Nutrition and Infant Feeding Fact Sheets

1. Cow's Milk Protein Allergy

Background and source of data

In 2016, Ruszcynski and colleagues systematically reviewed the quality of existing guidelines across the world on CMPA. 

The quality, methodological rigour and transparency of 15 sets of guidelines were assessed with the use of the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool.

Two of the 15 sets of guidelines scored a maximum of 100 out of 100 on the AGREE II tool.  These were:

  1. British Society for Allergy and Clinical Immunology guidelines as published by Luyt et al, Clinical and Experimental Allergy. 44. 642-672. 2014.
  2. European Academy of Allergy and Clinical Immunology guidelines as published by Muraro et al, Allergy. 69 1008-1025. 2014.

The following key information has been taken from one or both of these publications unless otherwise referenced.


  • 1.8% to 7.5% of infants in the first year of life.
  • Symptoms suggestive of CMPA may be found in between 5% to 15% of infants (Mousan et al 2016)
  • Onset rare after 12 months of age.

Classification and symptoms

CMPA is classified as immediate onset IgE mediated allergy or delayed onset non IgE mediated allergy.

Symptoms of both classifications include urticaria, and/or angioedema with vomiting and/or wheeze.  In IgE mediated CMPA such symptoms occur soon after consumption of CMP.  In non IgE mediated allergy, symptoms are delayed for upto 48 hours or later (Koletzko et al, 2012) after consumption of CMP.


The diagnosis of IgE mediated CMPA is based on a number of factors, including physical examination, clinical history, allergy testing that includes skin prick tests and serum specific IgE levels.

The gold standard for the diagnosis of non IgE mediated CMPA involve elimination diets followed by milk re introduction.


Following diagnosis, cow’s milk from any source should be completely avoided and in children a suitable replacement should be found to ensure that the child is receiving adequate amounts of energy, protein, phosphorous, calcium, B Vitamins and Vitamin A that is usually provided by cow's milk in the diet.

In breast fed infants, breast feeding should continue with elimination of CMP from the maternal diet.

In non breast fed infant infants, options include the use of an extensively hydrolysed formula with proven efficacy, a soy based protein in infants older than 6 months of age and a rice based formula that meets all other nutritional needs.


  • Koletzko et al, Diagnostic approach and management of Cow’s milk protein allergy in infants and children:ESPGHAN GI committee practical guidelines. Journal of Pediatric Gastroenterology and Nutrition. 55. 221-229. 2012.
  • Luyt et al,BSACI guideline for the diagnosis and management of cow’s milk allergy. Clinical and Experimental Allergy. 44. 642-672. 2014.
  • Muraro et al, EAACI Food allergy and anaphylaxis guidelines: diagnosis and management of food allergy. Allergy. 69 1008-1025. 2014.
  • Ruszczynski et al, Cow’s milk allergy guidelines: a quality appraisal with the AGREE II instrument. Clinical and Experimental Allergy. 46. 1236-1241. 2016.
  • Mousan et al, Cow’s milk protein allergy. Clinical Pediatrics 55 (11) 1054-1063. 2016.

Download the Cow's Milk Protein Allergy Management Plan

Compiled by Professor Peter Davies, Director Children's Nutrition Research Centre and CNRC members