Cows milk protein allergy management

Question 1

What is the onset time for IgE-mediated cow’s milk protein allergy (CMA)?

Answer 1

IgE-mediated CMA onset is within minutes (up to 2 hours) of ingestion.

Question 2

What should be done for mild to moderate IgE-mediated CMA?

Answer 2

For mild to moderate IgE-mediated CMA, allergy testing at a specialist allergy clinic and paediatric dietician referral should be done.

Question 3

What dietary advice should be given to an exclusively breast-feeding mother with a baby who has IgE-mediated CMA?

Answer 3

An exclusively breast-feeding mother should exclude all cow’s milk protein from her diet and take calcium and vitamin D supplements.

Question 4

What formula should be tried for formula-fed or mixed-fed infants with mild to moderate IgE-mediated CMA?

Answer 4

For formula-fed or mixed-fed infants, trial extensively hydrolysed formula.

Question 5

What additional steps should be taken for severe IgE-mediated CMA?

Answer 5

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.

Question 6

What is the onset time for non-IgE-mediated cow’s milk protein allergy (CMA)?

Answer 6

Non-IgE-mediated CMA onset is 2-72 hours after ingestion.

Question 7

What caution should be taken when diagnosing infants with non-IgE-mediated CMA?

Answer 7

Be wary of diagnosing infants with CMA as GI symptoms of vomiting and diarrhoea are very common.

Question 8

What should an exclusively breast-feeding mother do if her baby has mild to moderate non-IgE-mediated CMA?

Answer 8

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.

Question 9

What formula should be tried for formula-fed or mixed-fed infants with mild to moderate non-IgE-mediated CMA?

Answer 9

Trial extensively hydrolysed formula.

Question 10

What classifies non-IgE-mediated CMA as severe?

Answer 10

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.

Question 11

What additional management steps should be taken for severe non-IgE-mediated CMA?

Answer 11

Continue management as per mild/moderate non-IgE-mediated CMA plus urgent referral to local paediatric allergy service and dietician.

Question 12

How long should a cow’s milk-free diet be advised for a child with non-IgE-mediated CMA?

Answer 12

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.

Question 13

What should be done for weaned infants or older children with cow’s milk protein allergy?

Answer 13

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.

Question 14

How often should children with cow’s milk protein allergy be re-evaluated for tolerance?

Answer 14

Children with cow’s milk protein allergy should be re-evaluated for tolerance every 6-12 months.

Question 15

What is the ‘Milk Ladder’ used for in the context of cow’s milk protein allergy?

Answer 15

The ‘Milk Ladder’ is used for reintroducing cow’s milk protein into the diet to assess whether tolerance has been acquired.

Question 16

How common is cow’s milk protein allergy in infants?

Answer 16

Cow’s milk protein allergy is common in infants, affecting 5-15% of them.

Question 17

What is the general treatment approach for cow’s milk protein allergy?

Answer 17

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.

Question 18

How long does it take to fully eliminate cow’s milk from breastmilk?

Answer 18

It takes 2-3 weeks to fully eliminate cow’s milk from breastmilk.

Question 19

Do children typically outgrow cow’s milk protein allergy?

Answer 19

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.

Question 20

cows milk protein allaery management summary

Answer 20

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