Prescribing Guidelines for Lactose Intolerance and Cow s Milk Protein Allergy

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1 Prescribing Guidelines for and Aim To clarify which products and in which circumstances milk substitutes can be prescribed for babies and young children in primary care, as well as to give a guide to prescribing quantities and duration of treatment. Background NICE produced guideline 116 in Feb 2011 relating to Food allergy in children and young people, it covers the diagnosis and assessment of food allergy in children and young people in primary care and community settings. The care pathway from NICE which covers initial recognition to referral to specialist is attached. Summary It is important to distinguish between CMPA and intolerance for effective. A limited range of products (foods/milk substitutes) can be prescribed as drugs, and these are defined in Borderline substances. Any prescription written needs to be marked ACBS It is acknowledged that infants will present to Health Visitors and GP practices with suspected intolerances to infant and it will not always be appropriate to wait for a diagnosis from secondary care but rather it is necessary to treat empirically. Soya based s are not recommended for prescribing to infants, especially those under 6 months of age.the reason for this is the risk that the baby may develop a secondary soya allergy. Soya milk also contains phytoestrogens which are an unproven health risk, particularly for male babies. (Babies of vegan mothers who choose not to breast feed may be given soya milk but not at the expense of the NHS). tose free milks can be bought at a similar cost to standard infant and prescribers should consider the need to prescribe at the expense of the NHS. The NHS Tees ry lists suitable s which are available from pharmacies and many supermarkets will stock on demand.* Healthy start vouchers can be used towards free infant s well as standard milk. *Parents should be directed towards a pharmacy to purchase free milk; Boots for example keep the milk in the dispensary rather than on the open shelves. Many supermarkets do not routinely stock free infant milk but will order it in on an individual basis, pharmacies can obtain stock the same day if not currently stocked. Key Points for Cow s Milk Protein allergy Adverse reactions to foods, mainly cow s milk protein, are most common in the first year of life (1). In infancy the main atopic symptoms are atopic dermatitis, gastrointestinal (GI) symptoms (, blood in stools, vomiting, abdominal distension, colic and constipation) and recurrent wheeze. CMPA may be caused by two distinct immune pathologies: IgE- and non IgEmediated. Acute IgE-mediated reactions (usually within 2 hours) include rash or urticaria, wheeze or vomiting. Delayed reactions may be non IgE-mediated or mixed (>2 hours) including eczema, colic, (see NICE Box 1) Prescribing Guidance for tose intolerance and CMPA KT Approved by Tees Medicine Management Committee June 12, - Review June 2014.

2 Suspect CMPA when: a child has one or more signs and symptoms, especially if persistent symptoms affecting different organ systems; when a child has not responded to treatment for atopic eczema reflux or chronic GI symptoms including constipation (2). Breast fed infants can display symptoms, as some cow s milk proteins from the mothers diet may be expressed in breast milk. Infants with CMPA should be referred to a paediatric dietitian for diagnosis, support and advice on the need for, and the timing of, re-challenge to cows milk to test if the allergy has resolved. Most children grow out of their allergy by months of age. Key Points for tose intolerance is defined as a non-immune mediated adverse reaction to food i.e. it is not due to allergy but to a lack of the enzyme lactase. Primary intolerance is rare; generally intolerance is secondary to gastroenteritis and is transient, usually lasting around 4 to 6. Should be treated with a free not a hypoallergenic milk free see decision aid for suitable s. tose free can be purchased at a similar price to standard and GP should consider whether prescription is actually necessary; advice to use a free infant with appropriate safety netting may be all that is required. usually resolve in 2-3 days when is removed from the diet and achievement of this confirms diagnosis. From the age of 1 year, infants continuing to require free milk should be weaned onto proprietary free milks purchased at supermarkets. (tose free infant should not be required beyond 18 months). tose free milk is more cariogenic than standard as it contains glucose in place of.. Managing Breast milk is the ideal choice for the infant with CMPA with maternal exclusion of cow s milk and supplementation with calcium (to provide 1000mg calcium daily) for a minimum trial of two. For bottle fed infants an appropriate hypoallergenic is required. These s vary in palatability and should be introduced as soon as possible. If not accepted initially introduce with incremental mixing with the standard. Give a minimum trial of two. It is advisable to inform parents /guardians that these s contain glucose, so that they may pay special attention to dental hygiene as new teeth appear. The paediatric dietitian will review and inform the GP of all planned monitoring, the follow up intended and guidance given to parents on weaning and the plan to stop milk. Typically the paediatric dietitians will usually recommend challenging with small amounts of cows milk from the age of months. In cases of IgE mediated allergy challenges need to be under medical supervision. By the age of 18months most infants a will have been recommended to (gradually) switch to normal cow s milk or if this is not tolerated, a commercially available liquid milk substitute (soya or oat) using varieties fortified with calcium Prescribing Guidance for tose intolerance and CMPA KT Approved by Tees Medicine Management Committee June 12, - Review June 2014.

