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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.||||

Journal of Pediatric Gastroenterology and Nutrition: August 2012 - Volume 55 - Issue 2 - p 221–229
doi: 10.1097/MPG.0b013e31825c9482
Medical Position Paper

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.

*Dr von Haunersches Kinderspital, Ludwig-Maximilians-University, Munich

Pediatric Allergology and Pneumology, German Red Cross Hospital Westend, Berlin, Germany

First Department of Pediatrics, Semmelweis University, Budapest, Hungary

§Department of Pediatrics, Hospital S. João, Porto, Portugal

||Department of Pediatric Gastroenterology, Addenbrooke's Hospital, Cambridge, UK

Hans Christian Andersen Children's Hospital, OUH, Odense, Denmark

#Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands

**First Department of Pediatrics, Athens Children's Hospital, P. & A. Kyriakou, Athens, Greece

††Université Paris Descartes, Sorbonne Cité, Paris, France

‡‡Department of Pediatrics, University of Naples “Federico II,” Naples, Italy

§§Unit of Pediatric Gastroenterology, Department of Pediatrics; University Hospitals of Geneva, Switzerland

||||UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium.

Address correspondence and reprint requests to Sibylle Koletzko, MD, PhD, Division of Pediatric Gastroenterology and Hepatology, Dr von Haunersches Kinderspital, Ludwig-Maximilians-University of Munich, Lindwurmstrasse 4, 80337 München, Germany (e-mail:

Received 23 April, 2012

Accepted 23 April, 2012

The authors declare the following conflicts of interest: B.N. served as a guest author as an expert for allergy. S.K.: speaker: Danone, Nestle Nutrition; consultant: Danone, Mead Johnson, Nestle Nutrition; research support: Mead Johnson, Nestle Nutrition. B.N.: none. A.P.: speaker: Ferring; research grant: Biogaia. A.A.: speaker: Danone; consultant: Danone. J.A.D.: speaker: Danone, Mead Johnson, Novalac. R.H.: educational grants from Nestle, Mead Johnson, Danone. S.H.: speaker: Mead Johnson, Nestle; research grant: Johnson & Johnson. L.M.: consultant: Danone; research support: Schär. F.R.: speaker: Nestle Nutrition, MSD, Jansson; consultant: Mead Johnson, Nestle Nutrition. M.S.: none. A.S.: speaker: Danone, Biogaia; research grant: Johnson & Johnson. Y.V.: speaker: Abbott, AstraZeneca, Biogaia, Mead Johnson Nutritionals; consultant and speaker: Biocodex, Danone (Nutricia, SHS), Shire (Movetis), Nestle Nutrition, United Pharmaceuticals.

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