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CMPA

Cow’s Milk Protein Allergy (CMPA) is the leading cause of food allergy in infants and young children, with a prevalence estimated between 2% and 5%. Unlike food intolerance, CMPA is an immune-mediated reaction triggered by the ingestion of cow’s milk proteins (CMP), typically presenting within the first weeks to months of life. Most children develop natural tolerance by 1 to 3 years of age. 

However, recent data suggest an increasing number of cases where CMPA persists beyond infancy, prompting greater clinical attention in children over 1 year of age.

Early diagnosis and appropriate management may support earlier tolerance acquisition.

Clinical Presentation

CMPA often mimics colic or reflux and should be considered when:

  • Symptoms start after formula introduction

  • There’s a family history of allergy

  • Symptoms persist despite standard treatment

  • Multiple systems are involved (e.g., skin and GI)

Common symptoms by system:

  • Skin: Eczema, rashes (70–75%)

  • GI: Vomiting, diarrhea, bloody stools (13–34%)

  • Respiratory: Cough, wheeze (1–8%)

Multisystem involvement is seen in up to 25% of cases.

Diagnostic Procedure

CMPA diagnosis is based on a thorough clinical history. The gold standard remains elimination of cow’s milk protein followed by a controlled oral food challenge.

Early recognition is key to preventing nutritional deficiencies and growth concerns. Delayed diagnosis may lead to impaired bone health and deficits in iron, calcium, iodine, and vitamins D, B12.

Management Approach – ESPGHAN 2024

First-line treatment: Extensively hydrolyzed formula (eHF)

  • Recommended for most infants with CMPA

  • Contains low-allergenicity peptides

  • Tolerated by ~90% of affected infants

Symptom-based approach:

  • Moderate symptoms:

    • Start CMP elimination diet with eHF for 2–4 weeks

    • If symptoms improve, continue eHF for 6 months, or until 9–12 months of age

    • Follow with a tolerance assessment

  • Severe symptoms or eHF failure:

    • Consider amino acid formula (AAF) for 2–4 weeks

    • If IgE-mediated allergy is confirmed: continue AAF for 12–18 months

1. Vandenplas Y., et al. Guidelines for the diagnosis and management of cow’s milk protein allergy in infants. Arch. Dis. Child. 92, 902–908 (2007).
2. Fiocchi A., et al. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow’s Milk Allergy (DRACMA) Guidelines. Pediatr Allergy Immunol Suppl 21, 1–125 (2010).
3. Luyt D., et al. BSACI Guideline for the diagnosis and management of cow’s milk allergy. Clin. Exp. Allergy 44, 642–672 (2014).
4. Koletzko S., et al. Diagnostic approach and management of cow’s-milk protein allergy in infants and children: ESPGHAN GI Committee practical guidelines. Journal Pediatrics of Gastroenteroly and Nutrition 55, 221–229 (2012).

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