Intended for healthcare professionals

Clinical Review

Managing cows’ milk allergy in children

BMJ 2013; 347 doi: (Published 16 September 2013) Cite this as: BMJ 2013;347:f5424
  1. Sian Ludman, paediatric allergy registrar1,
  2. Neil Shah, consultant paediatric gastroenterologist23,
  3. Adam T Fox, consultant paediatric allergist14
  1. 1Children’s Allergy Service, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, UK
  2. 2Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, UK
  3. 3TARGID, KU Leuven University, Belgium
  4. 4Division of Asthma, Allergy and Lung Biology, MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King’s College London, UK
  1. Correspondence to: A T Fox adam_fox{at}
  • Accepted 29 August 2013

Cows’ milk allergy mainly affects young children and because it is often outgrown is less commonly seen in older children and adults. It is one of the most common childhood food allergies in the developed world, second to egg allergy,1 affecting 2-7.5% of children under 1 year of age.2 The mainstay of treatment is to remove cows’ milk protein from the diet while ensuring the nutritional adequacy of any alternative.

Summary points

  • Cows’ milk allergy is common, occurring in up to 7% of children and usually presents in infancy

  • Allergy may be IgE mediated with rapid onset of symptoms such as urticaria or angioedema or non-IgE mediated, producing more delayed symptoms such as eczema, gastro-oesophageal reflux, or diarrhoea

  • Management is by exclusion of cows’ milk protein from the diet (including from the diet of a breastfeeding mother) under dietetic supervision

  • Most children with milk allergy outgrow it (average age 5 years for IgE mediated and majority by age 3 years for uncomplicated non-IgE mediated allergy)

Cows’ milk allergy can often be recognised and managed in primary care. Patients warranting a referral to specialist care include those with severe reactions, faltering growth, atopic comorbidities, multiple food allergies, complex symptoms, diagnostic uncertainty, and incomplete resolution after cows’ milk protein has been excluded.

Although there are non-immune reactions to cows’ milk, such as primary lactose intolerance (when malabsorption of sugar can cause bloating and diarrhoea), these are extremely rare in very young children. Except after a gastrointestinal infection, infants with gastrointestinal symptoms on exposure to cows’ milk are more likely to have cows’ milk allergy than lactose intolerance. This article focuses on immune mediated reactions to cows’ milk in children and reviews the evidence on how to diagnose and manage the condition

Sources and selection criteria

Our search included PubMed, the Cochrane Collaboration using the search terms …

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