Hertfordshire Guidelines for Specialist Infant Feeds - CMPA - (HMMC) Feb 2015 (Updated July 2015 and June 2016)

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1 COWS MILK PROTEIN ALLERGY (CMPA) Symptoms and Diagnosis Refer to NICE Clinical Guideline 116 (February 2011) Food Allergy in children and young people for full details of symptoms, an allergy focused clinical history taking, diagnosis and assessment in primary care and community settings Refer also to MAP guideline (Milk Allergy in Primary Care) electronic interactive version - see algorithms on Page 7 & 8 Most infants with non-ige mediated CMPA develop symptoms within 2-72 hours of ingestion of cow s milk protein whereas in IgE-mediated CMPA, symptoms usually develop within minutes Most babies presenting with colic, restlessness and/or crying do not have CMPA. Seek health visitor advice to resolve any problems with feeding technique and formula reconstitution. Infantile colic is often defined by the rule of three : crying for more than three hours a day, for more than 3 days a week, and for longer than three weeks in an infant who is well-fed and otherwise healthy. If IgE mediated CMPA is suspected NICE recommends referral to secondary/specialist care for further investigation with a serum specific IgE antibody blood test or a skin prick test. Onward referral Most infants with CMPA can be managed in primary care Make referral to a paediatric dietitian to support the management of the infant in primary care: - o Prior to weaning for all infants who require a cow s milk free diet o Breastfeeding mothers following a milk free diet o Any other advice on the diagnostic home milk challenge, review periods, milk ladder and any other issues with specialist infant formulae. Refer to secondary/specialist care if any of the following apply: - o Faltering growth with one or more GI symptoms o Acute systemic reactions or severe delayed reactions o Significant atopic eczema where multiple or cross-reactive food allergies are suspected o Possible multiple food allergies o Persisting parental suspicion of food allergy despite a lack of supporting history (especially where symptoms are difficult or perplexing) o If IgE-mediated CMPA is suspected Treatment EXCLUSIVELY BREAST FED INFANTS Breast milk is the optimum choice for most infants with CMPA A strict exclusion of cow s milk foods from maternal diet is indicated for a minimum of 2 weeks. See Appendix 2 and for dietary advice. Calcium (1000mg) and vitamin D (10mcg or 400iu) supplementation is recommended for breastfeeding mothers on a cow s milk free diet. If breastfeeding mother does not wish to or unable to follow milk-free diet, or are following a milk free diet and top-ups are required, an amino acid formula (AAF) can be prescribed in primary care Treatment FORMULA/BOTTLE FED INFANTS Extensively hydrolysed formulae (ehfs) are the 1 st choice to be prescribed unless the infant has a history of anaphylactic symptoms. Trial an ehf for a minimum of 2 weeks. Amino acid formulae (AAF) should normally be started in secondary/specialist care or on the advice of a dietitian. They are suitable only when an ehf does not resolve symptoms and/or there 1

2 is evidence of severe (anaphylactic) allergy (see MAP guideline on page 8) If infant has history of anaphylactic reaction to CMP, AAF can be started in primary care with immediate onward referral to secondary/specialist care Only 10% of infants with CMPA should require management with an AAF. 90% should improve with an ehf SPECIALIST INFANT FORMULAE USED IN CMPA Only prescribe 1-2 tins initially to assess tolerance/ acceptance and to avoid waste Infants who do not tolerate one formula due to palatability may accept another formula Specialist Infant Formula for CMPA Age Range Size of tin Cost (NHS*) per tin EXTENSIVELY HYDROLYSED FORMULAE ehf (Lactose Free) 1 st CHOICE in PRIMARY CARE 1 st line EHF 2 nd line EHFs Recommended quantity prescribed per month Similac Alimentum Birth to 2yrs 400g 9.10 (<6m) tins Casein based. Lactose free. (>6m) 7 13 tins This is the most cost effective EHF in primary care. Prescribing this EHF will give a cost saving of approx in the first year of life compared to the other 2 nd line EHFs listed below Nutramigen 1 with