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Diagnosing and managing infants with suspected cow’s milk allergy

Allergy testing should be used to diagnose suspected IgE-mediated CMA, whereas exclusion and reintroduction of dietary cow’s milk should be used to confirm suspected non-IgE-mediated CMA1–3

Confirming the diagnosis of suspected IgE-mediated CMA

Infants presenting with mild-to-moderate symptoms should be diagnosed and managed in primary care without referral to a specialist service.1,2

If the clinical history suggests IgE-mediated CMA, cow’s milk protein should be eliminated from the infant’s diet (and from the mother’s diet, if necessary), and the infant must be referred to secondary care or an allergy referral centre for IgE antibody testing.1,3

  • A supervised challenge should only be carried out if the IgE testing is inconclusive3

Initial testing should be followed-up with serial IgE testing and later a planned challenge to test for acquired tolerance.1–3

Confirming the diagnosis of suspected non-IgE-mediated CMA

If non-IgE-mediated CMA is suggested by the clinical history, and no severe reaction has been observed, a diagnosis of suspected mild-to-moderate CMA should be confirmed by a trial of elimination and reintroduction of cow’s milk protein in the infant’s diet.1–3

Infants who present with severe symptoms should be managed by eliminating cow’s milk protein from their diet and must be referred to the local paediatric allergy service.1,3

1. Eliminating dietary cow’s milk protein

Exclusive breastfeeding is the first choice recommendation until 6 months, and this should be actively encouraged and supported:*1

  • If an exclusively breastfed infant is symptomatic, then a strict elimination of cow’s milk containing foods from the maternal diet with daily supplements of calcium and vitamin D is recommended (early support from a dietitian is advised to facilitate this)1–3

If exclusive breastfeeding is not possible or the mother chooses a mixed feeding approach, then a trial of hypoallergenic formula should be initiated:1–3

  • In most cases, an extensively hydrolysed formula (eHF) should be recommended, while amino acid-based formulas (AAF) are used if an eHF is not well tolerated and for the management of severe cases1–3
  • If mixed feeding, the mother can continue to consume cow’s milk protein, but if her child’s symptoms persist, she should exclude it from her diet (with the support of a dietitian)1,3


Breast milk provides the nutrition and immune support infants need to face their first adventures.4–6

Learn more

2. Reintroduction trial (suspected mild-to-moderate non-IgE-mediated CMA only)

If symptoms clearly improve in the elimination stage, it is very important to carry out the reintroduction step to confirm the diagnosis of mild-to-moderate CMA (this is now a NICE Food Allergy Quality Standard requirement).1–3

For infants presenting with non-IgE-mediated CMA, cow’s milk protein can be reintroduced at home with guidance from a healthcare professional.1–3


If there are no clear signs of improvement following the elimination trial and CMA is still suspected, then consider initiating an AAF and refer the infant to the local paediatric service.1,3

Useful Resources

Please see ‘The iMAP Home Reintroduction’ tool for parents and carers on the GP Infant Feeding Network (UK) webpage.

The iMAP guideline also advises on the length of the diet before cow’s milk protein can be gradually trialled back into the infant’s diet to test for the expected acquisition of tolerance over time – download the iMAP Milk Ladder.

IMPORTANT NOTICE: Breastfeeding is best for infants and is recommended for as long as possible during infancy. Alimentum and EleCare are infant formulas for special medical purposes and should only be used under the recommendation or guidance of a healthcare professional.

*Every effort should be made to encourage the continuation of breast feeding as per current World Health Organization and iMAP guidelines.
The 2'-FL (2'-fucosyllactose) used in this formula is biosynthesised and structurally identical to the human milk oligosaccharide (HMO) 2'-FL, found in most mothers' breast milk.7

AAF: amino acid-based formula; CMA: cow’s milk allergy; eHF: extensively hydrolysed formula; IgE: immunoglobulin E; iMAP: International Milk Allergy in Primary Care; NICE: National Institute for Health and Care Excellence.


IE-SIMILAC-2100003 February 2021