Cow's milk allergy: management

Finally, we will talk about the management of cow's milk allergy.

The overall nutritional strategies.

Breastfeeding a baby with cow's milk allergy and what to do in terms of the maternal diet is probably one of the biggest debated areas in food allergy. This is a paper, again, written by the DRACMA guideline group with Vicki McWilliam as the first author. They highlight the fact that there are many debates about whether we should ask the mom to take milk out of her diet if a child is presenting with cow's milk allergy while being breastfed and that we probably do not have the correct answer. But what we do know is that if we ask the mom to take milk out of her diet and the symptoms get better, we need to ask the mother to reintroduce cow's milk back into her diet after a two to four-week period of exclusion. She needs to consume cow's milk for at least one week to see if the symptoms reappear. If the child had improved by taking cow's milk out of the mom's diet and then the symptoms recur when the mom reintroduces the milk into her diet, that is normally when we can make a diagnosis of cow's milk allergy while being breastfed. We then need to ask the mother to avoid the milk from her diet for a period of time. We really need to discuss that avoidance as well as reintroduction plans with mothers very clearly. We can consider maternal elimination diets during breastfeeding in children with IgE-mediated cow's milk allergy only if the infant is symptomatic on breastfeeding alone. In non-IgE-mediated forms of cow's milk allergy, if the history and examination suggest that the child may have cow's milk allergy via the milk consumed by the breastfeeding mother or in infants with moderate to severe eczema/atopic dermatitis who are not responding to optimal use of topical steroids and are sensitized to cow's milk protein. A very nice paper summarizing all the complexities but then giving very clear advice on avoidance, reintroduction, and which three groups of children one could consider for maternal avoidance of cow's milk while breastfeeding.