A parent’s perspective of the diagnosis and management of cow’s milk allergy in infants in the healthcare setting in Ireland

Cow’s Milk Allergy (CMA) is estimated to affect 2-3% of infants, typically developing in the first year of life (1) . The risks of misdiagnosing CMA include acute reactions, micronutrient deficiencies, growth faltering, increased burden on healthcare systems, and reduced quality of life for infants and caregivers (2) . The guidelines for diagnosis and management are not always followed due to lack of awareness, or difficulties with implementation (1,3) . The aim of this study was to obtain parent-reported data on the diagnosis and management of CMA in Ireland. A 23-item questionnaire was developed and distributed through an online parenting club, targeting parents of infants aged 0-12 months with CMA. The quantitative and qualitative data was analysed on SPSS (V29) using descriptive statistics and cross-tabulation tests. A total of 62 parents with an infant under 12 months responded that their infant currently has (n = 56) or previously had CMA (n = 6). Five cases were self-diagnosed and were partially excluded from analysis. General practitioners (42%) and paediatricians (39%) were the most common healthcare professionals (HCPs) to diagnose CMA. The number of visits it took before receiving a CMA diagnosis ranged from 1-15 visits, with a median of 2 visits. Some infants were diagnosed on their first appointment (n = 11) while others took 4-5 months before being diagnosed (n = 2). Only 23% of infants underwent a skin-prick/blood test, suggesting most HCPs were using symptom resolution to decipher a diagnosis. An extensively hydrolysed formula (EHF) was recommended as first-line management to most formula-fed infants (82%, n = 40), while 14% (n = 7) were initially recommended an amino acid formula (AAF). Of the 17 suspected non-IgE infants who did not exclusively breastfeed, only 41% were given advice to reintroduce standard infant formula after 2-4 weeks of being on a hypoallergenic formula, to assess if symptoms reappeared. Of this 41%, only 57% followed this advice. Of breastfeeding mothers (n = 30), 87% were advised to eliminate cow’s milk from the maternal diet, however 57% were not advised on reintroduction upon symptom resolution (1) . Faltering growth was reported in 11% (n = 5) of formula-fed infants and all were prescribed an EHF, despite guidelines recommending an AAF if faltering growth is evident (1) . After diagnosis, 26 infants (46%) had no follow-up with their HCP. Of the 22 infants diagnosed by a paediatrician, 77% received a follow-up appointment which was significantly greater compared to follow-up rates from other HCPs ( P = 0.006). Limitations include the use of a small convenience cohort and selfreporting of data. These results indicate a clear gap between CMA diagnosis and management guidelines, and their practical implementation within the Irish healthcare setting. Any strategy to further educate and support HCPs in this specialist area of healthcare could mitigate risk of misdiagnosis, delayed diagnosis, and inappropriate management.