3 Managing Breast milk remains the ideal choice for the infant with intolerance. Breast fed babies with intolerance can be prescribed Colief at a dose of four drops per feed for 4-6 or until symptoms have resolved. For bottle fed babies, free milks are available at a similar price to standard. See NHS Tees ry for details of products available. As intolerance is generally temporary, babies should be re-challenged after 4 to 6 to test if the intolerance has resolved. Re-challenge by introducing an increasing amount of standard into the free milk and monitoring for symptoms Other Specialist infant Secondary care will lead in prescribing for several special groups of infants and young children. Pre-term and low birth weight infants ( may also require iron and vitamin supplements) Disease specific conditions Complex food intolerances Faltering growth Complex medical cases All such prescribing should be initiated by secondary care. The letter should include details of all planned monitoring and follow up intended and guidance for the GP on when the should be stopped. Unsettled Babies For infants who appear unsettled, colicky etc. but are not allergic or intolerant to cow s milk, there are a range of commercially available milks designed to be easier to digest as well as a range of anti colic medicines which parents may wish to try but should not be prescribed. Produced in conjunction with the paediatric dietitians across NHS Tees especial thanks to the support from Susanna Earnshaw Lead Paediatric Dietitian for North Tees and Hartlepool NHS Foundation Tr. REFERENCES 1. Vandenplas Y et al: Guidelines for the diagnosis and of cow s milk allergy in infants. Arch Dis Child 2007;92: NICE Clinical Guideline 116 Food Allergy in children and young people 3. BDA Paediatric Group (2008) Paediatric Group Position Statement on the use of Soya protein for infants. British Dietetic Association; London. Prescribing Guidance for tose intolerance and CMPA KT Approved by Tees Medicine Management Committee June 12, - Review June 2014.

