Symptoms, diagnostics and therapy of allergy to cow’s milk

Introduction. Diagnosis and treatment of allergy to cow’s milk is subject to dispute in the absence of specific symptoms and reliable diagnostic tests.

Method. Databases were used to search for original articles and reviews on the subject.

Results. As before, a «provocative test» is recommended as the most specific and sensitive diagnostic test, despite the fact that a positive provocative test does not prove involvement in the pathological process of the immune system. A provocative test is not only recommended in case of anaphylaxis, which is extremely rare.

To raise awareness among physicians in order to better recognize symptoms caused by the consumption of cow’s milk, a Scale of symptoms arising from the use of cow’s milk (CoMiSS) has been developed but not yet validated. Today the recommended diagnostic approach includes an elimination diet with the intake of a complete hydrolysate of cow’s milk, followed by provocative tests. In severe cases amino acid mixtures are used. The growing popularity of rice hydrolysates is due to the fact that they have proven effective, better tolerated and cheaper than a mixture on the basis of a complete hydrolysate of cow’s milk. An additional alternative could be soy-based baby formulas as in accordance with the data of the review about 10–15% of children with allergy to cow’s milk will have the same response to soy.

Use of probiotics could be an additional tool in the treatment of allergy to cow’s milk.

Conclusion. For most patients, complete hydrolysates of cow’s milk remains the first tool in the treatment of allergy to cow’s milk and amino acid mixtures used in the most severe cases. Rice hydrolysates and soy infant formula are considered the second choice means. 

1. Sicherer SH. Epidemiology of food allergy. J All Clin Immunol, 2011, 127: 594-602.

2. Sackesen C. Epidemiology of cow’s milk allergy: has it changed? Clin Transl Allergy, 2011, 1(Suppl 1): S50.

3. Fiocchi A, Brozek J, Schünemann H, World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow’s Milk Allergy (DRACMA) Guidelines. World Allergy Organ J, 2010, 3: 157-61.

4. Koletzko S, Niggemann B, Arato A, et al. European Society of Pediatric Gastroenterology, Hepatology, and Nutrition. Diagnostic approach and management of cow’s-milk protein allergy in infants and children: ESPGHAN GI Committee practical guidelines. J Pediatr Gastroenterol Nutr, 2012, 55: 221-9.

5. Host A. Frequency of cow’s milk allergy in childhood. Ann Allergy Asthma Immunol, 2002, 89(6 Suppl 1): 33-7.

6. Host A, Halken S. A prospective study of cow milk allergy in Danish infants during the first 3 years of life. Clinical course in relation to clinical and immunological type of hypersensitivity reaction. Allergy, 1990, 45: 587-96.

7. Gordon BR. The allergic march: can we prevent allergies and asthma? Otolaryngol Clin North Am, 2011, 44: 765-77.

8. Vandenplas Y, Cruchet S, Faure C, et al. When should we use partially hydrolysed formulae for frequent gastrointestinal symptoms and allergy prevention? Acta Paediatr, 2014, 103: 689-95.

9. Fuertes E, Standl M, von Berg A, et al. Parental allergic disease before and after child birth poses similar risk for childhood allergies. Allergy, 2015 (in press).

10. Papadopoulou A, Tsoukala D, Tsoumakas K. Rhinitis and asthma in children: comorbitity or united airway disease? Curr Pediatr Rev, 2014, 10: 275-81.

11. Scadding GK, Brock C, Chouiali F et al. Laryngeal inflammation in the sudden infant death syndrome. Curr Pediatr Rev, 2014, 10: 309-13.

12. Vandenplas Y, Alarcon P, Alliet P, et al. Algorithms for managing infant constipation, colic, regurgi￾tation and cow’s milk allergy in formula-fed infants. Acta Paediatr, 2015, 104: 449-57.

13. Vandenplas Y, Dupont C, Eigenmann P, et al. A workshop report on the development of the Cow’s Milk-related Symptom Score awareness tool for young children. Acta Paediatr, 2015, 104: 334-9.

14. Vandenplas Y, Althera Study group, Steenhout P, et al. A pilot study on the application of a symptom-based score for the diagnosis of cow’s milk protein allergy. SAGE Open Medicine, 2014. doi 10.1177/221050312114523423.

15. Coscia A, Orrù S, Di Nicola P et al. Cow’s milk proteins in human milk. J Biol Regul Homeost Agents, 2012, 26(3 Suppl): 39-42.

16. Lowe AJ, Dharmage SC, Allen KJ et al. The role of partially hydrolyzed whey formula for the prevention of allergic disease: evidence and gaps. Expert Rev Clin Immunol, 2013, 9: 31-41.

17. Ah-Leung S, Bernard H, Bidat E et al. Allergy to goat and sheep milk without allergy to cow’s milk. Allergy, 2006, 61: 1358-65.

