Skip Navigation LinksHome > August 2012 - Volume 55 - Issue 2 > Diagnostic Approach and Management of Cow's-Milk Protein All...
Journal of Pediatric Gastroenterology & Nutrition:
doi: 10.1097/MPG.0b013e31825c9482
Medical Position Paper

Diagnostic Approach and Management of Cow's-Milk Protein Allergy in Infants and Children: ESPGHAN GI Committee Practical Guidelines

Koletzko, S.*; Niggemann, B.; Arato, A.; Dias, J.A.§; Heuschkel, R.||; Husby, S.; Mearin, M.L.#; Papadopoulou, A.**; Ruemmele, F.M.††; Staiano, A.‡‡; Schäppi, M.G.§§; Vandenplas, Y.||||

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Objectives: This guideline provides recommendations for the diagnosis and management of suspected cow's-milk protein allergy (CMPA) in Europe. It presents a practical approach with a diagnostic algorithm and is based on recently published evidence-based guidelines on CMPA.

Diagnosis: If CMPA is suspected by history and examination, then strict allergen avoidance is initiated. In certain circumstances (eg, a clear history of immediate symptoms, a life-threatening reaction with a positive test for CMP–specific IgE), the diagnosis can be made without a milk challenge. In all other circumstances, a controlled oral food challenge (open or blind) under medical supervision is required to confirm or exclude the diagnosis of CMPA.

Treatment: In breast-fed infants, the mother should start a strict CMP-free diet. Non–breast-fed infants with confirmed CMPA should receive an extensively hydrolyzed protein-based formula with proven efficacy in appropriate clinical trials; amino acids–based formulae are reserved for certain situations. Soy protein formula, if tolerated, is an option beyond 6 months of age. Nutritional counseling and regular monitoring of growth are mandatory in all age groups requiring CMP exclusion.

Reevaluation: Patients should be reevaluated every 6 to 12 months to assess whether they have developed tolerance to CMP. This is achieved in >75% by 3 years of age and >90% by 6 years of age. Inappropriate or overly long dietary eliminations should be avoided. Such restrictions may impair the quality of life of both child and family, induce improper growth, and incur unnecessary health care costs.

© 2012 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,


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