Cow’s milk allergy: towards an update of DRACMA guidelines

Table 2 Choosing the appropriate substitute formula in different presentations (original source: DRACMA guidelines [1])

Clinical presentation	1st choice	2nd choice	3rd choice
Anaphylaxis	AAF^a	eHF^{e, d}	SF
Immediate gastrointestinal allergy	eHF^{d, b}	AAF^f/SF^g
Food protein-induced enterocolitis syndrome (CMAES)	AAF	eHF^c
Asthma and rhinitis	eHF^{d, b}	AAF^f/SF^g
Acute urticaria or angioedema	eHF^{d, b}	AAF^f/SF^g
Atopic dermatitis	eHF^{d, b}	AAF^f/SF^g
Gastroesophageal reflux disease (GERD)	eHF^b	AAF
Allergic eosinophilic oesophagitis	AAF
Cow’s milk protein-induced enteropathy	eHF^{d, b}	AAF
Constipation	eHF^b	AAF	Donkey milkⁱ
Severe irritability (colic)	eHF^b	AAF
CM protein-induced gastroenteritis and proctocolitis	eHF^b	AAF
Milk-induced chronic pulmonary disease (Heiner’s syndrome)^h	AAF^f	SF	eHF

^aRecommendation 7.1
^bRecommendation 7.2
^cIf AAF refusal
^dSubject to local availability, RHF can be considered instead than eHF (7.4)
^eSubject to a negative SPT with the specific formula (panel recommendation)
^fAAF if a relatively high value on avoiding sensitization by SF and/or a low value on resource expenditure are placed
^gSF if a relatively low value on avoiding sensitization by SF and/or a high value on resource expenditure are placed
^hThis suggestion attributes a high value on avoiding exposure to even residual antigenic cow’s milk proteins
ⁱBased on reports from one case series

ISSN: 1939-4551