Download Cows milk protein allergy / intolerance

Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group
Guidelines for managing cow’s milk protein allergy/intolerance in primary care
Incidence




Cow’s milk allergy affects approximately 2-3% of infants under 12 months of age.
The majority of children outgrow their milk allergy by 2 years of age, although some cases persist until adolescence
Milk allergy is more likely to persist in children who have other food allergies (most commonly egg allergy) and
concomitant asthma and allergic rhinitis.
Children can continue to achieve tolerance well into adolescence.
Presentation
Symptoms/Signs
IgE/Non-IgE
Comments
Acute allergic reaction:
Occurring within 1 hour of
milk ingestion
Redness, swelling, pruritus, wheeze,
coughing, urticaria
Usually IgE
mediated
Symptoms usually occur on the first or
second exposure to cow’s milk protein
Delayed reaction:
Occurring > 1 hour
following ingestion of milk
and usually < 72 hours
Eczema, vomiting, gastro-oesophageal
reflux (especially if the baby is irritable
or miserable), dysphagia, diarrhoea,
failure to thrive, extreme colic,
constipation, blood in the stool
Usually non-IgE
mediated
Symptoms are almost always multiple and
fail to respond to standard management.
Management in primary care: Follow the steps below for managing cow’s milk allergy / intolerance in children
Step
Action:
1
Take an allergy focused clinical history: history of reaction, history of eczema, feeding history, family history of atopic disease.
2
Confirm the suspected diagnosis by allergy testing:
 Measure specific IgE to cow’s milk in blood (refer to appendix 2 for allergy testing advice for children in general practice).
 A positive result is > 0.35kuA/L and supports the diagnosis of IgE mediated cow’s milk allergy.
 Children with cow’s milk allergy are commonly also allergic to egg, so check IgE to egg also.
 If results are negative consider if symptoms are compatible with non-IgE mediated reaction or an alternative diagnosis.
3
Complete exclusion of cow’s milk from the diet:
 This is essential for children with IgE mediated cow’s milk allergy.
 For children with non-IgE mediated symptoms, cow’s milk should be removed from the diet for a trial period, followed by
re-introduction after 4 weeks, to confirm diagnosis.
Recommend an
alternative milk
formula:
4
NB: products cited
are currently those
of lowest
acquisition cost.
For children under 6 months of age:
 Recommend exclusive breastfeeding until 6 months of age.
 Milk protein (cow, goat, sheep) only needs to be excluded from the diet of breastfeeding mothers if
the baby is reacting to breast milk. Breastfeeding mothers on a milk free diet require calcium and
vitamin D supplementation for prevention of osteoporosis (see bnf section 9.64 and refer to local
vitamin D guidelines available on the intranet).
 For children who are not breastfed, or where the mother wishes to supplement breastfeeding, an
extensively hydrolysed milk formula (eHF) with reduced allergenicity is required (e.g. Althéra, Aptamil
Pepti 1, Nutramigen Lipil 1 or Similac Alimentum).
 For children with severe eczema whilst being exclusively breastfed, with faltering growth,
gastrointestinal symptoms or those who have experienced an anaphylactic reaction to cows’ milk
protein , an amino acid formula should be used (e.g. Nutramigen AA or Neocate LCP). These should
also be tried in children who refuse an eHF.
Prescribe a tin of alternative milk formula to try. If the baby tolerates this milk formula, then prescribe
enough for a month : Suggested monthly amounts (vary with larger size and stage of weaning):
<6 months old: 13x400g;
6-12 months old : 7-13x400g;
12months+old : 7x400g
 Formulas based on goat milk or off the shelf goat, sheep, soy, pea, oat, rice or other milks should not
be used due to nutritional inadequacy.
 Soy formulas are contra-indicated in children under 6 months of age due to phyto-oestrogen content.
1
Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group
For children over 6 months of age:
 A suitable alternative as above (see steps 2,3,4) should be advised (Note Nutramigen Lipil and Aptamil
Pepti are both available in a stage 2 formulation). Soya formula may also be used.
 Solids should be introduced after 6 months and should be free from cow’s milk or cow’s milk
derivatives.
 Children under 5 years of age should not be fed rice milk as a milk substitute as it contains arsenic.
5
Avoidance advice:
Verbal and written advice should be provided on the avoidance of food containing cow’s milk protein. A patient information
sheet is available on the Allergy UK website (www.allergyuk.org): cow’s milk free diet
Other information sheets are also available: soya, egg, peanut and tree nut, fish, food, oral allergy, house and dust mite,
adrenaline auto-injectors
6
Provision of a management plan:
Provide a management plan to parent/carers for children with IgE mediated reactions. management plan templates available
on the British Society for Allergy and Clinical Immunology (BSACI) website (www.bsaci.org): management plan templates
7
If symptoms do not respond:
to exclusion of cow’s milk then refer the patient to a paediatric allergy clinic.
Note: children with multiple food allergies or who are failing to thrive should be referred to a paediatric allergy clinic.
8
Re-introduction of
cow’s milk:
For children with non-IgE mediated cow’s milk allergy:
 Re-challenge should be considered every 6 months
 In the first instance, milk protein in the form of a malted milk biscuit should be tried.
 If there is no reaction to this, a spoonful of cow’s milk yoghurt should be introduced.
 If this is tolerated, the amount of yoghurt could be gradually increased and cow’s milk introduced.
For children with IgE mediated cow’s milk allergy:
 Following a 6 month period of cow’s milk exclusion, children older than 1 year will need to be
reviewed by a health care professional, approximately every 6 months. These children will normally
be under the care of a paediatric dietician who will advise about re-introduction of cow’s milk
products.
Risk of developing other allergies:
 Children with cow’s milk allergy are more likely to develop other allergies. If an infant is reacting to other food proteins in addition
to cow’s milk (for example egg) it is vital that this food protein and its derivatives are removed from the diet as well. For children
with multiple food allergies, a referral to a paediatric allergy clinic should be made.
 The risk of nutritional deficiencies is increased when multiple food groups are excluded from the diet. Unnecessary food exclusion
should be avoided, and multiple food avoidance should be supervised in a paediatric allergy clinic.
Refer to paediatric allergy service (which will include paediatric allergy dietetic assessment and advice):
Patients who present with, or develop any of the following symptoms/situations during primary care
management:

