A UK birth cohort study published in 2008 showed that 2–3% of 1–3 year olds suffer from confirmed CMA [
13]. Worldwide this prevalence ranges between 1.9 and 4.9% [
14], making it one of the most common food allergies in the first years of life. In 2010 a review of 1000 infants with CMA randomly chosen from a UK primary care database [
6] showed that 86% were first diagnosed in primary care and that the majority remained there for their care. 42% of the infants were referred on, usually to the care of a general paediatrician. Only a few were seen at a specialist level multidisciplinary paediatric allergy service. The majority presented clinically with mild-to-moderate symptoms of suspected non-IgE-mediated CMA. Significantly smaller numbers could have been categorised as either severe non-IgE-mediated CMA or immediate-onset IgE-mediated CMA. The review highlighted evidence of under-recognition, misdiagnosis, significant delay in diagnosis and sub-optimal management of the infants especially in choosing the most appropriate initial alternative formula suitable for the management of CMA, when breast milk is not available. Fewer than 1 in 5 families had received support from a dietitian [
6]. The problem of over and under diagnosis of CMA with its inherent undesirable nutritional management is not unique to the UK. Van den Hooge et al. [
15] and Vieira et al. [
11] report similar problems in the Netherlands and Latin America respectively. To address the need for better diagnosis of food allergy, six international guideline papers were published from the: United States (US) [
1], World Allergy Organization (WAO) [
14], European Academy of Allergy, Asthma and Clinical Immunology (EAACI) [
16], UK, National Institute of Health and Care Excellence (NICE) [
17], British Society for Allergy and Clinical Immunology (BSACI) [
18] and European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) [
19].
The UK NICE 2011 clinical guideline on the ‘Diagnosis and assessment of food allergy in children and young people in primary care and community settings’, Clinical Guideline 116 (CG116) [
17], addressed within its given scope only the presentation and initial assessment of any suspected food allergy. As part of the initial assessment, it particularly emphasised the need to clinically differentiate between non-IgE-mediated and IgE-mediated expressions of food allergy.
Subsequently, a subgroup of the clinicians on the NICE guideline development group published the MAP guideline in 2013 [
7]. It addressed in a simple algorithm-based pathway the initial presentation of the differing clinical expressions of CMA in infancy (both non-IgE and IgE) and the on-going management in primary care of those children with confirmed mild-to-moderate non-IgE-mediated CMA.