International guidance on diagnosing allergies to cow’s milk in babies may be fuelling the overdiagnosis of the condition in infants, according to a report by the British Medical Journal (BMJ) published today (Wednesday, December 8).

“Guidelines designed to help the non-specialist to diagnose cow’s milk allergy in infants may unintentionally medicalise normal infant symptoms and promote overdiagnosis of cow’s milk allergy,” said study lead Rose Vincent

The team behind the investigation – the University of Bristol, St. George’s University of London and King’s College, London – assessed 1,300 infants and found that nearly three quarters (74%) of those aged 3-12 months exhibited mild to moderate symptoms outlined in the international Milk Allergy in Primary Care (iMAP) guidelines.


The iMap guidelines were first published as the Milk Allergy in Primary care (MAP) guidelines in 2013 and updated to iMap in 2017, when it began being accessed internationally. It was updated again in 2019.

Mild to moderate symptoms in the latest iMAP include: colic; vomiting; food refusal; diarhoea/constipation/blood in stool; abdominal discomfort; itching; flushing; non-specific rashes; and moderate to persistent dermatitis.

According to BioMed Central (BMC), iMap has previously been criticised for promoting the overdiagnosis of cow’s milk allergy (CMA) in 2018, as well as for negatively impacting breastfeeding and the possibility of industry influence on the guidelines.

However, the 2019 iMap UK adaption does note that there is a risk of overdiagnosis of CMA if mild, transient or isolated symptoms are over-interpreted or if milk exclusion diets are not followed up by diagnostic milk reintroduction.

Trial exclusion diets, it said, should only be considered if history and examination strongly suggest CMA.

It also notes that less than 2% of UK infants have CMA, that the symptoms are very common in otherwise well babies and that clinical judgement is required.