Cow's milk protein intolerance/allergy (CMPI/CMPA) occurs in around 3-6% of all children and typically presents in the first 3 months of life in formula-fed infants, although rarely it is seen in exclusively breastfed infants.

Both immediate (IgE mediated) and delayed (non-IgE mediated) reactions are seen. The term CMPA is usually used for immediate reactions and CMPI for mild-moderate delayed reactions.

Features

• regurgitation and vomiting
• diarrhoea
• urticaria, atopic eczema
• 'colic' symptoms: irritability, crying
• wheeze, chronic cough
• rarely angioedema and anaphylaxis may occur

Investigations

Diagnosis is often clinical (e.g. improvement with cow's milk protein elimination). Investigations include:

• skin prick/patch testing
• total IgE and specific IgE (RAST) for cow's milk protein

Management

If the symptoms are severe (e.g. failure to thrive) refer to a paediatrician.

Management if formula-fed

• extensive hydrolysed formula (eHF) milk is the first-line replacement formula for infants with mild-moderate symptoms
• amino acid-based formula (AAF) in infants with severe CMPA or if no response to eHF