World Allergy Organization Journal (Nov 2023)
World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines update – X – Breastfeeding a baby with cow's milk allergy
- Vicki McWilliam, PhD, AdvAPD,
- Merryn J. Netting, PhD, BSc, BND,
- Evelyn Volders, PhD, AdvAPD,
- Debra J. Palmer, PhD, BSc, BND,
- Ignacio Ansotegui,
- Stefania Arasi,
- Amal H. Assa'ad,
- Sami L. Bahna,
- Roberto Berni Canani,
- Antonio Bognanni,
- Martin Bozzola,
- Jan Brozek,
- Derek Chu,
- Lamia Dahdah,
- Christophe Dupont,
- Piotr Dziechciarz,
- Motohiro Ebisawa,
- Ramon T. Firmino,
- Alessandro Fiocchi,
- Elena Galli,
- Rose Kamenwa,
- Gideon Lack,
- Haiqi Li,
- Alberto Martelli,
- Anna Nowak-Węgrzyn,
- Nikolas G. Papadopoulos,
- Ruby Pawankar,
- Maria Said,
- Mario Sánchez-Borges,
- Holger Schunemann,
- Raanan Shamir,
- Jonathan Spergel,
- Hania Szajewska,
- Luigi Terracciano,
- Yvan Vandenplas,
- Susan Waserman,
- Carina Venter,
- Amena Warner,
- Gary W.K. Wong
Affiliations
- Vicki McWilliam, PhD, AdvAPD
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia; Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
- Merryn J. Netting, PhD, BSc, BND
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia; School of Medicine, University of Adelaide, Adelaide, SA, Australia; Nutrition Department, Women's and Children's Health Network, North Adelaide, SA, Australia
- Evelyn Volders, PhD, AdvAPD
- Nutrition, Dietetics & Food, Monash University, Clayton, Vic, Australia
- Debra J. Palmer, PhD, BSc, BND
- Telethon Kids Institute, University of Western Australia, Nedlands, WA, Australia; School of Medicine, University of Western Australia, Crawley, WA, Australia; Corresponding author. Telethon Kids Institute, University of Western Australia, Nedlands, WA, Australia and School of Medicine, University of Western Australia, Crawley, WA, Australia.
- Ignacio Ansotegui
- Department of Allergy & Immunology, Hospital Quironsalud Bizkaia, Bilbao, Spain
- Stefania Arasi
- Translational Research in Pediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, Rome, 00165, Italy
- Amal H. Assa'ad
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Sami L. Bahna
- Allergy & Immunology Section, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
- Roberto Berni Canani
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
- Antonio Bognanni
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Martin Bozzola
- Department of Pediatrics, Section of Pediatric Allergy and Immunology. British Hospital. Buenos Aires, Argentina
- Jan Brozek
- Paris Descartes University, Pediatric Gastroenterology, Necker Hospital, Paris, Clinique Marcel Sembat, Boulogne-Billancourt, France
- Derek Chu
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Lamia Dahdah
- Translational Research in Pediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, Rome, 00165, Italy
- Christophe Dupont
- Paris Descartes University, Pediatric Gastroenterology, Necker Hospital, Paris, Clinique Marcel Sembat, Boulogne-Billancourt, France
- Piotr Dziechciarz
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
- Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan
- Ramon T. Firmino
- Faculty of Medical Sciences of Campina Grande, UNIFACISA University Centre, Campina Grande, Paraiba, Brazil
- Alessandro Fiocchi
- Translational Research in Pediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, Rome, 00165, Italy
- Elena Galli
- Pediatric Allergy Unit, San Pietro Hospital - Fatebenefratelli, Rome, Italy
- Rose Kamenwa
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Nairobi, Kenya
- Gideon Lack
- Department of Woman and Childrens' Health/Peter Gorer Department of Immunobiology, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, UK; Evelina London Children's Hospital, Guy's St Thomas' Hospital, NHS Foundation Trust, London, UK
- Haiqi Li
- Department of Primary Child Care, Children's Hospital, Chongqing Medical University, China
- Alberto Martelli
- Allergist, Edmondo de Amicis School, Milan, Italy
- Anna Nowak-Węgrzyn