4 Page 4 for a minimum trial of 2. (Milupa) contains.if symptoms do not after 2 or the child. due to occult confirmed or Iron deficiency for a minimum trial of 2. : free within 4-6 of GI after two on free diet, consider use free milk available advised that is w s milk protein free diets to the. se for a minimum trial of 2. 1 and 2 (Milupa) -contains.if symptoms do not after 2 or the child. due to occult confirmed or Iron deficiency for a minimum trial of 2. : free within 4-6 of GI after two on free diet, consider use free milk available advised that is w s milk protein free diets to the. se for a minimum trial of 2. (Milupa) contains.if symptoms do not after 2 or the child. due to occult confirmed or Iron deficiency for a minimum trial of 2. (Milupa) contains.if symptoms do not after 2 or the child. due to occult confirmed or Iron deficiency for a minimum trial of 2. : free within 4-6 of GI after two on free diet, consider use free milk available advised that is w s milk protein free diets to the. se for a minimum trial of 2. 1 and 2 (Milupa) -contains.if symptoms do not after 2 or the child. due to occult confirmed or Iron deficiency for a minimum trial of 2. For a minimum trial of 2 4 : free within 4-6 of GI after two on free diet, consider use free milk available advised that is w s milk protein free diets to the. of for a minimum trial of 2. (Milupa) contains.if symptoms do not after 2 or the child. due to occult confirmed or Iron deficiency for a minimum trial of 2. : free within 4-6 of GI after two on free diet, consider use free milk available advised that is w s milk protein free diets to the. se for a minimum trial of 2. 1 and 2 (Milupa) -contains.if symptoms do not after 2 or the child. due to occult confirmed or Iron deficiency for a minimum trial of 2. : free within 4-6 of GI after two on free diet, consider use free milk available advised that is w s milk protein free diets to the. se for a minimum trial of 2. (Milupa) contains.if symptoms do not after 2 or the child. due to occult confirmed or Iron deficiency for a minimum trial of 2. (Milupa) contains.if symptoms do not after 2 or the child. due to occult confirmed or Iron deficiency for a minimum trial of 2. : free within 4-6 of GI after two on free diet, consider use free milk available advised that is w s milk protein free diets to the. se for a minimum trial of 2. 1 and 2 (Milupa) -contains.if symptoms do not after 2 or the child. due to occult confirmed or Iron deficiency for a minimum trial of 2. For a minimum trial of 2 4 : free within 4-6 of GI after two on free diet, consider use free milk available advised that is w s milk protein free diets to the. of to revert back to normal within 4 to 6 of GI insult but if symptoms do not after two on free diet, consider alternative diagnosis. use free milk available from most supermarkets

5 NHS Tees Infant ry Please note quantities of prescribed will need to be ed according to the infant s age, growth, stage of weaning and severity of allergy and will be advised by the dietitian. The typical requirements included below are a guide only though usually quantities are reduced by the age of 12 months with an aim to discontinue by months. Product Indication Age suitability Monthly Requirements tose Free Infant SMA LF (400g/ 4.60) tose From Birth Enfamil O- (400g 4.35) intolerance tose intolerance Extensively Hydrolysed Infant Nutramigen lipil1 Cow s Milk Protein (400g/ 9.72) Allergy Nutramigen lipil 2 (400g/ 9.72) Aptamil Pepti 1 CMPA and unable (400g/ 9.03)(900g/ 20.30) to tolerate taste of Aptamil Pepti 2 Nutramigen (900g/ 19.39) Amino-Acid Based Infant (400g/ 24.97) Cows Milk Protein Nutramigen AA Allergy (se ) (400g/ 23.95) Soya Based Infant Infasoy (900g/ 7.73) Wysoy (430g / 4.59)(860g/ 8.75) Infants with Cows milk protein allergy that are unable to tolerate other From Birth 6-10 tins Generally no NHS prescription should be necessary Additional Information From 12mths a commercially available free milk should be sourced from a supermarket Healthy start vouchers can be used to pay for free milk. More cariogenic than standard From birth From 6 months 6-10 tins 6-10 tins Website has information on introducing to baby. More cariogenic than standard From birth 6-8 tins (400g) Prescribe if above not tolerated 3-4 tins(900g) due to taste From 6mths 3-4 tins More cariogenic than standard From birth From birth 8-14 tins 6-10 tins Prescribe if above not tolerated after a trial of a minimum of two, or if symptoms se. More cariogenic than standard From 6months From 6months 6-10 tins Only prescribe if other milks are not tolerated as potential health risk of phytoestrogens for babies fed predominately on soya milk, also high incidence of soya allergy in children with CMPA. Do not prescribe for infants of vegan parents at the cost of the NHS. Health Start vouchers can not be used to purchase soya milk. More cariogenic than standard. Re-challenge with cow s milk 4 to 6 starting with 1oz/30ml standard in one bottle of free a day increasing incrementally IgE mediated allergy will be challenged under the medical supervision. Non IgE the dietitians will advice usually at the age of 12-18months Starting with 1oz/30ml whole milk in one bottle of milk free per day increasing incrementally until a full feed of cows milk is tolerated From 12-18mths commercially available soya or oat milk is available in most supermarkets. Page 5

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