Cow's milk protein intolerance/allergy in afya

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3-6% presents <3/12 in formula fed infants, and rarely in exclusively breastfed infants.
Both immediate (IgE mediated) and delayed (non-IgE mediated) reactions are seen. 
CMPA -  immediate reactions, CMPI for mild-moderate delayed reactions.

''Features''
    regurgitation and vomiting
    diarrhoea
    urticaria, atopic eczema
    'colic' symptoms: irritability, crying
    wheeze, chronic cough
    rarely angioedema and anaphylaxis may occur

''Diagnosis'' - mostly clinical  (e.g. improvement with cow's milk protein elimination).

''Investigations''
    skin prick/patch testing
    total IgE and specific IgE (RAST) for cow's milk protein

''Management''
If severe (e.g. failure to thrive) refer to a paediatrician.

if formula-fed
    1st line - extensive hydrolysed formula (eHF) milk 
    2nd line or if severe - amino acid-based formula (AAF) 
    10% of infants are also intolerant to soya milk

if breast-fed
    continue breastfeeding
    eliminate cow's milk protein from maternal diet
    use eHF milk when breastfeeding stops, until 12 months of age and at least for 6 months

CMPI usually resolves by 1-2 years of age.
 A challenge is often performed in the hospital setting as anaphylaxis can occur.

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