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WAO牛奶过敏的诊断与基本原理指南

花匠小妙招
2026-02-27 17:06

The diagnosis of cow's milk allergy (CMA) in infants and young children remains a challenge because many of the presenting symptoms are similar to those experienced in other diagnoses. Both over- and under-diagnosis occur frequently. Misdiagnosis carries allergic and nutritional risks, including acute reactions, growth faltering, micronutrient deficiencies and a diminished quality of life for infants and caregivers. An inappropriate diagnosis may also add a financial burden on families and on the healthcare system. Elimination and reintroduction of cow's milk (CM) and its derivatives is essential for diagnosing CMA as well as inducing tolerance to CM. In non-IgE mediated CMA, the diagnostic elimination diet typically requires 2-4 weeks before reintroduction, while for IgE mediated allergy the time window may be shorter (1-2 weeks). An oral food challenge (OFC) under medical supervision remains the most reliable diagnostic method for IgE mediated and more severe types of non-IgE mediated CMA such as food protein induced enterocolitis syndrome (FPIES). Conversely, for other forms of non-IgE mediated CMA, reintroduction can be performed at home. The OFC cannot be replaced by the milk ladder after a diagnostic elimination diet. The duration of the therapeutic elimination diet, once a diagnosis was confirmed, can only be established through testing changes in sensitization status, OFCs or home reintroduction, which are directed by local protocols and services' availability. Prior non-evidence-based recommendations suggest that the first therapeutic elimination diet should last for at least 6 months or up to the age of 9-12 months, whichever is reached first. After a therapeutic elimination diet, a milk-ladder approach can be used for non-IgE mediated allergies to determine tolerance. Whilst some centers use the milk ladder also for IgE mediated allergies, there are concerns about the risk of having immediate-type reactions at home. Milk ladders have been adapted to local dietary habits, and typically start with small amounts of baked milk which then step up in the ladder to less heated and fermented foods, increasing the allergenicity. This publication aims to narratively review the risks associated with under- and over-diagnosis of CMA, therefore stressing the necessity of an appropriate diagnosis and management.

婴儿和幼儿牛奶过敏（CMA）的诊断仍然是一个挑战，因为许多表现出的症状与其他诊断相似。诊断过度和诊断不足都很常见。误诊会带来过敏和营养风险，包括急性反应、生长迟缓、微量营养素缺乏以及婴儿和照料者的生活质量下降。不恰当的诊断也可能给家庭和医疗保健系统增加经济负担。消除和重新引入牛奶（CM）及其衍生物对于诊断CMA以及诱导对CM的耐受性至关重要。在非IgE介导的CMA中，诊断性消除饮食通常需要2-4周才能重新引入，而对于IgE介导的过敏，时间窗口可能更短（1-2周）。对于IgE介导的和更严重的非IgE介导的CMA，如食物蛋白诱导的小肠结肠炎综合征（FPIES），在医学监督下的口服食物激发（OFC）仍然是最可靠的诊断方法。相反，对于其他形式的非ige介导的CMA，可以在家中进行重新引入。诊断性排除饮食后，OFC不能被牛奶阶梯所取代。一旦确诊，治疗性消除饮食的持续时间只能通过检测致敏状态、OFCs或家庭重新引入的变化来确定，这是根据当地协议和服务的可用性来指导的。先前的非循证建议建议，第一次治疗性消除饮食应持续至少6个月或9-12个月，以先达到者为准。在治疗性消除饮食后，牛奶阶梯法可用于非ige介导的过敏，以确定耐受性。虽然一些中心也使用牛奶梯治疗IgE介导的过敏，但人们担心在家会有立即反应的风险。牛奶阶梯已经适应了当地的饮食习惯，通常从少量的烘焙牛奶开始，然后沿着阶梯上升到较少加热和发酵的食物，这增加了过敏原。本出版物旨在叙述性地回顾与CMA的诊断不足和过度相关的风险，因此强调适当诊断和管理的必要性。