If the child had an acute systemic reaction involving wheezing, difficulty breathing, drowsiness, loss of consciousness

If the child has a severe delayed reaction

If the child has a history of reacting to other foods (multiple food allergies)

If the child also has or develops asthma (which puts him/her into a higher risk group for having a more severe allergic response to
milk following accidental ingestion)

If the patient has faltering growth, especially in combination with any gastro-intestinal symptoms

If symptoms do not respond to exclusion of cow’s milk

If the child has a clinical history strongly suggestive of IgE mediated cow’s milk allergy and their serum IgE is positive (for
confirmation of diagnosis and advice about reintroduction of cow’s milk products in due course).

If the child has a clinical history strongly suggestive of IgE mediated cow’s milk allergy but the allergy tests are negative.

Persisting parental/carer suspicion of food allergy or concern once primary care measures have been tried
2
Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group
Refer to paediatric dietetic service:

If there is concern about the nutritional adequacy of the child’s diet

If the mother is having difficulty getting the baby to take a milk free formula

If the parents would like support around reintroduction of cow’s milk protein.

Refer breastfeeding mothers to a community dietician if they wish to remove milk from their own diets and there
are additional risk factors or concerns about their nutritional status.
Appendix 1: Other milk related conditions
1. Cow’s milk protein proctocolitis
Presents with blood or mucus in the stool of happy, thriving breast fed babies, following ingestion of, or maternal ingestion of
milk protein. It improves when cow’s milk protein is eliminated from the maternal diet. If mother wishes to stop breastfeeding,
offer an amino acid formula or if the child is over 6 months offer a soya formula. This usually resolves by a year of age, when
normal cow’s milk can be re-introduced.
2. Lactose intolerance
This is a condition which occurs as a result of a deficiency of the lactase enzyme in the intestine. It usually occurs in children
who were previously able to tolerate cow’s milk. Symptoms occur as a result of lactose malabsorption; abdominal distension,
abdominal pain and diarrhoea. Primary lactose deficiency occurs in up to 70% of the world population, although it is
uncommon in Western Europe. It is due to a decline in activity of the lactase enzyme, which can occur at varying rates, from a
few months of age. Secondary lactose intolerance is a temporary phenomenon, which results from injury to the gut wall
following acute gastroenteritis. This usually resolves within a 2-4 weeks. Treat with a lactose free diet including a lactose free
milk. For infants under 1 year SMA LF or Enfamil O-Lac with Lipil can be prescribed. For infants over 1 year lactose free milk can
be purchased over the counter by the parents/carers.
3. FPIES (Food protein enterocolitis syndrome)
FPIES presents in neonate with profuse vomiting, diarrhoea, acidosis and shock, 1-3 hours after ingestion of milk or other food
proteins. The child may be assessed for sepsis. It may be associated with a raised white cell count but the child is afebrile and
stool samples are clear. FPIES requires hospital referral.
Appendix 2: Allergy testing advice for children in general practice
Introduction
Allergic diseases are common, affecting up to 40% of British children5. Although specialist advice within hospitals is available
for difficult cases, many children with straight forward allergies can be managed in general practice.
Taking a History
Diagnosis of allergic diseases is primarily made by taking a detailed history of exposure and reactions, and by physical
examination. Children from families where other family members also have allergic disease are particularly at risk. On the basis
of the history, clues should emerge which can then be confirmed by performing allergy tests.
Allergy Tests
The most appropriate tests for diagnosing allergy in general practice are specific IgE tests (RAST tests). These should only be
performed to confirm a suspected diagnosis. Screening, using large panels of tests is inappropriate. Testing should be
considered in children aged 2 months and above presenting with allergic conditions.
Allergic Conditions
The immunology laboratory can measure specific IgE to an enormous variety of allergens. If the patient presents with a specific
allergy, then request IgE to the particular allergen. The following is a list of allergic conditions with their commonly associated
