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Food allergy remains common in children. However, the diagnosis and management of food allergy can vary between clinical practice settings. To promote the best clinical practices, worldwide, scientific organizations or groups of experts provide guidelines. Even if such documents are typically based on systematic reviews, the guidelines often differ. This presentation will discuss the most recent documents, including: 1) the 2021 guideline from the Global Allergy and Asthma European Network (GA²LEN), focusing on food allergy in general, and 2) two 2022/2023 documents focusing on cow’s milk allergy (CMA), which remains the most common food allergy in infants and young children, i.e., the World Allergy Organization DRACMA (Diagnosis and Rationale for Action against Cow’s Milk Allergy) guidelines and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines. Key similarities and differences will be discussed.

Dietary management of CMA requires choosing the best suitable cow’s milk substitute for use in infancy and beyond. This presentation will discuss how and when to choose a suitable substitute, which is dependent on many factors. These factors include the infant’s symptomatic presentation, age, and nutritional needs, the latter which may include a hypoallergenic formula, maternal elimination diet if the infant is symptomatic during exclusive breastfeeding, or plant-based formulas. The question as to what to do when recommendations from medical societies are not in agreement will be addressed. The gaps in the current evidence will be presented and discussed with recommendations for future research and/or clinical trials to address these gaps.

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The many confounding variables in the pathogenesis of allergy may contribute to the differences between animal studies, where all variables are controlled, and trials in infants. The mode of delivery, perinatal administration of antibiotics to the mother or infant and feeding all influence the GI microbiota and the risk of developing allergy. An important feature characterizing epigenetically-mediated processes is the existence of a time frame where the induced effects are the strongest and, therefore, most crucial.
Breastfeeding should be promoted for its multiple benefits, although its preventive effect on allergy has not been consistently documented There is no convincing scientific evidence that the avoidance or delayed introduction of CM-based formula reduces or increases the risk of CMA in infants considered at high risk of allergic diseases. Complementary bottles given at maternity hospitals to newborns who will later be exclusively breastfed increases the risk of developing CMA. For infants with a documented family history of allergic disease who cannot be exclusively breastfed, there is insufficient evidence to recommend the routine use of pHF, eHF-Whey, eHF-Casein for preventing CMA.In some prevention trials randomisation was allowed up to the age of 1 month, meaning that a number of infants were fed intact CMP before inclusion in the trial. Sensitisation to CMP may also develop through skin contact. It should be considered whether a pHF-W with effectiveness in the reduction of the risk of allergic manifestations such as atopic eczema demonstrated in allergy prevention studies, is chosen until complementary food is introduced. A reduced cumulative incidence of atopic dermatitis was found among infants who received a pHF-W or eHF-C versus CM formula during a 20-year follow up. In addition, after 16 to 20 years of follow-up, the prevalence of asthma after puberty in a high-risk population was lower in both the eHF-C and pHF-W groups.
There is insufficient evidence to recommend the use of probiotics, prebiotics or synbiotics studied so far for CMA prevention. There is insufficient evidence to recommend the use of long chain poly-unsaturated fatty acids (LCPUFAs) for CMA prevention.Vitamin D supplementation during pregnancy, during lactation or infancy had little to no effect on food allergy in early childhood.