title: Cow's milk allergy: towards an update of DRACMA guidelines.
abstract: BACKGROUND
  In 2010, the diagnosis and treatment of IgE-mediated CMA were systematized in a GRADE guideline.
  
  
  OBJECTIVE
  After 6 years, the state of the knowledge in diagnosis and treatment of CMA has largely evolved. We summarize here the main advances, and exemplify indicating some specific points: studies aimed at better knowledge of the effects of breastfeeding and the production of new special formulae intended for the treatment of CMA. The literature (PubMed/MEDLINE) was searched using the following algorithms: (1) [milk allergy] AND diagnosis; (2) [milk allergy] AND [formul*] OR [breast*], setting the search engine [6-years] time and [human] limits. The authors drew on their collective clinical experience to restrict retrieved studies to those of relevance to a pediatric allergy practice.
  
  
  RESULTS
  Several clinical studies did address the possibility to diagnose CMA using new tools in vitro and in vivo, or to diagnose it without any evaluation of sensitization. Some studies also addressed the clinical role of formulae based on milk hydrolysates, soy, or rice hydrolysates in the treatment of CMA. Many studies have elucidated the effects of selective nutrients in breastfed infants on their immunologic and neurologic characteristics.
  
  
  CONCLUSIONS
  Evidence-based diagnostic criteria should be identified for non-IgE-mediated CMA. Debate is ongoing about the best substitute for infants with CMA. In particular, Hydrolyzed Rice Formulae have been widely assessed in the last six years. In the substitute choice, clinicians should be aware of recent studies that can modify the interpretation of the current recommendations. New systematic reviews and metanalyses are needed to confirm or modify the current DRACMA recommendations.
authors.affiliation: Division of Allergy, University Department of Pediatrics, Pediatric Hospital Bambino Gesù, Rome, Vatican City Italy.
authors.forename: Alessandro
authors.identifier: 0000-0002-2549-0523
authors.initials: A
authors.lastname: Fiocchi
authors.affiliation: Division of Allergy, University Department of Pediatrics, Pediatric Hospital Bambino Gesù, Rome, Vatican City Italy.
authors.forename: Lamia
authors.initials: L
authors.lastname: Dahda
authors.affiliation: Service d'Explorations Fonctionnelles Digestives Pédiatriques, Hôpital Necker, Université Paris-Descartes, 149, rue de Sèvres, 75015 Paris, France.
authors.forename: Christophe
authors.initials: C
authors.lastname: Dupont
authors.affiliation: Department of Paediatrics, Centre of Excellence for Paediatric Research EURISTIKOS, School of Medicine, University of Granada, Avda. De Madrid 11, 18012 Granada, Spain ; Department of Paediatrics, University of Granada, Avda. de la Investigación 11, 18016 Granada, Spain.
authors.forename: Cristina
authors.initials: C
authors.lastname: Campoy
authors.affiliation: Division of Allergy, University Department of Pediatrics, Pediatric Hospital Bambino Gesù, Rome, Vatican City Italy.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Fierro
authors.affiliation: Pediatric Pulmonology & Allergy Unit, Children's Hospital La Fe, Valencia, Spain.
authors.forename: Antonio
authors.initials: A
authors.lastname: Nieto
keywords: Cow’s milk allergy; DRACMA guidelines; Infants