February 2014 Issue

Cow’s Milk Allergy — Gaining an International Perspective
By Judith C. Thalheimer, RD, LDN
Today’s Dietitian
Vol. 16 No. 2 P. 16

Cow’s milk is one of the most common causes of childhood food allergy in the United States and abroad. The World Allergy Organization, an international umbrella organization of allergy and immunology societies from around the world, calls cow’s milk allergy “a burdensome, worldwide public health problem.”1 To help resolve this issue, researchers in many countries are uncovering pieces to the food allergy puzzle and developing guidelines and recommendations for better diagnosis and treatment.

Knowledge of these international guidelines, practices, and policies can be a valuable tool for American nutrition professionals working with cow’s milk allergy sufferers. The active sharing of information is growing, as are opportunities for collaboration with practitioners around the globe.

At Home and Abroad
Milk is the second most common food allergen not only in the United States but also in countries as diverse as Germany, Spain, Switzerland, Israel, and Japan. Failure to diagnose cow’s milk allergy can, in some cases, lead to anaphylaxis, asthma exacerbation, hypoalbuminemia, anemia, or failure to thrive and can leave infants and young children suffering needlessly from repeated episodes of diarrhea and vomiting, rashes, gastroesophageal reflux disease, constipation, colic, and inflammatory gastrointestinal conditions.1 Even with a correct diagnosis, improper treatment can prolong symptoms, lead to food aversions, or cause malnutrition.

Despite how relatively common cow’s milk allergy is and the dizzying array of symptoms it provokes, there’s an acknowledged lack of high-quality data on the topic. The 2010 Guidelines for the Diagnosis and Management of Food Allergy in the United States, an expert panel report sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), states that “studies on the incidence, prevalence, and epidemiology of [food allergy] are lacking, especially in the United States.”2

When citing prevalence data on cow’s milk allergy, the NIAID recommendations and other US guidelines often rely on studies conducted in Europe. In five European oral food challenge–confirmed studies, the prevalence of cow’s milk allergy during infancy ranged from 1.9% to 4.9%. Anaphylaxis occurred in 0.8% to 9% of cases; skin symptoms in 5% to 90%, and gastrointestinal symptoms in 32% to 60%.1

“To better understand cow’s milk allergy and other food allergies, we need to look beyond research available in the US, not only because there are areas where US research is currently lacking, but also because there’s information out there that we cannot get here,” says Sherry Coleman Collins, MS, RDN, LD, a food allergy expert.

Collins points to geographic, cultural, and environmental differences between the United States and other countries as opportunities for expanding our understanding of food allergies. “It makes sense that geography is a significant influencer for food allergies,” she explains. “What’s in our environment that we’re exposed to? Celery is a common allergen in other countries but not in the United States, perhaps because of how it’s eaten in other countries or because of similar sensitization (cross-reactivity) to environmental allergens. If dairy isn’t common in your culture, you’re not exposed to it, so you don’t become sensitized.”

In Thailand, where dairy isn’t part of the traditional diet, the marketing of milk-containing products to pregnant women has coincided with an increase in cow’s milk allergy.3 Studying this phenomenon can give researchers insight into the role prenatal exposure plays in the development of allergies, perhaps leading to new prevention strategies.

Moreover, examining the practices of other countries can offer valuable public policy and clinical practice ideas. Indonesia provides allergy-detection scorecards to pediatricians, obstetricians, general practitioners, and midwives to standardize food allergy diagnosis. In Australia and New Zealand, which have among the highest prevalence of food allergies in the world, the government subsidizes extensively hydrolyzed and amino acid–based infant formulas.3 Universally, these formulas are considered the best alternatives for non–breast-fed infants with cow’s milk allergy and other food allergies, but they’re significantly more expensive than dairy or soy-based formulas worldwide, putting them out of reach for many families.1

When children are too old for formula or weaned off the breast, American families searching for cow’s milk substitutes may consider using the milk of other mammals. Looking to recommendations in countries where goat, sheep, or even camel milk are a bigger part of the culture can guide dietary advice in this area. Recommendations in Singapore, for example, specifically mention avoiding giving goat or sheep’s milk to children with immunoglobulin E–mediated cow’s milk allergy due to a “90% likelihood of cross-reactivity with cow’s milk.”3

International Guidelines
“The diagnosis and management of cow’s milk allergy has been different between countries,” says Lynn Christie, MS, RD, LD, a clinical and research dietitian in the department of pediatric allergy and immunology at Arkansas Children’s Hospital.

