Cow’s Milk Allergy: Where have we Come from and where are we Going?
Arne Host and Susanne Halken
Affiliation: Department of Paediatrics, Hans Christian Andersen Children's Hospital, Odense University Hospital, DK-5000 Odense C, Denmark.
Keywords: Childhood, cow’s milk allergy, diagnosis, infancy, prognosis, treatment.
Since the 1930’s the scientific literature on cow’s milk protein allergy (CMPA) has accumulated. Over the last
decade new diagnostic tools and treatment approaches have been developed. The diagnosis of reproducible adverse
reactions to cow’s milk proteins (CMP), i.e. CMPA, still has to be confirmed by controlled elimination and challenge
procedures. Advanced diagnostic testing using epitope and microarray technology may in the future improve the
diagnostic accuracy of CMPA by determination of specific IgE against specific allergen components of cow’s milk
protein. The incidence of CMPA in early childhood is approximately 2-3% in developed countries. Symptoms suggestive
of CMPA may be encountered in 5-15% of infants emphasizing the importance of controlled elimination/milk challenge
procedures. Reproducible clinical reactions to CMP in human milk have been reported in 0.5% of breastfed infants. Most
infants with CMPA develop symptoms before 1 month of age, often within 1 week after inter introduction of CMP-based
formula. The majority has two or more symptoms from two or more organ systems. Approximately 50-70% have
cutaneous symptoms, 50-60% gastrointestinal symptoms and 20-30% respiratory symptoms. Symptoms may occur within
1 hour after milk intake (immediate reactions) or after 1 hour (late reactions). The prognosis of CMPA is good with a
remission rate of approximately 45 to 50% at 1 year, 60 to 75% at 2 years and 85 to 90% at 3 years. Associated adverse
reactions to other foods develop in up to 50% and allergy against inhalants in 50 to 80%.
The basic treatment of CMPA is avoidance of CMP. In early childhood a milk substitute is needed. Documented
extensively hydrolysed formulas are recommended, whereas partially hydrolysed formulas should not be used because of
a high degree of antigenicity and allergenicity associated with adverse reactions. In case of intolerance to extensively
hydrolysed formulas and multiple food allergies a formula based on aminoacids is recommended. Alternative milk
substitutes such as sheep’s and goat’s milk should not be used because of a high degree of cross reactivity with CMP.
Milk from other mammals such as mare and donkey may be tolerated by some children with CMPA. Soy protein is as
allergenic as CMP and soy formula is not recommended for young children with CMPA because of a great risk of
development of allergy to soy, whereas soymilk is normally tolerated in older children with CMPA.
Recent treatment modalities are oral immunotherapy (OIT) involving the ingestion of increasing amounts of milk allergen
on a regular basis to desensitize and potentially permanently tolerize patients to CMP. OIT can increase the reaction
thresholds to CMP, but questions about safety and long-term efficacy remain. Anti-IgE therapy with Omalizumab may
improve the safety and efficacy of OIT and may provide benefit in monotherapy.
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