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Guidelines for the diagnosis and management of cow’s milk protein allergy in infants
  1. Yvan Vandenplas1,
  2. Martin Brueton2,
  3. Christophe Dupont3,
  4. David Hill4,
  5. Erika Isolauri5,
  6. Sibylle Koletzko6,
  7. Arnold P Oranje7,
  8. Annamaria Staiano8
  1. 1
    Department of Paediatrics, Universitair Ziekenhuis Brussel Kinderen, Vrije Universiteit Brussel, Brussels, Belgium
  2. 2
    Chelsea and Westminster Hospital, London and Child Health at Imperial College Faculty of Medicine, University of London, London, UK
  3. 3
    Neonatology and Nutrition Department, Université René Descartes Paris V, Hospital Cochin Saint Vincent de Paul, Paris, France
  4. 4
    Murdoch Children’s Research Institute, Royal Children’s Hospital, Melbourne, Victoria, Australia
  5. 5
    University of Turku, Turku, Finland
  6. 6
    Dr. v. Haunersches Kinderspital, Ludwig Maximillians-Universität, Munich, Germany
  7. 7
    Department of Dermatology and Venereology, Erasmus MC, University Medical Centre (Sophia Children's Hospital) Rotterdam, Rotterdam, The Netherlands
  8. 8
    University Federico II of Naples, Naples, Italy
  1. Professor Yvan Vandenplas, Department of Paediatrics, Vrije Universiteit Brussel, Laarbeeklaan 101, Brussels, Belgium; yvan.vandenplas{at}


Our aim was to develop guidance for general paediatricians and primary care physicians in diagnosing and managing cow’s milk protein allergy in infants. The guidelines were developed by discussion based on existing national recommendations and standards, clinical experience and, whenever possible, evidence from the literature. Separate algorithms cover breast-fed and formula-fed infants. The recommendations emphasise the importance of comprehensive history taking and careful physical examination. Patients with severe symptoms need to be referred to a specialist. Elimination of cow’s milk protein from the infant’s or mother’s diet and challenges are the gold standard for diagnosis. This guidance is intended as a basis for local discussion, implementation and prospective evaluation. The algorithms should be regularly assessed using clinical audit standards. Once validated, the diagnostic framework could provide a standardised approach in epidemiological and therapeutic studies.

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Supplementary materials

  • In the original figure, there were two arrows pointing from the box "open challenge with cow's milk formula under clinical observation" to the bow just below "no CMPA symptoms; resume CMP and monitor". The right arrow should point to the box to the right "CMPA symptoms" (there was no arrow pointing to this box in the orginal figure).

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  • Funding: The consensus panel, the literature search and the drafting of the manuscript were funded by a grant from SHS/Nutricia. The paper was drafted by Mark Greener, a medical writer. SHS International Ltd and Nutricia did not have any editorial control over the final manuscript, which remains entirely the responsibility of the authors.

  • Competing interests: DH, CD, MB, SK and YV declare they have received support for clinical research projects from SHS/Nutricia and the same authors and MB declare they have presented lectures at SHS/Nutricia-sponsored meetings. Also, SK has presented lectures at sponsored meetings and received support for scientific work from Mead Johnson and Nestle. YV has received support from Janssen Pharmaceuticals, Astra, Wyeth, Biocodex and Nestle. None of the other authors made any declarations relevant to the preparation of this manuscript. The authors declare the absence of competing interests and confirm their independence regarding the content of this manuscript.

  • Yvan Vandenplas and Sibylle Koletzko are joint lead authors.

  • Abbreviations:
    amino acid formula
    cow’s milk protein
    cow’s milk protein allergy
    extensively hydrolysed formula
    gastro-oesophageal reflux disease
    immunoglobulin E
    radioallergosorbent test
    skin prick test

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  • Corrections
    BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health