SummaryThis guideline advises on the management of patients with cow's milk allergy. Cow's milk allergy presents in the first year of life with estimated population prevalence between 2% and 3%. The clinical manifestations of cow's milk allergy are very variable in type and severity making it the most difficult food allergy to diagnose. A careful age-and diseasespecific history with relevant allergy tests including detection of milk-specific IgE (by skin prick test or serum assay), diagnostic elimination diet, and oral challenge will aid in diagnosis in most cases. Treatment is advice on cow's milk avoidance and suitable substitute milks. Cow's milk allergy often resolves. Reintroduction can be achieved by the graded exposure, either at home or supervised in hospital depending on severity, using a milk ladder. Where cow's milk allergy persists, novel treatment options may include oral tolerance induction, although most authors do not currently recommend it for routine clinical practice. Cow's milk allergy must be distinguished from primary lactose intolerance.

Children allergic to peanuts with negative allergy tests to tree nuts had no co-existing allergy, but were at risk of tree nut allergy where PTs were positive. Children with tree nut allergy were at risk of co-existing peanut or other tree nut allergy whether PTs were positive or negative. Oral challenges to clarify allergy status in all nuts show co-existing allergies even in young children and in so doing may reduce anxiety, minimize unnecessary dietary restrictions and prevent later episodes of anaphylaxis through uninformed exposure.

BackgroundAlthough the natural history of cow’s milk allergy is to resolve during childhood or adolescence, a small but significant proportion of children will remain allergic. Specific oral tolerance induction to cow’s milk (CM-SOTI) provides a treatment option in these children with continuing allergy with high success rates. However current sentiment limits widespread availability as existing reports advise that it is too soon to translate CM-SOTI into routine clinical practice.MethodsIn January 2007 we implemented a slow up-dosing CM-SOTI program. Eligible subjects were identified at routine visits to our children’s allergy clinic. Persisting cow’s milk allergy was confirmed from recent contact symptoms or a positive baked milk challenge. As allergic symptoms are common during CM-SOTI, families were provided with ready dietetic access for advice on dosing and symptom treatment. Subjects were continuously monitored at subsequent clinic visits or telephonically, where no longer followed, for a median of 49 months.ResultsThe first 50 subjects (35 males) treated ranged in age from 5.1 to 15.8 years (median 10.3 years). Full tolerance (250 mL) was achieved in 23 subjects, 9 without any symptoms, and a further 9 achieved partial tolerance with continued ingestion. Eighteen children failed to achieve any regular milk ingestion; 11 because of persistent or significant symptoms whilst 8 withdrew against medical advice. Allergic symptoms were predominantly mild to moderate in severity, although 2 cases needed treatment with inhaled salbutamol and a further 2 required intramuscular adrenaline. Clinical tolerance, both full and partial, persists beyond 5 years.ConclusionWe have demonstrated that a CM-SOTI program can be successfully and safely implemented as routine clinical practice with acceptable compliance during prolonged home up-dosing, despite frequent allergic symptoms, and for up to 4 years after starting treatment. CM-SOTI can thus be put into practice more widely where there is appropriate support.

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Softback 371 pages, £39.99, ISBN 9781405170369.Food allergy is a term that is overused; over 20% of the population believe that they have a food allergy when, in reality, this figure is as low as 1.4% in adults and 1.4-4% in children. So what are the others suffering from and how should we be dealing with these? Food Hypersensitivity tackles the whole subject of adverse reactions to food, whether it is food allergy or intolerance, and provides information to help identify, diagnose and manage this often complicated subject.The introductory chapter leads with the classification of food hypersensitivity and the types of conditions generally seen with each class aiming to help identify the mechanism involved and the potential severity. It then briefly summarises the elements involved in food hypersensitivity reactions, which stimulates the reader to explore further.Food 'allergy' is often implicated in contributing to a range of conditions, ranging from skin complaints to respiratory, gastrointestinal, neurological and musculoskeletal disorders. Chapter 2 looks at the evidence behind these claims and so allows the reader to have an informed opinion on the role that food actually has in these conditions.The diagnosis of food hypersensitivity is a complicated area. Some test results are quite definite in their findings, whereas many are not. Misdiagnosis is common as a result of poor interpretation of test results or poor quality unvalidated tests. Chapter 3 helps the reader to understand testing so to ensure correct interpretation and diagnosis. It also discusses alternative tests that are available. Exclusion diets are also mentioned, along with the gold standardfood challenges. This is supported in the appendices, which provide information on how to conduct challenges, who should have one and, importantly, when to stop.The second part of the book focuses on the dietary management of food hypersensitivity looking at all of the major food groups most commonly involved, as well as the many chemical triggers. These look at the diagnosis and management as well as potential cross-or co-reactivities that are often seen. The subsection on fruit and vegetable allergy also explains oral allergy syndrome, the 'new' condition becoming increasingly prevalent.The last part of the book focuses on other practical lifestyle issues around food avoidance, looking at nutritional adequacy, as well as providing a comprehensive review of the literature on prevention. Although there is actually little that can be concluded on prevention, it provides the information that there is rarely a need for excessive restrictions.There are many books available on food allergy but this book is easy to read, practical and uses the experience of the highly regarded contributors, as well as having a comprehensive list of up-to-date references. Food hypersensitivity helps to demystify this fascinating and huge subject. This book needs to be on the bookshelf of every dietetic department, as well as any other health professional who is likely to see a pati...