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Diagnosis

Taking an allergy-focused history1

Diagnosis of cow’s milk allergy starts with taking an allergy-focused clinical history, including:

- Family/personal history of atopy
 
- Feeding history (formula, breast, mixed)
 
- Presenting symptoms/signs of cow’s milk allergy
 
- Details of previous management and perceived response
 
- Details of attempts to change diet and outcome
 

Differentiating between IgE or non-IgE and severe versus moderate disease1

An important diagnostic step is to categorise infants with cow’s milk allergy into 1 of 4 main groups.  These differ by symptoms, symptom severity and speed of onset. 



Diagram taken from Dupont 2012 . p11​


Acute onset symptoms mostly occur within minutes after ingestion.  Delayed onset symptoms mostly occur within 2-72 hours of ingestion.1 

N.B. In clinical practice, clear-cut differentiation is not always possible as some infants have mixed IgE and non-IgE symptoms.


Mild to moderate non-IgE-mediated cow’s milk allergy - delayed onset symptoms

Occurs in formula-fed, exclusively breast-fed infants or with onset of mixed feeding

One or more of the following symptoms:

GI symptoms: colic, reflux (GORD), food refusal/aversion, loose or frequent stools, perianal redness, constipation, abdominal discomfort, blood and/or mucus in stools in an otherwise well infant

Skin symptoms: pruritus, erythema, significant atopic eczema

Respiratory symptoms: ‘catarrhal’ airway symptoms (usually in combination with other symptoms)

These infants can be managed in primary care

 

Severe non-IgE-mediated cow’s milk allergy - delayed onset symptoms

Occurs in formula-fed, exclusively breast fed infants or at onset of mixed feeding

Severe persistent symptoms, one or more of the following:

GI symptoms: diarrhoea, vomiting, abdominal pain, food refusal/aversion, significant blood and/or mucus in stools, irregular or uncomfortable stools, +/- faltering growth

Skin symptoms: severe atopic eczema, +/- faltering growth

These infants require referral to an allergy specialist

 

Mild to moderate IgE-mediated cow’s milk allergy - acute onset symptoms

Occurs mostly in formula-fed infants or at onset of mixed feeding

One or more of the following symptoms:

Skin symptoms: acute pruritus, erythema, urticaria, angioedema, acute ‘flaring’ of atopic eczema

GI symptoms: vomiting, diarrhoea, abdominal pain/colic

Respiratory symptoms: acute rhinitis and/or conjunctivitis

These infants require referral to an allergy specialist


Severe IgE-mediated cow's milk allergy - anaphylaxis

Immediate reaction with severe respiratory and/or CVS signs and symptoms.  Rarely presents with severe GI symptoms.

These infants require emergency treatment and admission

 

Diagnosing and managing cow's milk allergy 

Testing for non-IgE-mediated cow’s milk allergy1

- Because there are no validated tests for non-IgE-mediated cow's milk allergy, diagnosis is normally
   via planned elimination of cow’s milk and food containing cow’s milk 
- This is usually followed by reintroduction of cow’s milk protein as an oral food challenge* to confirm
   the diagnosis  
* challenge should be medically supervised

Testing for IgE-mediated cow’s milk allergy
1

- Skin prick tests (SPTs) or specific serum IgE tests are recommended†

- A positive skin prick test together with a clear history of a reaction usually confirms diagnosis

- If a diagnostic oral food challenge is needed, it should be medically supervised
 
† Interpreting tests requires extensive experience, so should only be performed by those competent to do so.


Bottle-fed infants1

An infant’s response to excluding cow’s milk is tested by substituting their normal formula with extensively hydrolysed formula (eHF) or amino acid-based formula (AAF) and excluding dairy if weaned.

If the infant has cow’s milk allergy, symptoms should usually settle within 2-4 weeks.
2

Exclusively breast-fed infants1

Mothers should exclude all cow’s milk and cow’s milk containing products from their diet. They should take calcium and vitamin D supplements.

If the infant has cow’s milk allergy, symptoms should usually settle within 2-4 weeks.
2

Click here to read the full guidelines on managing cow’s milk allergy in primary care


References
  1. Venter 2013
  2. Vandenplas 2007