3

  • In cases where extensively hydrolysed formula (eHF) is ineffective, or where the infant has severe/multiple food allergy, or if the infant is sensitive to cows’ milk in maternal breast milk, an amino acid-based formula (AAF) should be used3

  • In cases of moderate-to-severe atopic eczema, bottle-fed babies who are suspected of having a food allergy should be offered a 6–8 week trial of an eHF or an AAF1

  • Soy protein formulae can be recommended for infants with CMPA after 6 months however, tolerance to soy protein should first be established by clinical challenge1

  • Infants and children with CMPA may also react to goats milk4

Extra support: HCPs

National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summary (CKS): cows’ milk protein allergy in children. (2014) https://cks.nice.org.uk/cows-milk-protein-allergy-in-children#!topicsummary

NICE Clinical Guideline 116: Food allergy in children and young people. February 2011 https://www.nice.org.uk/guidance/cg116

References Show all Hide all
  1. National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summary (CKS): cows' milk protein allergy in children. 2014 Available here.

  2. Hill DJ et al. J Pediatr 1986; 109: 270–276.

  3. Vandenplas Y et al. Arch Dis Child 2007; 92: 902–908.

  4. Caffarelli, C. et al. (2010). Cow’s milk protein allergy in children: a practical guide. Italian Journal of Paediatrics, 36, 5.