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Childrens' Hospital, New York, NY, USA; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
- Nikolas G. Papadopoulos
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK; Allergy Unit, 2nd Paediatric Clinic, University of Athens, Athens, Greece
- Ruby Pawankar
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan
- Maria Said
- Allergy & Anaphylaxis Australia (AAA), Castle Hill, New South Wales, Australia
- Mario Sánchez-Borges
- Allergy and Clinical Immunology Department, Centro Médico - Docente La Trinidad and Clínica El Avila, Caracas, Venezuela
- Holger Schunemann
- Paris Descartes University, Pediatric Gastroenterology, Necker Hospital, Paris, Clinique Marcel Sembat, Boulogne-Billancourt, France; Cochrane Canada and McMaster University GRADE Center, Hamilton, Ontario, Canada
- Raanan Shamir
- Institute for Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Lea and Arieh Pickel Chair for Pediatric Research, Sackler Faculty of Medicine, Tel Aviv University, Petach Tikva, Israel
- Jonathan Spergel
- Division of Allergy-Immunology, Dept of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
- Hania Szajewska
- Pediatric Primary Care, National Pediatric Health Care System, Milan, Italy
- Luigi Terracciano
- Institute for Quality and Efficiency in Health Care, Cologne, Germany
- Yvan Vandenplas
- KidZ Health Castle, Dept of Pediatrics UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
- Susan Waserman
- Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Carina Venter
- Section of Allergy and Immunology, University of Colorado Denver School of Medicine, Children's Hospital Colorado, Aurora, CO, USA; The David Hide Asthma and Allergy Research Centre, Newport, Isle of Wight, UK
- Amena Warner
- Allergy UK, London, England, UK
- Gary W.K. Wong
- Department of Paediatrics, Faculty of Medicine, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong
- Journal volume & issue
-
Vol. 16,
no. 11
p. 100830
Abstract
Cow's milk allergy is rare in exclusively breastfed infants. To support the continuation of breastfeeding an infant after diagnosis with a cow's milk allergy, it is critical to examine the evidence for and against any form of cow's milk elimination diet for lactating mothers. In this narrative review, we highlight the lack of high-quality evidence, hence subsequent controversy, regarding whether the minuscule quantities of cow's milk proteins detectable in human milk cause infant cow's milk allergy symptoms. Current clinical practice recommendations advise a 2–4 week trial of maternal cow's milk dietary elimination for: a) IgE-mediated cow's milk allergy only if the infant is symptomatic on breastfeeding alone; b) non-IgE-mediated associated symptoms only if the history and examination strongly suggest cow's milk allergy; and c) infants with moderate to severe eczema/atopic dermatitis, unresponsive to topical steroids and sensitized to cow's milk protein. There should be a clear plan for home reintroduction of cow's milk into the maternal diet for a period of 1 week to determine that the cow's milk elimination is responsible for resolution of symptoms, and then subsequent reoccurrence of infant symptoms upon maternal cow's milk reintroduction. The evidence base to support the use of maternal cow's milk avoidance for the treatment of a breastfed infant with cow's milk allergy is of limited strength due to a lack of high-quality, adequately powered, randomised controlled trials. It is important to consider the consequences of maternal cow's milk avoidance on reducing immune enhancing factors in breast milk, as well as the potential nutritional and quality of life impacts on the mother. Referral to a dietitian is advised for dietary education, along with calcium and vitamin D supplementation according to local recommendations, and a maternal substitute milk should be advised. However, for most breastfed infants with cow's milk allergy maternal cow's milk dietary elimination will not be required, and active support of the mother to continue breastfeeding is essential.
