INFORMATION FOR HEALTHCARE PROFESSIONALS ONLY. NOT TO BE DISTRIBUTED TO THE GENERAL PUBLIC.
DIFFERENTIATING CMPA FROM LACTOSE INTOLERANCE
Because CMPA symptoms overlap with other conditions, misdiagnosis is common. One of the most frequent confusions is with lactose intolerance, which is the inability to digest milk sugar due to insufficient levels of the enzyme lactase. This is rare in children under 5 and primarily causes GI symptoms such as bloating, gas and diarrhoea.2
CMPA is an allergy to the proteins in cows milk-casein & whey.3 It is an immune-mediated disease, common in infants, affecting multiple systems including; digestion, respiration and skin.4,5 Because of its immune nature, even very small amounts of milk protein can trigger symptoms.7
It is important to understand the difference between cow’s milk protein allergy and lactose intolerance, as the underlying cause, symptoms, and management are very different.6
Importantly, lactose itself is not harmful to most infants with CMPA. On the contrary, lactose can benefit infants in the following ways:
- Improves palatability9
- Supports absorption of calcium and magnesium which are required for normal growth and development.10,11
- Has a prebiotic effect that helps positively shape the gut microbiota12-15
TYPES OF CMPA
CMPA can also be classified as IgE-mediated (rapid onset, systemic risk, validated diagnostic tools available) or non-IgE-mediated (delayed onset, GI-focused, no validated diagnostic tests).16,17
WHY IT’S IMPORTANT TO RECOGNIZE THE DIFFERENCE BETWEEN IgE & non-IgE MEDIATED ALLERGIES
Recognizing these distinctions helps healthcare professionals avoid misdiagnosis and ensures infants receive the appropriate management strategy.
Triggering Dose
IgE reactions can occur after even very small doses. Non-IgE reactions appear to need a larger dose to trigger them.18,19
Presenting Symptoms
For example, a child with GI symptoms is more likely to have non-IgE mediated allergy than IgE mediated allergy.20
Speed of Onset of Symptoms
IgE-mediated reactions are rapid; usually occurring less than 30 minutes after the consumption of the offending food protein. Non-IgE reactions may take hours or even days to occur.21
Diagnosis
Skin and blood tests for IgE are useful in diagnosing IgE mediated allergy, but of little use in non-IgE mediated allergy.22
Treatment Option
The type of allergy can influence the choice of treatment option.23
1. T aylor SL, Kabourek J. Encyclopedia of Food Sciences and Nutrition (Second Edition). 2003; 2631–2634.
2. Scholtens PA, et al. Annu Rev Food Sci T echnol. 2012;3:425–447
3. Giannetti A, T oschi Vespasiani G, Ricci G, et al. Nutrients. 2021;13(5):1525
4. Flom JD, Sicherer SH. Nutrients. 2019;11(5):1051.
5. Edwards CW, Younus MA. StatPearls [Internet]. T reasure Island (FL): StatPearls Publishing; 2023
6. Heine RG, AlRefaee F, Bachina P, et al. World Allergy Organ J. 2017;10(1):41.
7 Cianferoni A. Curr Pediatr Rev. 2020;16(2):95–105.
8. Malik TF, Panuganti KK. StatPearls [Internet]. T reasure Island (FL): StatPearls Publishing; 2024.
9. Koletzko S, Niggemann B, Arato A, et al. J Pediatr Gastroenterol Nutr. 2012;55(2):221–229.
10. Heyman MB. Pediatrics. 2006;118(3):1279–1286.
11. Ziegler EE, Fomon SJ. J Pediatr Gastroenterol Nutr. 1983;2(2):288–294.
12. Høst A, Koletzko B, Dreborg S, et al. Arch Dis Child. 1999;81(1):80–84.
13. Misselwitz B, Pohl D, Frühauf H, et al. United European Gastroenterol J. 2013;1(3):151–159.
14. Francavilla R, Calasso M, Calace L, et al. Pediatr Allergy Immunol. 2012;23(5):420–427.
15. Suchy FJ, Brannon PM, Carpenter TO, et al. NIH Consens State Sci Statements. 2010;27(2):1–27 .
16. Fiocchi A, Brożek J, Schünemann H, et al. World Allergy Organ J. 2010;3(4):57–161.
17 . Boyce JA, Assa’ad A, Burks AW, et al. J Allergy Clin Immunol. 2010;126(6):1105–1118.
18. Cianferoni A. Curr Pediatr Rev. 2020;16(2):95–105.
19. Nowak-Węgrzyn A, Katz Y, Mehr SS, Koletzko S. J Allergy Clin Immunol. 2015;135(5):1114–1124.
20. Venter C, Brown T, Meyer R, et al. Clin T ransl Allergy. 2017;7:26.
21. Venter C, Brown T, Shah N, et al. Clin T ransl Allergy. 2013;3(1):23.
22. Anvari S, Miller J, Y eh CY, Davis CM. Clin Rev Allergy Immunol. 2019;57(2):244–260.
23. Chehade M. Curr Opin Allergy Clin Immunol. 2007;7(3):264–268.
HOW TO DIAGNOSE CMPA
Accurate diagnosis requires a careful, step by step approach:1
DIAGNOSTIC TESTS2
Blood test
- Enzyme-linked Immunosorbent assay (ELISA) e.g. ImmunoCAP
- Blood specific IgE: > 0,1 kU/L
ATOPIC PATCH TEST (APT)
SKIN PRICK TEST (SPT)
- Wheel size > 3mm
TRIAL FOOD ELIMINATION DIETS
Oral Food Challenge
- Open food challenge (OFC): suitable for diagnosis of immediate objective symptoms
- Double-blind placebo-controlled food challenge (DBPCFC): suitable for diagnosis of delayed and mainly subjective symptoms
- Many clinicians suggest that OFC is used in children under the age of three, whilst DBPCFC should be used in older children
Starting elimination early can shorten the path to diagnosis, improve growth outcomes, and reduce the burden on infants and their families.1,4 However, tests alone are not sufficient and must be combined with clinical history and observation.2,5
1. Koletzko S, Niggemann B, Arato A, et al. J Pediatr Gastroenterol Nutr. 2012;55(2):221–229.
2. Boyce JA, Assa’ad A, Burks AW, et al. J Allergy Clin Immunol. 2010;126(6):1105–1118.
3. Sladkevicius E, et al. J Med Econ. 2010;13(1):119–128.
4. Vandenplas Y, et al. Arch Dis Child. 2007;92:902–908.
5. Fiocchi A, Brożek J, Schünemann HJ, et al. World Allergy Organ J. 2010;3(4):57–161.
6. Fox A, Brown T, Walsh J, et al. An update to the Milk Allergy in Primary Care Guideline. Clin T ransl Allergy. 2019;9:40.
FOR HEALTHCARE PROFESSIONALS ONLY, NOT TO BE DISTRIBUTED TO THE GENERAL PUBLIC.
IMPORTANT NOTICE: Breastfeeding is the best form of nutrition for infants and provides many benefits to babies and mothers. Combined breast and bottle-feeding in the first weeks of life may reduce the supply of breast milk, and reversing the decision not to breastfeed is difficult. The social and financial implications of not breastfeeding should be considered.
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