Recognizing this fact, the World Allergy Organization released the 2010 Diagnosis and Rationale for Action Against Cow’s Milk Allergy (DRACMA) guidelines.1 “DRACMA evaluated all of the current literature and, based on the strength of the literature, developed clinical recommendations that can be used by all physicians,” Christie says. “In addition to providing an international evidence-based foundation for practice, DRACMA pointed out missing information that opens up areas for research. Now clinical practice and research study designs can be based on this international publication’s recommendations. Then hopefully study results can be more easily compared. Dietitians are an important part of the food allergy management team. As nutrition professionals, the better the information we have, the better we can help our food-allergic clients.” (See below for excerpts from the DRACMA guidelines.)

Opportunities for Collaboration
At a time when allergies are reported to be on the rise globally, nutrition professionals have much to gain from collaborating with their international colleagues, and the opportunity for such collaboration is growing.

One example of worldwide partnership is the International Network for Diet and Nutrition in Allergy (INDANA), formed in 2009 by a group of academic dietitians and food scientists specializing in food allergies and intolerances. This global network is open to dietitians and other health care professionals working in the field of food hypersensitivity. INDANA is actively working internationally to provide education on evidence-based best practices, develop supporting tools and materials, and initiate research projects.4 “There is great need for more scientifically trained dietitians in food allergy,” says Christie, the US representative on the INDANA steering committee. “INDANA is working towards collaborative multiprofessional activities such as education and research.”

In today’s highly connected world, international cooperation and sharing knowledge and practice guidelines can be highly beneficial to nutrition professionals and to their clients’ health and well-being.

— Judith C. Thalheimer, RD, LDN, is a freelance nutrition writer and community educator living outside Philadelphia.


Key DRACMA Recommendations
The World Allergy Organization, an international umbrella group of allergy and immunology societies from around the world, released the 2010 Diagnosis and Rationale for Action Against Cow’s Milk Allergy (DRACMA) guidelines. The following is an excerpt from the DRACMA guidelines1:

• Resolution of symptoms after a period of dairy elimination supports a diagnosis of cow’s milk allergy. (This can take several weeks in cases of chronic or severe gastrointestinal symptoms or atopic eczema.)

• Oral food challenge should be considered the standard reference test for diagnosing cow’s milk allergy.

• Mothers of infants with cow’s milk allergy should continue breast-feeding while avoiding all dairy, and they should supplement with calcium (1,000 mg/day divided into several doses).

• For infants at high risk of anaphylactic reactions, amino acid–based formula should be used.

• Extensively hydrolyzed formula is recommended for infants not at high risk of anaphylaxis, but patients should be monitored carefully when the formula is introduced since 10% of infants with cow’s milk allergy may react to it.

• Soy formula may be used in babies older than 6 months of age if the cost of extensively hydrolyzed formula is prohibitive, but soy formula may cause adverse reactions and a growth deficit. Soy shouldn’t be used in the first 6 months of life because of nutritional risks.

• Other mammal milks aren’t recommended because of high cross-reactivity and nutritional problems.

• Periodic food challenges should be done to prevent unnecessarily prolonged elimination diets.

• Education is necessary to ensure nutritional adequacy and compliance.

• A dietitian should help provide lists of acceptable foods and suitable substitutes.

• Cow’s milk allergy elimination diets need to be formally assessed for their nutritional adequacy with regard to protein, energy, calcium, vitamin D, and other micronutrient content to avoid possible malnutrition.



1. Fiocchi A, Brozek J, Schünemann H, et al. World allergy organization (WAO) Diagnosis and Rationale for Action Against Cow’s Milk Allergy (DRACMA) guidelines. World Allergy Organ J. 2010;3(4):57-161.

2. Boyce J, Assa’ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. 2010;126(6 Suppl):S1-S58.

3. Fiocchi A, Sinn J, Yan H, et al. Current practice and recent trends in preventing and treating CMPA. Asian Pacif J Allergy Immunol. 2012;30(Suppl 4):S27-S35.

4. Venter C, Laitinen K, Vlieg-Boerstra B. Nutritional aspects in diagnosis and management of food hypersensitivity—the dietitian’s role. J Allergy (Cairo). 2012;2012:269376. doi:10.1155/2012/269376.