NHD CPD eArticle NETWORK HEALTH DIGEST
Volume 8.03 - 5th March 2018
THE MAP MILK ALLERGY GUIDELINES: WHAT’S NEW? Carina Venter PhD, RD Assistant Professor University of Colorado Denver School of Medicine USA Carina is currently working in the Section of Allergy and Immunology at the Children's Hospital Colorado where she is conducting research and working with children and adults.
Dr Trevor Brown MRCP (UK), FRCPCH Honorary Consultant in Paediatric Allergy, Children’s Allergy Service, Ulster Hospital, Northern Ireland Trevor has acted as an advisor to the UK National Care Pathway for food allergy in children, the NICE food allergy guideline, NICE quality standard for food allergy and the NICE e-learning programme for food allergy.
In 2011, the UK Department of Health commissioned a National Institute for Health and Care Excellence (NICE) Guideline on Food Allergy with a very specific and targeted scope: the ‘Diagnosis and assessment of food allergy in children and young people in primary care and community settings’.1 They recommended that many presentations of food allergy should be managed in primary care UK, but no particular focus was placed on cows’ milk allergy (CMA). CMA is the most common cause of food allergy in the early months of life and its diagnosis and management is complex.2 For example, the majority of infants in the UK and Europe present as suspected mild to moderate non-IgE-mediated CMA,3,4 which then requires challenges at home to confirm or exclude the diagnosis. Additionally, with regard to the initial elimination trial prior to the required challenge, there are added complexities; in the formula-fed infant, choosing the most appropriate formula and in the exclusively breastfed infant, advising and supporting a strict maternal elimination diet.5 Given these particular complexities in the initial assessment and diagnosis of CMA, and the then ongoing need to practically advise on the management of mild to moderate non-IgE-mediated CMA within UK primary care, a subgroup of the clinicians on the NICE Food Allergy guideline development group published the MAP (Milk Allergy in Primary Care) guidelines. MAP particularly focused on the following questions:5 • How to distinguish between: i) IgE-mediated and non-IgEmediated presentations of CMA;
ii) Severe and mild to moderate clinical expressions of CMA. • Which children should be considered for early specialist referral. • How to provide guidance on formula choice in the initial diagnosis of CMA, based on the current international guidelines. • How to provide guidance about confirming the diagnosis and then the ongoing management of mild to moderate non-IgE-mediated CMA in primary care. To answer these questions, the MAP guideline authors developed a simple algorithm-based pathway covering the initial clinical presentations of CMA in infancy (both non-IgE and IgE), followed by the management in primary care of those children with confirmed mild to moderate nonIgE-mediated CMA. Since 2013, UK NICE followed up with two more publications: in 2015, a NICE Clinical Knowledge Summary (CKS) on the diagnosis and management in primary care of ‘Cows’ milk protein allergy in children’6 and in 2016, a NICE Quality Standard for food allergy.7
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