AKT · Child health/Growth, GI & MSK

Cow milk protein allergy

Immune reaction to cow milk protein (IgE or non-IgE)

Overview

Immune-mediated reaction to cow milk protein, IgE-mediated (rapid: urticaria, vomiting, anaphylaxis) or non-IgE (delayed: reflux, eczema, blood/mucus in stool, colic). Managed by cow-milk elimination with a suitable formula.

Recognise

IgE-mediated: rapid urticaria, angioedema, vomiting, wheeze, anaphylaxis
Non-IgE: GORD-like symptoms, eczema, loose/bloody mucousy stools, colic, faltering growth
Onset in formula-fed or via maternal dairy in breastfed infants

Red flags

Anaphylaxis (IgE); faltering growth

Differentials & how to tell them apart

Lactose intolerancesugar (not protein) — bloating/diarrhoea, no immune/eczema/blood features

GORDno allergic features, no response to milk exclusion

Infective gastroenteritisacute, contacts

Investigations

Clinical + response to elimination and planned reintroduction. IgE-mediated: specific IgE/skin-prick testing. Non-IgE: trial of elimination then challenge.

Management

Extensively hydrolysed formula (or maternal dairy exclusion if breastfed)

1Eliminate cow milk protein: extensively hydrolysed formula if formula-fed; maternal dairy-free diet if breastfed.Gate: If symptoms persist on eHF, or severe/anaphylaxis → amino-acid formula
2Reintroduce later using the milk ladder (non-IgE); dietitian input; ensure calcium/vit D.

Extensively hydrolysed formula (eHF) — first-line in formula-fed infants

Amino-acid formula (AAF) — if severe or no response to eHF

Maternal dairy exclusion — if breastfed (with calcium/vit D)

Key points

Distinguish from lactose intolerance (a SUGAR problem, not protein/immune). Most children outgrow CMPA.

Monitor & prognosis

Growth, symptom resolution; tolerance via milk ladder.

Most resolve by age 3–5.

Source: NICE CKS Cow milk allergy