Cow's milk protein allergy: An entity for recognition in developing countries

Aim: The aim of this prospective study was to determine cow's milk protein allergy (CMPA) cases in a tertiary care hospital in India and to study its clinical presentations and outcome following treatment. Methods: Consecutive children with chronic diarrhea from June 2004 to December 2007 were evaluated with hemogram, anti-endomysial antibody, upper gastrointestinal endoscopy, sigmoidoscopy and intestinal biopsies. Initial diagnosis of CMPA was based on characteristic intestinal biopsy (> 6 eosinophils/HPF) and diagnosis was confirmed by positive milk challenge. Results: Forty CMPA cases (25 boys, with a mean age of 17.2 +/- 7.8 months and symptom duration of 8.3 +/- 6.2 months) presented with diarrhea (bloody in 16, watery in 16, combined in three, recurrent hematemesis in two, rectal bleeding in one and one case each with pain in the abdomen with vomiting and anemia with occult bleeding). Sigmoidoscopy revealed aphthous ulcers in 82% of cases and rectal biopsy was positive in 97% of cases. All children improved on a milk-free diet. Milk challenge was positive in 100% of cases when it was done early (within 6 months). On follow up of 15 +/- 9 months, milk was successfully restarted in 25 cases after a median milk-free period of 15 months, 10 were still on a milk-free diet and five were lost to follow up while on a milk-free diet. Conclusions: CMPA is not uncommon in a developing country such as India. Presence of aphthous ulcers and abnormal rectal biopsy are clues to initial diagnosis. Milk challenge confirms the diagnosis in all if it is done on time.