allergens. Specific IgE blood tests are available to all these allergens (this is not an exhaustive list):
Food Allergy: cows milk, egg white, wheat, soya, peanuts, tree nuts, fish, shellfish, sesame
Atopic eczema: cows milk, egg, soya, wheat, house dust mite, cat, dog, tree pollen, grass
Asthma: House dust mite, cat, dog, tree pollen, grass pollen, mould
Seasonal rhinitis/conjunctivitis: Grass pollen, tree pollen, mould
Perennial rhinitis/conjunctivitis: House dust mite, cat, dog
3
Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group
Bee and wasp stings: Bee and wasp venom
Latex allergy: Natural rubber latex
Requesting an allergy test
Selection of allergens to be tested should be based on the history of exposure and reactions. Allergy tests can be requested
from Immunology at Kings College Hospital and Guy’s & St Thomas’ Hospital using TQuest.
0.2mls of blood is required for each allergen tested, so it will be necessary to limit the number of tests in very small children to
those thought to be the most important. Please specify which allergens you would like the child tested for.
Taking the blood sample
To refer to Kings paediatric phlebotomy, provide parents with a referral form, listing the specific allergens to be tested and ask
them to phone 020 3299 3560 to book a phlebotomy appointment.
Paediatric phlebotomy is also available at the Evelina Children’s Hospital (walk-in service, no appointment needed.)
Interpreting a test
Specific IgE results should be read in conjunction with the clinical history. A test result of >0.35 kuA/L indicates sensitisation.
ImmunoCAP Grade
6 – strong positive
5 – strong positive
4 – strong positive
3 – positive
Level of allergen specific IgE
antibody (kuA/L)
100+
50-100
17.5-50
3.5-17.5
2 - positive
1 – low, weak positive
0.7-3.5
0.36-0.7
0 – undetectable, negative
 0.35
Comment
Very high. Refer to patient history.
Very high. Refer to patient history.
Very high. Refer to patient history.
High. Grades 1-3 vary in significance dependent
on allergen. Consider patient history and risk of
severe reaction/anaphylaxis.
Moderate
Low. Grade 1 to inhaled allergens is of doubtful
significance. Grade 1 to foods or moulds of
greater significance.
Absent or undetectable.
Higher values are more likely to indicate clinical allergy. A low level of IgE (grade 1 or 2) may be more significant in younger
children (less than 2 years of age), and an intermediate level of IgE (grade 2 or 3) may be less significant in a child with severe
atopic dermatitis or a child who is outgrowing a more severe allergy. Some patients have a positive IgE but do not react on
exposure to the allergen, whilst others may have a negative specific IgE yet still react to allergen. Where there is a discrepancy
between the clinical history and the specific IgE result, patients should be referred to a paediatric allergy clinic for further
evaluation.
References:
1. Cow’s milk protein allergy/intolerance in nutrition in the under 5’s guidelines. 2001. Lambeth PCT.
2. Fiocchi, A., Brozek, J., et al. (2010). World Allergy Organisation (WAO) diagnosis and rationale for action against cow’s milk
allergy (DRACMA) guidelines. Pediatric Allergy and Immunology, 21:1-125.
3. Vandenplas, Y., Brueton, M., et al. (2007). Guidelines for the diagnosis and management of cow’s milk protein allergy in
infants. Archives of Disease in Childhood, 92 (10):902-908.
4. NICE guidelines for the management of food allergy in children and young people (CG116). February 2011.
5. Allergy:The unmet need 2003 Report of the Royal College of Physicians working party on the provision pf allergy services in
the UK
Acknowledgements: Our thanks go to Dr Susan Leech (Consultant Paediatric Allergist – KCH), Dr Adam Fox (Consultant Paediatric
Allergist – GSTFT), Sarah Heath (Paediatric allergy dietician, KCH), Karishma Manwani (Paediatric Allergy Dietician – KCH), Zöe
Wood (London Procurement Partnership (LPP) Dietician Project Manager), Southwark GPs Dr Jane Cliffe, Dr Naomi Kemp, Dr Alex
Bunn and Dr Frances Williams and Lambeth GP Dr Patricia Kirkman for giving their time and expert advice to produce these
guidelines.
These guidelines have been developed by the Southwark Clinical Commissioning Group, Lambeth Clinical Commissioning Group,
Departments of Paediatric Allergy at KCH and GSTFT. Please direct clinical queries to the Departments of Paediatric Allergy at
either KCH or GSTFT and prescribing and other queries to Southwark CCG & Lambeth CCG Medicines Management Teams.
Revised: July 2013
To be reviewed: July 2015
4