PAEDIATRIC
TB/TB/AF/ Suspected Cow’s Milk Allergy (CMA) in the 1st Year of Life NS/CV/JW -‐ having taken an Allergy-‐focused Clinical History Oct 2013 Figure 1: Suspected Cows’ Milk Allergy (CMA) in the 1st Year of Life Severe Mild to Moderate Mild to Moderate IgE-‐mediated CMA Non-‐IgE-‐mediated CMA Non-‐IgE-‐mediated CMA ‘Acute’ Onset Symptoms ‘Delayed’ Onset Symptoms ‘Delayed’ Onset Symptoms
Mostly 2-‐72 hrs. a/er inges4on of CMP
Mostly 2-‐72 hrs. a/er inges4on of CMP Formula fed, exclusively breast fed or at onset of mixed feeding
One, or o/en, more than one of these symptoms: Gastrointes=nal ‘Colic’ Vomi4ng -‐ ‘Reflux’ -‐ GORD Food refusal or aversion Loose or frequent stools Perianal redness Cons4pa4on Abdominal discomfort, Blood and/or mucus in stools in an otherwise well infant
Severe persis4ng symptoms of one or more of:
Gastrointes=nal
Diarrhoea, vomi4ng, abdominal pain, food refusal or food aversion, significant blood and/or mucus in stools, irregular or uncomfortable stools. +/-‐ Faltering growth
Respiratory ‘Catarrhal’ airway symptoms (usually in combina4on with one or more of the above symptoms ) Can be managed in
Primary Care See Management Algorithm
One or more of these symptoms:
Skin Acute pruritus, erythema, ur4caria, angioedema Acute ‘flaring’ of atopic eczema
Gastrointes=nal Vomi4ng, diarrhoea, abdominal pain/colic
Skin Severe Atopic Eczema +/-‐ Faltering Growth
Cow’s Milk Free Diet
Skin Pruritus, erythema Significant atopic eczema
Formula fed, exclusively breast fed or at onset of mixed feeding
Mostly within minutes of inges4on of CMP Mostly formula fed or at onset of mixed feeding
Amino Acid Formula AAF
Advise breast feeding mother to exclude all CMP from her own diet and to take daily Calcium (1000mg) and Vitamin D (10mcg) supplements
Ensure: Urgent referral to a paediatrician with an interest in allergy
Urgent diete4c referral
Respiratory Acute rhini4s and/or conjunc4vi4s
Cow’s Milk Free Diet
Severe IgE CMA
Extensively Hydrolysed Formula -‐ eHF
(Ini4al choice, but some infants may then need an Amino Acid Formula -‐ AAF trial if not se^ling)
ANAPHYLAXIS
Immediate reac4on with severe respiratory and/or CVS signs and symptoms. (Rarely a severe gastrointes4nal presenta4on)
Emergency Treatment and Admission
Advise breast feeding mother to exclude all CMP from her own diet and to take daily Calcium (1000mg) and Vit D (10mcg) supplements IgE tes4ng needed.
If diagnosis confirmed (which may require a Supervised Challenge) – Follow-‐up with serial IgE tes4ng and later planned and Supervised Challenge to test for acquired tolerance
Diete4c referral required
If competencies to arrange and interpret tes=ng are not in place -‐ early referral to a paediatrician with an interest in allergy -‐ advised
Source: Milk Allergy in Primary Care (MAP) Guideline (2013)
scepticism that true allergy sufferers encounter in the wider public domain. Patients can often be resistant to accepting that these alternative tests are worthless, particularly when these tests can be quite costly. The BDA Food Fact Sheet Allergy and Intolerance Testing (www.bda.uk.com/foodfacts/ AllergyTesting.pdf) is a patient-friendly resource, useful educating on the problems with allergy and intolerance testing. MANAGING FOOD ALLERGIES
First presentations Very often, the first presentation of food allergy occurs in the young infant when formula is introduced, or through milk proteins in mother’s milk. Midwives and health visitors are best placed to support parents of children with suspected cows’ milk protein allergy, as they are in regular contact with these children at the time of presentation. The 2013, Milk Allergy in Primary Care (MAP) Guideline was produced to provide guidance on the diagnosis and management of cows’ milk protein allergy in primary care. It provides information about assessing the symptoms of cows’ milk protein 22
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allergy, the appropriate use of hypoallergenic formulas, how and when to attempt to reintroduce cows’ milk and when to refer-on for more specialist advice, including to a dietitian. A new version of these guidelines are due to be released within the first quarter of 2017, but the current version is available online at www. cowsmilkallergyguidelines.co.uk. For a patient-friendly resource on choosing an appropriate infant milk, check out the BDA resource ‘Suitable milks for children with cows’ milk allergy’ at www.bda.uk.com/foodfacts/ CowsMilkAllergyChildren.pdf. Breastfeeding Food proteins from the mother’s diet transfer in breast milk.20,21 Whilst sensitization to a food protein requires a prior exposure to the food, sensitization can occur in utero, through breast milk and through non-gut exposure (e.g. skin, airways) after birth. Breastfeeding should be promoted as far as possible in an allergic infant, where the first step would be elimination of the suspected allergen from the mother’s diet for up to four weeks. If symptoms resolve,