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

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

Clinical presentation 1st choice 2nd choice 3rd choice
Anaphylaxis AAFa eHFe, d SF
Immediate gastrointestinal allergy eHFd, b AAFf/SFg  
Food protein-induced enterocolitis syndrome (CMAES) AAF eHFc  
Asthma and rhinitis eHFd, b AAFf/SFg  
Acute urticaria or angioedema eHFd, b AAFf/SFg  
Atopic dermatitis eHFd, b AAFf/SFg  
Gastroesophageal reflux disease (GERD) eHFb AAF  
Allergic eosinophilic oesophagitis AAF   
Cow’s milk protein-induced enteropathy eHFd, b AAF  
Constipation eHFb AAF Donkey milki
Severe irritability (colic) eHFb AAF  
CM protein-induced gastroenteritis and proctocolitis eHFb AAF  
Milk-induced chronic pulmonary disease (Heiner’s syndrome)h AAFf SF eHF
  1. aRecommendation 7.1
  2. bRecommendation 7.2
  3. cIf AAF refusal
  4. dSubject to local availability, RHF can be considered instead than eHF (7.4)
  5. eSubject to a negative SPT with the specific formula (panel recommendation)
  6. fAAF if a relatively high value on avoiding sensitization by SF and/or a low value on resource expenditure are placed
  7. gSF if a relatively low value on avoiding sensitization by SF and/or a high value on resource expenditure are placed
  8. hThis suggestion attributes a high value on avoiding exposure to even residual antigenic cow’s milk proteins
  9. iBased on reports from one case series