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Case Studies

The interactive case studies in this section are based on real-life cases reported by leading dietitians. The cases will help you gain an understanding of how CMA may present in day-to-day practice, and how it may be managed with the appropriate hypoallergenic formula.


Lucy first presented at an allergy centre aged 3 months with chronic diarrhoea and mild-to-moderate eczema across her body and face. Lucy’s weight was on the 25th centile and she had been formula fed from birth. There was a maternal history of eczema, asthma and hay fever, but no paternal history of allergy.


Lucy’s gastrointestinal symptoms were suggestive of non-IgE-mediated cow’s milk allergy, and she was switched onto an extensively hydrolysed formula (eHF), Nutramigen LIPIL 1, in line with current guidelines.1,2

At age 6 months, Lucy’s diarrhoea had resolved and her eczema had cleared, with only the occasional flare. Because Lucy was weaning, her mother was provided with advice, websites and recipes for dairy-free weaning. In addition, Lucy’s formula was switched to Nutramigen LIPIL 2, which contains more calcium and other nutrients to match the needs of older babies. At age 9 months, Lucy’s weight had increased and she was now on the 50th centile.

Regular skin prick tests (SPTs) between ages 6 months and 2 years were positive for cow’s milk, suggesting some involvement of IgE-mediated allergy.


At age 2 years 4 months, Lucy accidentally drank a cup of milk without an adverse reaction. An oral challenge was performed in hospital, and continued at home for a week, with no allergic reaction. Consequently, dairy was gradually reintroduced to Lucy’s diet, and by age 3 years Lucy was tolerating all foods.

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Test your understanding

  1. At presentation, what was the most important clue that Lucy might have CMA?

    1. Lucy's skin symptoms
      Incorrect, please try again
    2. Lucy’s gastrointestinal symptoms
      Incorrect, please try again
    3. The family history of allergy
      Incorrect, please try again
    4. All of the above

      Recognising patterns of symptoms can be a crucial first step for diagnosing CMA. Considered in isolation, none of Lucy’s signs and symptoms would necessarily indicate CMA, but the overlap of skin and gastrointestinal symptoms, together with a family history of allergy, provided sufficient cause to suspect CMA.

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  2. What is the recommended first-line formula for the majority of infants with CMA?

    1. Extensively hydrolysed formula (eHF)

      Clinical guidelines recommend extensively hydrolysed formula (eHF), such as Nutramigen LIPIL, as the first-line choice for the majority of infants with CMA.1,3 Amino acid formula (AAF), such as Nutramigen AA, should be reserved for cases of severe CMA or multiple food allergies or when eHF is ineffective.1,3 Soya formula is not recommended for infants.4,5

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    2. Amino-acid formula (AAF)
      Incorrect, please try again
    3. Soya formula
      Incorrect, please try again
  3. The follow-on formula Nutramigen LIPIL 2 contains more of which key nutrient?

    1. Calcium

      Switching at age 6 months from Nutramigen LIPIL 1 to Nutramigen LIPIL 2 helped provide Lucy with higher levels of key nutrients like calcium, thereby addressing the specific nutritional needs of older babies.

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    2. Vitamin C
      Incorrect, please try again
Show references
  1. Vandenplas Y, Koletzko S, Isolauri E et al. Guidelines for the diagnosis and management of cow's milk protein allergy in infants. Arch Dis Child 2007;92:902-8.

  2. National Institute for Health and Clinical Excellence. CG57: Atopic eczema in children. 2007.

  3. Fiocchi A, Brozek J, Schunemann H et al. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines. World Allergy Organization Journal 2010;3:57-161.

  4. Agostoni C, Axelsson I, Goulet O et al. Soy protein infant formulae and follow-on formulae: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2006;42:352-61.

  5. Department of Health. CMO's Update 37: Advice issued on soya-based infant formulas. 2004.

Cows milk allergy

Learn more about Nutramigen for the management of CMA - Nutramigen LIPIL 1 and 2