Micronutrient status and growth outcomes in children with cow's milk allergy: beyond elimination diets

Cow's milk allergy (CMA) is among the most common food allergies in early childhood, affecting approximately 2-3% of children under 3 years of age. Management requires strict elimination of cow's milk and dairy products, typically replaced with hypoallergenic formulas. Although essential, this dietary restriction may predispose infants-particularly during the first 2 years of life-to nutritional imbalances. This mini review synthesizes current evidence on micronutrient status and growth outcomes in children with CMA, with emphasis on the impact of dietary management. Across observational studies, vitamin D inadequacy is the most consistently reported abnormality, with insufficiency affecting approximately 30-55% of children and deficiency around 20-25%. Iron deficiency is also frequent, including both overt anemia and subclinical depletion. Lower levels of calcium, vitamin B12, and iodine have been described, generally within reference ranges but suggestive of suboptimal intake. Growth impairment is commonly observed at diagnosis, particularly affecting weight more than linear growth. Appropriate nutritional management, including the use of hypoallergenic formulas (HF) and dietary counselling, is associated with significant catch-up growth. However, an increased risk of being overweight has been reported during follow-up, highlighting the need for balanced nutritional strategies. Key risk factors for nutritional compromise include multiple food allergies, prolonged dietary restriction without adequate substitution, poor adherence to supplementation, and restrictive maternal diets during breastfeeding. Overall, CMA management should extend beyond allergen avoidance to include proactive nutritional surveillance, targeted supplementation, and individualized dietary planning to support optimal growth and long-term health.