Prevention and Management of Cow's Milk Allergy in Non-Exclusively Breastfed Infants

Introduction: The prevention and management of cow milk allergy (CMA) is still debated. Since CMA is much less frequent in breastfed infants, breastfeeding should be stimulated. Method: Literature was searched using databases to find original papers and reviews on this topic. Results: Hydrolysates with a clinical proof of efficacy are recommended in the prevention and treatment of CMA. However, not all meta-analyses conclude that hydrolysates do prevent CMA or other atopic manifestations such as atopic dermatitis. There are pros and cons to consider partially hydrolysed protein as an option for starter infant formula for each non-exclusively breastfed infant. A challenge test is still recommended as the most specific and sensitive diagnostic test, although a positive challenge test does not proof that the immune system is involved. The Cow Milk Symptom Score (CoMiSS™) is an awareness tool that enables healthcare professionals to better recognize symptoms related to the ingestion of cow milk, but it still needs validation as diagnostic tool. The current recommended elimination diet is a cow milk based extensive hydrolysate, although rice hydrolysates or soy infant formula can be considered in some cases. About 10 to 15% of infants allergic to cow milk will also react to soy. Mainly because of the higher cost, amino acid based formula is reserved for severe cases. There is no place for infant formula with intact protein from other animals as cross-over allergenicity is high. During recent years, attention focused also on the bifidogenic effect of prebiotics and more recently also on human milk oligosaccharides. A bifidogenic gastrointestinal microbiome may decrease the risk to develop allergic disease. The addition of probiotics and prebiotics to the elimination diet in treatment may enhance the development of tolerance development. Conclusion: Breastfeeding is the best way to feed infants. Cow milk based extensive hydrolysates remain the first option for the treatment of CMA for the majority of patients, while amino acid formulas are reserved for the most severe cases. Rice hydrolysates and soy infant formula are second choice options. Partial hydrolysates with clinical proof of efficacy are recommended in some guidelines in the prevention of CMA and allergic disease in at risk infants, and may be considered as an option as protein source in starter infant formula.