Download Cows milk protein allergy / intolerance

Guidelines for managing cows milk protein allergy / intolerance in
primary care
Incidence




Cows milk allergy affects approximately 2-3% of infants under 12 months of age.
The majority of children outgrow their milk allergy.
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
IgE/Non-IgE
Comments
Acute allergic
reaction
redness, urticaria,
swelling, pruritis
Usually IgE
mediated
Symptoms usually occur on the first or second exposure
to cows milk protein
Delayed
reaction
eczema, vomiting,
GOR (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 approaches in a child
with a family history of atopy.
Management in primary care: Follow the steps below for managing cow’s milk allergy /
intolerance in children
Step Action:
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Take an allergy focused clinical history: history of reaction, history of eczema, feeding history, family history
of atopic disease.
Confirm the suspected diagnosis by allergy testing:
 Measure specific IgE to cows milk in blood (refer to guidelines for allergy testing for children in general
practice)
 A positive result is >0.35kU/L and supports the diagnosis of IgE mediated cows milk allergy
 Children with cows milk allergy are commonly also allergic to egg, so it would be useful to check IgE to egg
in addition
 If results are negative consider if symptoms are compatible with non-IgE mediated reaction or an
alternative diagnosis
Complete exclusion of cows milk from the diet:
 This is essential for children with IgE mediated cows milk allergy
 For children with non-Ige mediated symptoms, cows milk should be removed from the diet for a trial
period, followed by re-introduction after 6 weeks
For children under 6 months of age:
Recommend an alternative
 Recommend exclusive breastfeeding until 6 months of age.
milk formula:
 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. Nutramigen or Aptamil Pepti.
 For children with severe eczema whilst being exclusively breastfed,
faltering growth or gastrointestinal symptoms, an amino acid formula
should be used. E.g. Nutramigen AA or Neocate. These should also be tried
in children who refuse an EHF.
 Formulas based on soy or goat milk or off the shelf goat, sheep, soy, pea,
oat, rice or other milks should not be used due to nutritional inadequacy
For children over 6 months of age:
 A suitable alternative as above should be advised. Soya formula may be
advised if the infant is eating a mixed diet with adequate alternative
protein sources.
 Solids should be introduced after 6 months and should be free from cows
milk or cows milk derivatives.
Avoidance
advice:
Verbal
and
written
advice should be provided on the avoidance of food containing cows
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milk protein.
Provision of a management plan: Provide a management plan to parent/carers for children with IgE mediated
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reactions (management plan templates available on Southwark Intranet).
If symptoms do not respond: If symptoms do not respond to exclusion of cows milk then refer patient to
paediatric allergy clinic.
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Note: children with multiple food allergies or who are failing to thrive should be referred to the paediatric
allergy clinic.
For children with IgE mediated cows milk allergy:
 Following a period of cow’s milk exclusion, the child will need to be
reviewed by a health care professional, approximately every 6 months,
and advised about re-introduction.
 Re-introduction should be considered if the child has not had any acute
allergic reactions, to cows milk, for at least 6 months.
 In the first instance, milk protein in the form of a malted milk biscuit
Re-introduction of cows
should be tried.
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milk:
 If there is no reaction to this, then a spoonful of cows milk yoghurt should
be introduced.
 If this is tolerated, the amount of yoghurt could be gradually increased and
cows milk introduced.
 Cheese should be avoided until cows milk is tolerated.
For children with non-IgE mediated cows milk allergy:
 It is reasonable to re-introduce cows milk after 4-6 weeks, to see if the
symptoms recur.
Risk of developing other allergies:
 Children with cows milk allergy are more likely to develop other allergies. If an infant is reacting to other food
proteins, in addition to cows milk, for example egg, it is vital this 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
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If the child has a severe delayed reaction
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If the child has a history of reacting to other foods (multiple food allergies)
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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)
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If the patient has faltering growth, especially in combination with any GI symptoms
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If symptoms do not respond to exclusion of cows milk
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If the child has a clinical history strongly suggestive of IgE mediated cows milk allergy, but the allergy tests are
negative
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Persisting parental/carer suspicion of food allergy or parental/carer concern once primary care measures have
been tried
Refer to paediatric dietetic service:
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If breastfeeding mothers wish to remove cows milk from their own diets
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If there is concern about the nutritional adequacy of the child’s diet
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If the mother is having difficulty getting the baby to take a milk free formula
Appendix: Other milk related conditions
1. Cows 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. Improves when cows milk protein is eliminated from the
maternal diet. If mother wishes to stop breastfeeding, offer an amino acid formula or soya formula if
the child is over 6 months. This usually resolves by a year of age, when normal cows milk can be reintroduced
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 cows 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 few weeks.
Patients with lactose intolerance can often tolerate cows milk protein in the form of cheese. A
lactose free formula, such as soya formula in children over 6 months of age or an extensively
hydrolysed milk formula in children under 6 months of age should lead to an improvement in
symptoms.
3. FPIES (food protein enterocolitis syndrome)
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. May be associated with a raised
white cell count but the child is afebrile and stool samples are clear. Requires hospital referral.