Separating the curds from the whey: Multiple facets of milk allergy

Infant cow’s milk allergy (CMA) is among the most common food allergies in infancy and childhood. Immune-mediated adverse reactions to cow’s milk proteins may present in numerous ways because it encompasses a range of mechanisms, including immunoglobulin E (IgE) mediated and non‐IgE-mediated processes. The history and knowledge of the differences among these varied presentations are critical to the diagnosis and management of each disease. Management across phenotypes centers on elimination of cow’s milk protein, a recommendation that carries nutritional, psychosocial, and socioeconomic burdens. Because elimination in infancy can affect growth and micronutrient intake, management should pair avoidance with dietician-supported counseling, monitoring of growth and key nutrients, and caregiver education. Recent advances in management for IgE-mediated CMA include oral immunotherapy (OIT), which can raise reaction thresholds and promote desensitization, and the use of biologic adjuncts, e.g., omalizumab. Adverse events and uncertain durability after discontinuation of OIT warrant careful patient selection and shared decision-making. In non‐IgE-mediated CMA, elimination remains foundational, with reintroduction individualized by subtype, particularly for food protein‐induced enterocolitis syndrome, for which supervised challenge is generally preferred. Milk ladders offer a practical, stepwise home reintroduction strategy for carefully selected children with mild-to-moderate non‐IgE-mediated CMA, and attention should be given to family readiness. Overall, phenotype-specific, family-centered care that balances safety with nutritional adequacy remains central as evidence continues to refine reintroduction strategies, predictors of durable tolerance, and the evolving role of immunomodulatory therapies across the CMA spectrum.