An ESPGHAN position paper on the diagnosis, management and prevention of cow's milk allergy

Yvan Vandenplas, Ilse Broekaert, Magnus Domellöf, Flavia Indrio, Alexandre Lapillonne, Corina Pienar, Carmen Ribes-Koninckx, Raanan Shamir, Hania Szajewska, Nikhil Thapar, Rut Anne Thomassen, Elvira Verduci, Christina West

Research output: Contribution to journalArticlepeer-review


A previous guideline on cow's milk allergy (CMA) developed by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) was published in 2012. This position paper provides an update on the diagnosis, treatment, and prevention of CMA with focus on gastrointestinal manifestations. All systematic reviews and meta-analyses regarding prevalence, pathophysiology, symptoms, and diagnosis of CMA published after the previous ESPGHAN document were considered. Medline was searched from inception until May 2022 for topics that were not covered in the previous document. After reaching consensus on the manuscript, statements were formulated and voted on each of them with a score between 0 and 9. A score of ≥6 was arbitrarily considered as agreement. Available evidence on the role of dietary practice in the prevention, diagnosis, and management of CMA was updated and recommendations formulated. CMA in exclusively breastfed infants exists, but is uncommon and suffers from over-diagnosis. CMA is also over-diagnosed in formula and mixed fed infants. Changes in stool characteristics, feeding aversion, or occasional spots of blood in stool are common and in general should not be considered as diagnostic of CMA, irrespective of preceding consumption of cow's milk. Over-diagnosis of CMA occurs much more frequently than under-diagnosis; both have potentially harmful consequences. Therefore, the necessity of a challenge test after a short diagnostic elimination diet of 2-4 weeks is recommended as the cornerstone of the diagnosis. This position paper contains sections on nutrition, growth, cost, and quality of life.

Original languageEnglish
Pages (from-to)386-413
Number of pages28
JournalJournal of Pediatric Gastroenterology and Nutrition
Issue number2
Early online date26 Jul 2023
Publication statusPublished - 1 Feb 2024

Bibliographical note

Publisher Copyright:
© 2023 European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.


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