PAEDIATRIC
WEANING AN INFANT WITH COW’S MILK PROTEIN ALLERGY (CMPA) CMPA is the most common food allergy in babies and young children and the management of CMPA is an ever-evolving landscape. Part 1 of this two-part article takes a look at how CMPA is diagnosed and managed during weaning. CMPA can be defined as a reproducible adverse reaction of an immunological nature induced by cow’s milk protein. CMPA can be classified into IgEmediated immediate-onset, or non-IgEmediated delayed-onset, or a mixed picture, depending on the timing of the onset of symptoms and the organs involved.1 The prevalence of CMPA varies between 1.8% and 7.5% of babies during the first year of life, depending on the type of feeding the infant is receiving: CMPA is more common in formulafed or mixed-fed infants (7%) than in breastfed infants (0.5%).2,3 CMPA most often presents with symptoms within the first three to six months of life and rarely presents after 12 months of age. The focus of CMPA management has shifted over the past 10 years from one of strict avoidance of the known food allergens and provision of suitable alternatives, to a balancing act between avoiding allergens and at the same time promoting the acquisition of oral tolerance.4 WHEN SHOULD COW’S MILK PROTEIN ALLERGY (CMPA) BE SUSPECTED?
CMPA should be suspected in infants or children who have one or more of the signs and symptoms described in Table 1 opposite.3 PROGNOSIS
The outlook for children with CMPA is very positive, with most children growing out of their CMPA, although the age at which this occurs is highly variable. Approximately 75% of children
with CMPA will grow out of their allergy by three years of age and 90% will have outgrown it by six years of age. CMPA will persist until adulthood in a small percentage of individuals. The ESPGHAN guidelines5 recommend that children be re-evaluated every 6-12 months to assess tolerance to cow’s milk protein. In 2015, Lifschitz et al2 reported that, overall, children with non-IgEmediated CMPA have a better chance of outgrowing their allergy, whereas children with IgE-mediated CMPA with high levels of milk-specific IgE antibodies, multiple food allergies and/ or concomitant asthma and allergic rhinitis, had a higher risk of CMPA persisting for longer.2,5
Paula Hallam RD, PG Cert (Paed Diet) Specialist Paediatric Dietitian Paula is a Specialist Paediatric Dietitian and owner of Tiny Tots Nutrition Ltd. She helps families of babies and children with many nutritional concerns, such as fussy eating, iron deficiency anaemia, constipation, growth faltering and food allergies. She also facilitates weaning workshops for new mums.
HOW IS CMPA DIAGNOSED?
Early and reliable diagnosis of CMPA is very important, so that the appropriate dietary restrictions can be initiated where CMPA is confirmed, or avoided where the diagnosis has been refuted.1 When there is a suspicion of CMPA in an infant, an allergy-focused clinical history, tailored to the presenting symptoms, is the first step in assessing the child.3 An ‘allergy-focused diet history’ tool has been developed by Isabel Skypala and Carina Venter to help guide the correct and accurate diagnosis of CMPA.6 The European Academy of Allergy and Clinical Immunology (EAACI) guidelines on food allergy suggest that the allergy-focused history is fundamental to the establishment of a diagnosis and the mechanisms and food triggers involved.7
REFERENCES Please visit the Subscriber zone at NHDmag.com
www.NHDmag.com October 2019 - Issue 148
39