LGG** Birth to 6 months 400g tins Nutramigen 2 with LGG ** 6 months to 2yrs 400g tins Casein based. Lactose free. Contains probiotic and requires reconstitution with boiled water that has been cooled to room temperature in a sterilised bottle. SMA Althera Birth to 3yrs (<6m) tins 450g Whey based (>6m) 7 13 tins Aptamil Pepti 1 400g tins Birth to 6 months Whey based. Contains lactose 800g tins Aptamil Pepti 2 400g tins 6 months to 2yrs Whey based. Contains lactose 800g tins EXTENSIVELY HYDROLYSED FORMULA ehf (with medium chain triglycerides) SPECIALIST INITIATION Pepti-Junior Birth to 2yrs/able 450g (<6m) tins Pregestimil LGG to tolerate CMP 400g (>6m) 7 13 tins These formulae are used where CMPA is accompanied by malabsorption SPECIALIST INITIATION ONLY AMINO ACID FORMULAE (AAF) USUALLY SPECIALIST/DIETITIAN INITIATION - reserved for when ehf does not resolve symptoms or when history of anaphylaxis SMA Alfamino (most cost effective AAF) Birth to 3yrs 400g (<6m) tins (>6m) 7 13 tins Nutramigen PurAmino Birth to 2yrs/able 400g Neocate LCP to tolerate CMP 400g Neocate Active >1 year 15 x 63g 4.44/sachet 56 sachets or as Neocate Active is a high calorie formula and will not be required automatically by all infants over 1 year. It is not suitable as a sole source of nutrition. recommended by dietitian Neocate Advance (unflavoured) >1 year 10x100g 5.86/sachet Neocate Advance (banana & vanilla) >1 year 15x50g 3.95/sachet Neocate Advance is a sole source of nutrition for tube fed only patients aged 1-10yrs. It is a high calorie product and will not be required automatically by all infants >1 year Neocate Spoon >6 months unless directed by specialist/dietitian 15x37g 2.62/sachet * NHS product costs obtained from Dictionary of Medicines and Devices March 2016 ** Nutramigen with LGG has replaced Nutramigen Lipil contains probiotic requiring a different reconstitution method stated age or when able to tolerate over the counter products containing CMP Quantity to be recommended by dietitian 2

3 Diagnostic Challenge with Cow s Milk in Mild to Moderate NON-IgE Mediated CMPA To confirm the initial diagnosis of CMPA, the MAP guideline recommends reintroduction of cow s milk after 2 weeks of exclusion in mild to moderate non-ige mediated CMPA. Therefore prescribe EHF for one month ONLY initially. A leaflet (Appendix 3) explaining the diagnostic milk challenge for parents is available to download Review, discontinuation of treatment and challenges with cow s milk Review prescriptions regularly to check that the formula prescribed is appropriate for the child s age. Quantities of formula required will change with age see page 2 and 4 and/or refer to the most recent correspondence from the paediatric dietitian. Avoid adding to the repeat prescription list for these reasons. Try to align the repeat interval to the review date with the dietitian. CMPA children should be reviewed at least every 6 months as paediatric allergy will often resolve as child acquires tolerance. Refer to NICE guidelines CG116 or see MAP guidelines/management Flow Charts for CMPA for when children are challenged with cow s milk in secondary setting (supervised challenge) and when the challenge can be performed at home under the supervision of a paediatric dietitian (reintroduction at home see appendix 4 or download from Prescriptions should be stopped when the child has grown out of the allergy % children outgrow CMPA by 2 years, rising to 85-90% by 3 years Review the need to continue with the prescription if the answer is YES to any of the following questions: - Is the patient over 2 years of age? Or has the formula been prescribed for more than 1 year? Is the patient prescribed more than the suggested quantities of formula according to their age? Is the patient prescribed a formula for CMPA but able to eat any of the following foods cow s milk, cheese, yoghurt, ice-cream, custard, chocolate, cakes, cream, butter, margarine or ghee? Children with multiple or severe allergies may require prescriptions beyond 2 years. This should always be on the recommendation of the paediatric dietitian/specialist. Notes Soya formula (SMA Wysoy ) should NOT be routinely used for CMPA. It should NOT be used at all for infants under 6 months due to high