18. Katz Y, Goldberg MR, Zadik-Mnuhin G, et al. Cross-sensitization between milk proteins: reactivity to a «kosher» epitope? Isr Med Assoc J, 2008, 10: 85-8.

19. Ehlayel MS, Hazeima KA, Al-Mesaifri F et al. Camel milk: an alternative for cow’s milk allergy in children. Allergy Asthma Proc, 2011, 32: 255-8.

20. Businco L Giampietro PG, Lucenti P, et al. Allergenicity of mare’s milk in children with cow’s milk allergy. J Allergy Clin Immunol, 2000, 105: 1031-4.

21. Vincenzetti S, Foghini L, Pucciarelli S et al. Hypoallergenic properties of donkey’s milk: a preliminary study. Veterinaria Italiana, 2014, 50: 99-107.

22. Iacono G, Carroccio A, Cavataio F et al. Use of ass’s milk in multiple food allergy. J Pediatr Gastr Nutr, 1992, 14: 177-81.

23. Monti G, Bertino E, Muratore MC et al. Efficacy of donkey’s milk in treating highly problematic cow’s milk allergic children: an in vivo and in vitro study. Pediatr Allergy Immunol, 2007, 18: 258-64.

24. Loss G, Depner M, Ulfman LH, et al; PASTURE study group. Consumption of unprocessed cow’s milk protects infants from common res￾piratory infections. Allergy Clin Immunol, 2015, 135: 56-62.

25. American Academy of Pediatrics. Committee on Nutrition. Hypoallergenic infant formulas. Pediatrics, 2000, 106: 346-9.

26. Katz Y, Gutierrez-Castrellon P, González MG, et al. A comprehensive review of sensitization and allergy to soy-based products. Clin Rev Allergy Immunol, 2014, 46: 272-81.

27. www.afssa.fr; Mars 2005.

28. Vandenplas Y, De Greef E, Hauser B, et al. Safety and tolerance of a new extensively hydrolyzed rice protein-based formula in the management of infants with cow’s milk protein allergy. Eur J Pediatr, 2014, 173: 1209-16.

29. Vandenplas Y, De Greef E, Hauser B; et al. An extensively hydrolysed rice protein-based formula in the management of infants with cow’s milk protein allergy: preliminary results after 1 month. Arch Dis Child, 2014, 99: 933-6.

30. Hojsak I, Braegger C, Bronsky J et al. Arsenic in rice: a cause for concern. J Pediatr Gastroenterol Nutr, 2015, 60: 142-5.

31. Vandenplas Y, Steenhout P, Planoudis Y et al. Treating cow’s milk protein allergy: a double￾blind randomized trial comparing two extensively hydrolysed formulas with probiotics. Acta Paediatr, 2013, 102: 990-8.

32. Canani RB, Di Costanzo M. Gut microbiota as potential therapeutic target for the treatment of cow’s milk allergy. Nutrients, 2013, 5: 651-62.

33. Mowat AM. Anatomical basis of tolerance and immunity to intestinal antigens. Nat Rev Immunol, 2003, 3: 331-41.

34. Majamaa H, Isolauri E. Probiotics: A novel approach in the management of food allergy. J Allergy Clin Immun, 1997, 99: 179-85.

35. Isolauri E, Arvola T, Sutas Y et al. Probiotics in the management of atopic eczema. Clin Exp Allergy, 2000, 30: 1604-10.

36. Isolauri E. Studies on Lactobacillus GG in food hypersensitivity disorders. Nutr Today Suppl, 1996, 31: 285-315.

37. Nermes M, Kantele JM, Atosuo TJ et al. Interaction of orally administered Lactobacillus rhamnosus GG with skin and gut microbiota and humoral immunity in infants with atopic dermatitis. Clin Exp Allergy, 2010, 41: 370-7.

38. Pohjavuori E, Viljanen M, Korpela R, et al. Lactobacillus GG effect in increasing IFN-γ production in infants with cow’s milk allergy. J Allergy Clin Immun, 2004, 114: 131-6.

39. Baldassarre ME, Laforgia N, Fanelli M et al. Lactobacillus GG improves recovery in infants with blood in the stools and presumptive allergic colitis compared with extensively hydrolyzed formula alone. J Pediatr, 2010, 156: 397-401.

40. Hol J, van Leer EH, Elink Schuurman BE et al. Cow’s milk allergy modified by elimination and lactobacilli study group. The acquisition of tolerance toward cow’s milk through probiotic supplementation: a randomized, controlled trial. J Allergy Clin Immunol, 2008, 121: 1448-54.

41. Berni Canani R, Nocerino R, Terrin G et al. Effect of extensively hydrolyzed casein formula supplemented with Lactobacillus GG on tolerance acquisition in infants with cow’s milk allergy: a randomized trial. J Allergy Clin. Immun, 2012, 129: 580-2.