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Concept: Milk allergy


Cow’s milk allergy (CMA) is one of the most common presentations of food allergy seen in early childhood. It is also one of the most complex food allergies, being implicated in IgE-mediated food allergy as well as diverse manifestations of non-IgE-mediated food allergy. For example, gastrointestinal CMA may present as food protein induced enteropathy, enterocolitis or proctocolitis. Concerns regarding the early and timely diagnosis of CMA have been highlighted over the years. In response to these, guideline papers from the United Kingdom (UK), Australia, Europe, the Americas and the World Allergy Organisation have been published. The UK guideline, ‘Diagnosis and management of non-IgE-mediated cow’s milk allergy in infancy-a UK primary care practical guide’ was published in this journal in 2013. This Milk Allergy in Primary Care (MAP) guideline outlines in simple algorithmic form, both the varying presentations of cow’s milk allergy and also focuses on the practical management of the most common presentation, namely mild-to-moderate non-IgE-mediated allergy. Based on the international uptake of the MAP guideline, it became clear that there was a need for practical guidance beyond the UK. Consequently, this paper presents an international interpretation of the MAP guideline to help practitioners in primary care settings around the world. It incorporates further published UK guidance, feedback from UK healthcare professionals and affected families and, importantly, also international guidance and expertise.

Concepts: Asthma, Milk, Allergy, United Kingdom, Europe, Food allergy, Lactose intolerance, Milk allergy


The mainstay of treatment of IgE-mediated cow milk allergy (IMCMA) is an avoidance diet, which is especially difficult with a ubiquitous food like milk. Milk oral immunotherapy (MOIT) may be an alternative treatment, through desensitization or induction of tolerance.

Concepts: Nutrition, Milk, Cattle, Lactose intolerance, Cheese, Milk allergy, Soy milk, Almond milk


Amino-acid-based formulas (AAFs) are recommended for children with cow’s milk protein allergy (CMPA) failing to respond to extensively hydrolyzed formulas (eHFs).

Concepts: Protein, Nutrition, Polymer, Milk, Cattle, Formula, Milk allergy


The prevalence of many phenotypes of food allergy is increasing. Specific gastrointestinal (GI) phenotype of food allergy (GI allergy) is also increasing but it is difficult to know the prevalence because of many entities. METHODS AND RESULTS: A 1 year retrospective study of pediatric patients complaining exclusively gastrointestinal symptoms after cow’s milk consumption and at least one positive specific IgE (sIgE) to cow’s milk (CM) proteins (CMP) was done (n = 39). The most prevalent symptom was abdominal cramps in 35 patients (90 %), discomfort or abdominal distention in 30 patients (75 %), diarrhea in 10 patients (25 %) and constipation in 5 patients (12 %). IgA anti-transglutaminase antibodies were absent and lactose intolerance was ruled out in all patients. Average of total IgE on this group was 288 UI/ml. sIgE against β-lactoglobulin was the dominant with an average of 4.14 kU/l. sIgE to casein (CAS), which is the dominant protein in systemic anaphylaxis was 1.74 kU/l; sIgE to α-lactoalbumin, the other whey protein, was 0.83 kU/l and sIgE levels to CM were 0.78 kU/l. The quotient sIgE CAS/sIgE β-lactoglobulin in these patients was always lower than 1. Patients experienced an improvement of their symptoms after a CM free diet. An open oral challenge with CM did mimic their initial symptoms in all patients. However, the open oral challenge with dairy products was well tolerated.

Concepts: Immune system, Disease, Milk, Allergy, Food allergy, Lactose intolerance, Cheese, Milk allergy


The UK NICE guideline on the Diagnosis and Assessment of Food Allergy in Children and Young People was published in 2011, highlighting the important role of primary care physicians, dietitians, nurses and other community based health care professionals in the diagnosis and assessment of IgE and non-IgE-mediated food allergies in children. The guideline suggests that those with suspected IgE-mediated disease and those suspected to suffer from severe non-IgE-mediated disease are referred on to secondary or tertiary level care. What is evident from this guideline is that the responsibility for the diagnostic food challenge, ongoing management and determining of tolerance to cow’s milk in children with less severe non-IgE-mediated food allergies is ultimately that of the primary care/community based health care staff, but this discussion fell outside of the current NICE guideline. Some clinical members of the guideline development group (CV, JW, ATF, TB) therefore felt that there was a particular need to extend this into a more practical guideline for cow’s milk allergy. This subset of the guideline development group with the additional expertise of a paediatric gastroenterologist (NS) therefore aimed to produce a UK Primary Care Guideline for the initial clinical recognition of all forms of cow’s milk allergy and the ongoing management of those with non-severe non-IgE-mediated cow’s milk allergy in the form of algorithms. These algorithms will be discussed in this review paper, drawing on guidance primarily from the UK NICE guideline, but also from the DRACMA guidelines, ESPGHAN guidelines, Australian guidelines and the US NIAID guidelines.

Concepts: Health care, Medicine, Asthma, Milk, Allergy, Food allergy, Lactose intolerance, Milk allergy



Specific IgE (sIgE) may be used for the diagnosis of cow’s milk allergy (CMA) and as a guide to perform food challenge tests in patients with CMA. The effect of genetic variants on the prognosis of food allergy is largely unknown.

Concepts: Asthma, Milk, Allergy, Food allergy, Allergology, Lactose intolerance, Cheese, Milk allergy


Inorganic arsenic intake is likely to affect long-term health. High concentrations are found in some rice-based foods and drinks widely used in infants and young children. In order to reduce exposure we recommend avoidance of rice drinks for infants and young children. For all rice products, strict regulation should be enforced regarding arsenic content. Moreover, infants and young children should consume a balanced diet including a variety of grains as carbohydrate sources. While rice protein based infant formulas are an option for infants with cows' milk protein allergy, the inorganic arsenic content should be declared and the potential risks should be considered when using these products.

Concepts: Infant, Metabolism, Nutrition, Milk, Food, Cereal, Carbohydrate, Milk allergy


Data on the mineral status of infants with cow’s milk allergy (CMA) consuming an amino acid-based formula (AAF) have not been published. The present study aims to assess mineral status of term infants aged 0-8 months diagnosed with CMA receiving an AAF for 16 weeks. Serum concentrations of calcium, phosphorus, chloride, sodium, potassium, magnesium and ferritin were determined in 82 subjects at baseline and in 66 subjects after 16 weeks on AAF using standard methods and evaluated against age-specific reference ranges. Additionally, individual estimated energy and mineral intakes were compared to Adequate Intakes defined by the European Food Safety Authority and the US Institute of Medicine. The results of this study show that the AAF was effective in providing an adequate mineral status in infants with CMA. The vast majority of infants aged 0-6 months (formula only) and aged 6-12 months (formula and complementary foods) had adequate mineral intakes.

Concepts: Milk, Allergy, Calcium, Food, Dietary mineral, Ion, Dietary minerals, Milk allergy


To examine the prevalence, clinical features, and influence on illness severity of cow’s milk protein intolerance in young people with chronic fatigue syndrome.

Concepts: Medicine, Epidemiology, Milk, Cattle, Fatigue, Chronic fatigue syndrome, Milk allergy, Young