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Milk allergy overdiagnosis is complex due to studies funded by the formula industry, and this Delphi consensus study sought to describe new guidelines that don’t result in overdiagnosis.

For a variety of reasons, overdiagnosis of milk allergy in young children is common throughout the world, with prescriptions for specialized formula used to feed infants with cow’s milk allergy increasing 10-fold beyond expected volumes in Australia, England, and Norway. This effect is complicated by the fact that formula milk manufacturers sponsor milk allergy guidelines, which is thought to promote overdiagnosis by labeling common symptoms of infancy as allergy indications. This article, published in Clinical & Experimental Allergy, conducted a Delphi consensus study to develop practical guidance for healthcare workers on the safe detection and management of milk allergy in infants under 2 years old. The Delphi consensus method was used due to the lack of high-certainty research evidence in this field.

To define the scope of the study, the authors searched MEDLINE and EMBASE to identify relevant literature on milk allergy, including epidemiology, guidelines for diagnosis and management of milk allergy, and discussions of milk allergy overdiagnosis. Participants were excluded based on conflicts of interest related to the formula industry in the past three years or any that were expected to occur in the next year.

In total, 28 experts from 11 countries were invited, of which 17 participated. New consensus recommendations were arrived at regarding milk allergy detection and management, some of which overlap with common guidelines, but many of which deviate. The participants agreed on 38 essential recommendations through consensus. These recommendations highlighted the importance of reproducibility and specificity in the diagnosis of milk allergy in children that exhibit acute or delayed symptoms soon after milk protein ingestion. It was determined that maternal dietary restriction is not usually necessary to manage milk allergy in breastfed infants. Additionally, the study results indicate that milk allergy does not need to be included as a potential diagnosis for certain symptoms if they do not occur soon after milk protein ingestion, such as stool changes, aversive feeding, or occasional blood in stool.

Overall, these guidelines are more restrictive than previous guidelines, and provide a smaller role for maternal dietary exclusions and specialized formula. The authors note that although the guidelines may better protect young children and their carers from overdiagnosis of milk allergy, further work is needed to formally evaluate the effectiveness of these guidelines in practice.

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Allen, H. I., Pendower, U., Santer, M., Groetch, M., Cohen, M., Murch, S. H., . . . Boyle, R. J. (2022). Detection and management of milk allergy: Delphi consensus study. Clinical and Experimental Allergy, 52(7), 848-858. doi:10.1111/cea.14179