🔑 Key Learning

  • CMPA is an immune-mediated allergy to cow’s milk protein. There are 2 main types:
    • IgE-mediated: rapid onset symptoms (minutes).
    • Non-IgE: delayed onset symptoms (hours to days).
  • Diagnosis is clinical via elimination and reintroduction.
  • Most children outgrow CMPA by age 3—use the milk ladder to reintroduce safely.
    • Step 1: Malted milk biscuits

     

🧬 Pathophysiology

  • IgE-mediated: allergen triggers mast cell degranulation and histamine release.
  • Non-IgE: T-cell-mediated delayed immune response.

    

👀 Clinical Features

  • Symptoms typically start within 1 week of milk exposure.
    • Exam clue: Previously breastfed, now on formula, subsequently develops various symptoms.
  • May be triggered via breastmilk in sensitised infants.
  • Most cases present before 6 months.

Dermatological

  • Pruritus, urticaria, angioedema
  • Facial rash, eczema flare

Gastrointestinal

  • Vomiting, colic
  • Diarrhoea, mucus, blood in stools
  • GORD, abdominal pain
  • Failure to thrive (non-IgE)

Respiratory

  • Cough, wheeze, sneezing, nasal discharge

      

🧪 Investigations

  • IgE-mediated suspected → consider skin prick or serum-specific IgE testing.
  • Diagnosis is clinical:
    1. Eliminate cow’s milk from infant or maternal diet. Symptoms resolve?
    2. Reintroduce after symptom resolution.
    3. Recurrence of symptoms confirms diagnosis.

      

💊 Management

Breastfed Infants

  • Eliminate all cow’s milk from maternal diet.

Formula-fed or mixed-fed

  • Gold standard: Encourage return to exclusive breastfeeding.
  • If not possible, offer extensively hydrolysed formula.
    • Examples: Nutramigen with LGG (Enfamil), Aptamil Pepti (Nutricia), and SMA Althera.

🥛 Reintroduction & The Milk Ladder

  • Maintain dairy-free diet for at least 6 months or until age 9–12 months.
  • Reintroduce using a stepwise approach. Step 1: Malted milk biscuit. 

     

❓ Cow’s Milk Intolerance

  • Not immune-mediated.
  • GI symptoms only (e.g. bloating, flatulence, diarrhoea).
  • No allergic features (rash, wheeze).
  • Most outgrow it by age 2–3.

       

📝 Exam Clues & Clinchers

  • Rapid urticaria/angioedema = IgE-mediated.
  • Delayed GI symptoms, rash, cough, diarrhoea + blood = Non-IgE.
  • GI symptoms only (bloating, diarrhoea) no allergy signs = intolerance.
  • Diagnosis: resolution on elimination, relapse on reintroduction.
  • Management: (1) Return to breastfeeding (2) Extensively hydrolysed formula if BF not possible 

      

🔗 Useful Links and References