# Cow's milk protein allergy (infant) - Category: paediatric - Review status: reviewed (every claim checked against a document named on this page) - Sources: SW London Integrated Medicines Optimisation Committee: Cow's Milk Protein Allergy primary care guidance (NHS, 2024) · No labelled dose - a dietary exclusion, not a medicine · SW London Integrated Medicines Optimisation Committee: Cow's Milk Protein Allergy primary care guidance (NHS,) - Verified date: 2026-08 ## Verified against - No labelled dose - a dietary exclusion, not a medicine - SW London Integrated Medicines Optimisation Committee: Cow's Milk Protein Allergy primary care guidance (NHS,) - Cow's milk protein allergy (infant) - disease-level clinical article (cows-milk-protein-allergy-clinical.txt) ## Treatment metadata - Maternal cow's milk exclusion (breastfed infant) - Extensively hydrolysed formula - Referral & safety-netting (no drug therapy) - Amino acid formula ## Complete treatment card ```text COW'S MILK PROTEIN ALLERGY (INFANT) Sources: SW London Integrated Medicines Optimisation Committee: Cow's Milk Protein Allergy primary care guidance (NHS, 2024) · No labelled dose - a dietary exclusion, not a medicine · SW London Integrated Medicines Optimisation Committee: Cow's Milk Protein Allergy primary care guidance (NHS,) Review status: REVIEWED against No labelled dose - a dietary exclusion, not a medicine, SW London Integrated Medicines Optimisation Committee: Cow's Milk Protein Allergy primary care guidance (NHS,), Cow's milk protein allergy (infant) - disease-level clinical article (cows-milk-protein- allergy-clinical.txt) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (8) - Onset is typically in the first few months of life, usually before 6 months of age - IgE-mediated reactions occur within an hour of ingestion - Non-IgE-mediated reactions take hours to days to appear - Hives (urticaria) can occur with a rapid-onset reaction [urticaria] - Itching or tingling around the mouth or lips [itching · tingling] - Swelling of the lips, tongue, or throat (angioedema) - Delayed reactions include diarrhea, blood in the stool, cramping, and colic [abdominal pain · bloody diarrhoea · diarrhoea · muscle cramps] - GI involvement can lead to dehydration and failure to thrive [dehydration · failure to thrive] SIGNS - what you find (1) - Anaphylaxis can show increased work of breathing, airway constriction, throat swelling, and facial flushing TESTS (3) - No single test confirms cow's milk allergy - diagnosis rests on history and exam - Skin prick testing and serum-specific IgE are sensitive but not specific, and can be positive in non-allergic children - An oral food challenge after an elimination diet is the gold-standard confirmatory test IF NOT THIS - what else fits (4) - Other food allergies are on the differential list - Celiac disease is a differential to distinguish from milk allergy - Inflammatory bowel disease is on the differential list - Lactose intolerance must be distinguished from milk protein allergy Source StatPearls "Cow Milk Allergy" - disease-level clinical article Status traced to the source above 1. MATERNAL COW'S MILK EXCLUSION (BREASTFED INFANT) [1st line] Adult The mother excludes cow's milk protein strictly for 2-4 weeks while breastfeeding continues x 2-4 weeks, then reintroduce to confirm Peds The infant carries on breastfeeding throughout. It is the mother's diet that changes. Source No labelled dose - a dietary exclusion, not a medicine Why Breast milk stays the best feed for these babies. The allergen is what leaves, not the breastfeeding. Caution Encourage her to keep breastfeeding. The commonest harm in this diagnosis is a mother being moved onto formula she did not need. A mother off dairy needs 10 micrograms (400 units) of vitamin D daily, and 1,000 mg of calcium if her diet will not cover it. Excluding dairy without replacing calcium takes it out of her bones. 2. EXTENSIVELY HYDROLYSED FORMULA [1st line] Adult Not applicable - an infant feed x 2-4 week trial, then reintroduce to confirm Peds Replaces the usual formula for 2-4 weeks. If the response is partial, try a second different EHF before moving on. Source SW London Integrated Medicines Optimisation Committee: Cow's Milk Protein Allergy primary care guidance (NHS,) Why First line for a formula-fed infant. At least nine in ten respond to it, which is why an amino acid formula is not where you start. Caution Three things that get used for this and should not be: soya formula, which is not for infants under 6 months; lactose-free formula, which removes the sugar and leaves the protein that is causing the problem; and goat or sheep milk, which cross-reacts. Reintroduce cow's milk over a week after 2-4 weeks. If nothing comes back, it was not CMPA and the diagnosis should be dropped rather than carried for years. If symptoms return, it is confirmed. Refer any suspected IgE-mediated case - immediate hives, swelling, wheeze, vomiting within minutes - to paediatric allergy without delay. Non-IgE disease, the slow gut-and- skin picture, can be managed in primary care. Faltering growth alongside gut symptoms, or any acute systemic reaction, is a referral not a formula trial. 3. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Cow's milk protein allergy (infant) - disease-level clinical article (cows-milk-protein- allergy-clinical.txt) Why Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen. Caution RED FLAG - Avoid soy-based formulas due to the high cross-intolerance risk. RED FLAG - An oral food challenge must be conducted in a medical setting. 4. AMINO ACID FORMULA [2nd line] Adult Not applicable - an infant feed - Ongoing, under dietetic review Peds Second line, after two different extensively hydrolysed formulas have been tried. Source SW London Integrated Medicines Optimisation Committee: Cow's Milk Protein Allergy primary care guidance (NHS,) Why For the roughly one in twenty who do not settle on hydrolysed formula, and for severe disease. Caution Two different EHFs first. Amino acid formula is far dearer and is not a stronger version of the same idea. Get a dietitian involved before weaning starts - the solid diet is where the exclusion goes wrong. Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)