Cows milk protein allergy management Flashcards
What is the onset time for IgE-mediated cow’s milk protein allergy (CMA)?
IgE-mediated CMA onset is within minutes (up to 2 hours) of ingestion.
What should be done for mild to moderate IgE-mediated CMA?
For mild to moderate IgE-mediated CMA, allergy testing at a specialist allergy clinic and paediatric dietician referral should be done.
What dietary advice should be given to an exclusively breast-feeding mother with a baby who has IgE-mediated CMA?
An exclusively breast-feeding mother should exclude all cow’s milk protein from her diet and take calcium and vitamin D supplements.
What formula should be tried for formula-fed or mixed-fed infants with mild to moderate IgE-mediated CMA?
For formula-fed or mixed-fed infants, trial extensively hydrolysed formula.
What additional steps should be taken for severe IgE-mediated CMA?
For severe IgE-mediated CMA, consider elemental (amino acid) formula if extensively hydrolysed formula is not effective and refer to A&E if severe respiratory or CVS signs are present.
What is the onset time for non-IgE-mediated cow’s milk protein allergy (CMA)?
Non-IgE-mediated CMA onset is 2-72 hours after ingestion.
What caution should be taken when diagnosing infants with non-IgE-mediated CMA?
Be wary of diagnosing infants with CMA as GI symptoms of vomiting and diarrhoea are very common.
What should an exclusively breast-feeding mother do if her baby has mild to moderate non-IgE-mediated CMA?
Exclude all cow’s milk protein from the mother’s diet for 2-4 weeks, followed by home reintroduction of cow’s milk to confirm diagnosis if there is clear symptom improvement. Mother should take calcium and vitamin D supplements.
What formula should be tried for formula-fed or mixed-fed infants with mild to moderate non-IgE-mediated CMA?
Trial extensively hydrolysed formula.
What classifies non-IgE-mediated CMA as severe?
Non-IgE-mediated CMA is classified as severe if symptoms persist and are severe despite the above measures. Symptoms include pruritis, erythema, atopic eczema, GORD, vomiting, loose stools, blood or mucus in stools, abdominal pain or discomfort, infantile colic, food refusal or aversion, constipation, perianal redness, pallor or tenderness, faltering growth, cough, chest tightness, wheezing, and shortness of breath.
What additional management steps should be taken for severe non-IgE-mediated CMA?
Continue management as per mild/moderate non-IgE-mediated CMA plus urgent referral to local paediatric allergy service and dietician.
How long should a cow’s milk-free diet be advised for a child with non-IgE-mediated CMA?
Advise a cow’s milk-free diet until the child is 9-12 months old and for at least 6 months if non-IgE-mediated allergy is confirmed. After which, commence a milk ladder for home reintroduction of cow’s milk to assess whether tolerance has been acquired.
What should be done for weaned infants or older children with cow’s milk protein allergy?
Exclude cow’s milk protein from their diet, offer nutritional counselling with a paediatric dietician, regularly monitor growth, and re-evaluate the child to assess for tolerance to cow’s milk protein every 6-12 months.
How often should children with cow’s milk protein allergy be re-evaluated for tolerance?
Children with cow’s milk protein allergy should be re-evaluated for tolerance every 6-12 months.
What is the ‘Milk Ladder’ used for in the context of cow’s milk protein allergy?
The ‘Milk Ladder’ is used for reintroducing cow’s milk protein into the diet to assess whether tolerance has been acquired.
How common is cow’s milk protein allergy in infants?
Cow’s milk protein allergy is common in infants, affecting 5-15% of them.
What is the general treatment approach for cow’s milk protein allergy?
The general treatment approach for cow’s milk protein allergy is to avoid cow’s milk in the maternal diet (for breastfeeding mothers) or switch to hypoallergenic formula.
How long does it take to fully eliminate cow’s milk from breastmilk?
It takes 2-3 weeks to fully eliminate cow’s milk from breastmilk.
Do children typically outgrow cow’s milk protein allergy?
Many children will grow out of cow’s milk protein allergy. Review in 6-12 months and consider reintroducing cow’s milk protein using a milk ladder.
cows milk protein allaery management summary
Cow’s Milk Protein Allergy (NICE CKS 2023)
IgE-mediated (Onset within minutes (up to 2 hours) of ingestion) o Mild-moderate
Allergy testing at specialist allergy clinic Paediatric dietician referral
Exclusively breast-feeding mother
Exclusion of all cow’s milk protein from mother’s diet
Mother to take calcium and vitamin D supplements
Formula fed or mixed feeding
Trial of extensively hydrolysed formula
o Severe
As above and:
Consider elemental (amino acid) formula if extensively hydrolysed formula not effective
Refer to A&E if severe respiratory or CVS signs present – risk of anaphylaxis
Non-IgE mediated (Onset 2-72 hours after ingestion)
o Mild- moderate
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Be wary of diagnosing infant with CMA as GI symptoms of vomiting and diarrhoea are very common
Exclusively breast-feeding mother
Exclusion of all cow’s milk protein from mother’s diet for 2-4 weeks,
followed by home reintroduction of cow’s milk to confirm diagnosis if
there is clear symptom improvement.
Mother to take calcium and vitamin D supplements
Formula fed or mixed feeding
Trial of extensively hydrolysed formula
o Severe
Classified as severe if above measures taken and symptoms persist and are
severe – symptoms to look out for:
Skin: pruritis/ erythema/ atopic eczema
GI: GORD/ vomiting/ loose stools/ blood or mucus in stools/ abdominal
pain or discomfort/ infantile colic/ food refusal or aversion/ constipation/
perianal redness/ pallor or tenderness/ faltering growth
Resp: cough/ chest tightness/ wheezing/ shortness of breath
Continue management as per mild/moderate non-IgE mediated CMA plus:
Urgent referral to local paediatric allergy service
Urgent referral to dietician
o Advise cow’s milk free diet until child 9-12 months old and for at least 6 months if non- IgE-mediated allergy confirmed. After which, commence milk ladder for home reintroduction of cow’s milk to assess whether tolerance acquired.
Weaned infants/older children:
o Exclude cows’ milk protein from their diet
o Offer nutritional counselling with a paediatric dietician
o Regularly monitor growth
o Re-evaluate the child to assess for tolerance to cows’ milk protein (every 6-12 months)
- this involves re-introducing cows’ milk protein into the diet
If tolerance is established, greater exposure of less processed milk is advised
following a ‘Milk Ladder’ (available from Allergy UK)
PACES TIPS
Explain the diagnosis (allergic reaction to some of the proteins in milk)
Explain that it is common (5-15% of infants)
Treatment is simple: avoid cows’ milk in maternal diet (breastfeeding) or switch to
hypoallergenic formula
o Consider calcium and vitamin D supplementation
o NOTE: it takes 2-3 weeks to fully eliminate cows’ milk from breastmilk
Many children will grow out of it (review in 6-12 months and consider re-introducing cows’ milk protein using a milk ladder)
Advise regularly monitoring growth
Support: British Dietetic Association (BDA) has produced a useful fact sheet