phyto-oestrogen content and the risk that infants with CMPA may also develop an allergy to soya. It is more likely that children will tolerate soya formula from 1 year. If soya formula is used, parents should be advised to purchase over the counter (OTC) as it is a similar cost to standard cow s milk formula and readily available. Alpro Junior 1+ soya milk may be suitable from 1 year. From 2 years, supermarket calcium enriched soya or oat milk may be suitable as alternative milk sources. The paediatric dietitian will advise on suitable OTC products. EHF and AAF have an unpleasant bitter taste and smell, which is better tolerated by younger patients. Unless there is anaphylaxis, advise that the new formula is introduced gradually by mixing with the usual formula in increasing quantities until transition complete. Serving in a bottle, closed cup or with a straw (depending on age) may improve compliance or use a minimal amount of milkshake flavouring take care to check ingredients if child has multiple allergies. Prescribe only 1 or 2 tins initially until compliance/tolerance is established to avoid waste. Lactose free formulae (SMA LF, Enfamil O-Lac ) are not suitable for treating CMPA. Do NOT advise sheep, goat or mammalian milk as an alternative due to cross sensitivity. Rice milk is not suitable for children under 5 years due to the arsenic content. 3

4 Weaning and Calcium Intake Daily volumes of CMPA required to meet calcium RNI ehf ehf with MCT AAF CMPA formula Age Range Calcium content (mg) Per 100g Per 100ml Daily volume intake required to meet RNI (524mg)in 6-12months Daily volume intake required to meet RNI (352mg) in 12-24months Similac Alimentum 0-24m ml 495ml Nutramigen 1 with LGG 0-6m N/A N/A Nutramigen 2 with LGG 6-24m ml 375ml SMA Althera 0-36m ml 535ml Aptamil Pepti 1 0-6m N/A N/A Aptamil Pepti m ml 560ml Pepti- Junior ,050ml 705ml Pregestimil LGG 0-24m ml 450ml SMA Alfamino 0-36m ml 620ml Nutramigen PurAmino 0-24m ml 550ml Neocate LCP ml 535ml When an infant with CMPA reaches 6 months and starts to be weaned, it is important that an adequate calcium intake is achieved, particularly whilst remaining on a milk-free weaning diet. Once weaning has been established, the volume of CMPA formula that the infant requires per day is reduced. The recommended intake for an infant >6 months on standard formula is ml per day. See table above for the daily volumes required for each of the CMPA formulae to meet the RNI (Reference Nutrient Intake) for calcium for infants aged 6-12 months and months. Therefore if the infant is not taking these daily volumes, there is the potential risk that there may be insufficient calcium intake from the CMPA formula feed particularly if the infant is not managing their recommended dietary intake of calcium-containing non-diary solid food. Nutramigen LGG 2 has the highest calcium content of all the ehfs and therefore it may be useful in ensuring adequate levels of calcium can be achieved in the daily volume of CMPA formula that the infant can consume without affecting the weaning process. Calcium and vitamin D supplementation may be needed for some infants depending on the volume and type of formula taken the paediatric dietitian will advise. Ensure all infants requiring a milk free diet are referred to a paediatric dietitian for support and advice on their diet PRIOR TO WEANING 4

5 MANAGEMENT FLOW CHART OF SUSPECTED CMPA IN AN INFANT < 12 MONTHS IN PRIMARY CARE Adapted from the MAP (milk allergy in primary care) guideline. For full details see (registration required): Also refer to NICE guideline CG116 Food Allergy in Children and Young People Feb 2011: Take an allergy focused clinical history and family history of atopy Electronic interactive MAP guideline eractive-algorithm/ Non IgE-mediated CMPA DELAYED onset symptoms (2-72 hours after ingestion of CMP formula fed, exclusively breast fed or at onset of mixed feeding)) IgE-mediated CMPA ACUTE onset symptoms (mostly within minutes of ingestion of CMP and mostly formula fed or at onset of mixed feeding) MILD TO MODERATE SYMPTOMS One, or often, more than one of: GI Skin - *Colic - Pruritus - Vomiting - Erythema - Reflux - Significant atopic - Constipation eczema - Loose or frequent stools - Food refusal/aversion - Blood and/or mucus in stools (in an otherwise well infant) Respiratory Catarrhal airway symptoms (usually with one or more of the above symptoms) Can be managed in Primary Care See Management Flow Chart for Mild to Moderate Non IgE-mediated CMPA (page 8) *Colic (infantile) is often defined by the rule of three : crying for more than three hours a day, for more than three days per week, and for longer than three weeks in an infant who is well-fed and otherwise healthy SEVERE SYMPTOMS one or more persisting severe symptoms: GI - Diarrhoea and vomiting - Significant blood and/or mucus in stools - Irregular/uncomfortable stools - Food refusal/aversion - Faltering growth Skin -Severe atopic eczema If formula fed: - initiate trial of AAF SMA Alfamino (Birth - 3yrs ) Only prescribe 1-2 tins initially to assess tolerance/acceptance and until infant seen by secondary care and paediatric dietitians. See page 5 for tips on improving palatability of feed. Ensure URGENT referral to secondary care paediatrician Ensure URGENT referral to paediatric dietitian SEVERE IgE-mediated CMPA ANAPHYLAXIS -Immediate reaction with severe respiratory and/or CVS signs and symptoms. -Rarely a severe GI presentation Emergency treatment and hospital admission If breast fed: advise breast feeding mother to exclude all cow s milk from maternal diet and to take daily calcium (1000mg) and vitamin D (10mcg) supplements or until the infant grows out of allergy MILD TO MODERATE SYMPTOMS - Immediate onset of one or more symptoms: GI Respiratory - Diarrhoea - Acute rhinitis - Vomiting - Conjunctivitis - Abdominal pain/ *colic Skin -Acute pruritus, erythema, urticaria, angioedema, acute flaring of atopic eczema If formula fed: initiate trial of ehf 1 st line: Similac Alimentum (Birth -2yrs ) Only prescribe 1-2 tins initially to assess tolerance/acceptance and until infant seen by secondary care and paediatric dietitians. See page 5 for tips on improving palatability of feed. Referral to paediatric dietitian required. IgE testing needed to confirm diagnosis referral to secondary care paediatrician required. If diagnosis confirmed (which may require a Supervised Challenge) follow-up serial IgE testing and later a planned and Supervised Challenge will be conducted to test for acquired tolerance 5 7

6 MANAGEMENT FLOW CHART FOR MILD TO MODERATE NON IgE-MEDIATED CMPA IN PRIMARY CARE: No initial IgE Skin Prick Tests or Serum Sepcific IgE Assays necessary. Adapted from the MAP (milk allergy in primary care) guideline. For full details see (registration required): Exclusively Breast-Fed Strict exclusion of cow s milk from maternal diet for 2-4 weeks Daily calcium (1000mg) and vitamin D (10mcg) supplements Referral to paediatric dietitian If CMPA, most symptoms will settle well within the 2-4 weeks exclusion period Electronic interactive MAP guideline: Formula-Fed or Mixed Feeding (Breast and Formula) Strict Cow s milk protein free diet for 2-4 weeks Formula fed: Initiate trial of ehf 1 st line: Similac Alimentum (Birth 2yrs ) 2 nd line: Nutramigen LGG 1 & 2 or SMA Althera or Aptamil Pepti 1 & 2 SOYA FORMULAE (Wysoy ) is NOT routinely recommended. Do not use in infants <6months due to high phyto-oestrogen content. Risk of developing soya allergy. Advise parent to buy OTC Mixed feeding: Trial of a cow s milk free maternal diet with ehf top-ups if needed No improvement or symptoms do not settle CMPA still suspected: Need to consider other maternal foods e.g. egg. Refer to secondary care paediatrician CMPA no longer suspected: Return to usual maternal diet. Refer to secondary care paediatrician if symptoms persist Improvement of symptoms need to confirm diagnosis Diagnostic Home Milk Challenge (to be done between 2-4 weeks of starting cow s milk exclusion diet) If breast fed: Re-try cow s milk in maternal diet gradually over one week } Refer to Appendix 3 of guideline If formula fed: Re-try standard cow s milk formula gradually over one week } with support of dietitian No return of symptoms - NOT CMPA SYMPTOMS RETURN If breast fed: Exclude cow s milk from maternal diet again (with support of dietitian) If symptoms settle: CMPA NOW CONFIRMED - Continue with maternal cow s milk free diet and daily calcium (1000mg) & vitamin D (10mcg) supplementation - Use an AAF if top-up formula feeds needed seek dietitian advice first: SMA Alfamino (Birth - 3 years ) PRIOR TO WEANING REFER INFANT TO PAEDIATRIC DIETITIAN SYMPTOMS RETURN If formula fed: Return to the ehf again. (with support of dietitian) If symptoms settle: CMPA NOW CONFIRMED - Continue to prescribe the ehf until infant has grown out of allergy or they are 2 years old Continue with cow s milk free diet until 9-12 months of age and for at least 6 months with the support of dietitian A planned REINTRODUCTION or SUPERVISED CHALLENGE is then needed to determine if tolerance is achieved: Does the child have CURRENT ECZEMA or ANY history at ANY time of acute onset symptoms? No improvement or symptoms do not settle CMPA still suspected: -Seek dietitian advice - Consider a trial of an AAF SMA Alfamino (0-3 years ) - Refer to secondary care paediatrician CMPA no longer suspected: Stop ehf and return to standard formula. - Refer to secondary care paediatrician if symptoms persist or until the infant grows out of allergy No current eczema (and no history at any stage of acute onset symptoms) No need to check Serum Specific IgE or perform Skin Prick Test REINTRODUCTION at home using a MILK LADDER to test for tolerance (Appendix 4) with the support of dietitian Current eczema Refer to secondary care paediatrician Check Serum Specific IgE or Skin Prick Test to cow s milk NEGATIVE POSITIVE History of acute onset symptoms at ANY time Refer to secondary care paediatrician for management to check Serum Specific IgE or perform Skin Prick Test NEGATIVE POSITIVE or tests not available A SUPERVISED CHALLENGE may be needed (managed by secondary care paediatrician) 6 8

7 Quantities of specialist formulae to prescribe When any infant formula is prescribed the guide below should be used: Powder Formula Age of Infant Number of tins for 28 days and Basis for Recommendation 13 x 400g tins OR 6-7 x 800g tins OR 6 x 900g tins Under 6 months Infants <6 months are exclusively formula fed and drink (on average) 150ml/kg/day of a normal concentration formula x 400g tins OR 3-7 x 800g tins OR 3-6 x 900g tins 6 12 months Infants aged 6-12 months require less formula as solid food intake increases 7 x 400g tins OR 3-4 x 800g tins OR 3 x 900g tins Over 12 months The Department of Health recommends infants >12 months drink 600ml of milk or milk substitute per day Always review recent correspondence from the paediatric dietitian/paediatrician Some infants may require more than the quantities stated above e.g. those with faltering growth Prescribing Do s and Don ts Do: Promote and encourage breast-feeding wherever possible where it is clinically safe Check any formula prescribed is appropriate for the age of the infant Check the quantity of formula prescribed is appropriate for the age of the infant (see page 2) and refer to the most recent correspondence from the paediatric dietitian Review any prescriptions where: - o Child is over 2yrs o Infant feed has been prescribed for more than 1 year o Larger quantities of formula are being prescribed than would be expected o CMPA infant feed is being prescribed but the infant is able to eat cow s milk, cheese, yoghurt, ice cream, custard, chocolate, cakes, cream, butter, margarine or ghee Prescribe 1 or 2 tins/bottles initially until compliance/tolerance is established Remind parent to follow the manufacturer s advice regarding safe storage of the feed once reconstituted or opened Provide parent with relevant patient information (See Appendices) Refer where appropriate to the paediatric dietitians and/or secondary/specialist care (as indicated in the management flow charts) Seek prescribing advice if needed in primary care from the CCG Pharmacy & Medicines Optimisation Team (PMOT) Herts Valleys CCG or East and North Herts CCG Seek prescribing advice if needed in secondary care from the hospital Medicines Information Centre Herts Valleys or East and North Herts Don t: Do not add infant feeds to the repeat prescription list in primary care, unless a review process is in place to ensure the correct product and quantity is prescribed for the age of the infant. Do not prescribe lactose free formulae (Aptamil LF, SMA LF, Enfamil O-Lac ) for infants with CMPA Do not routinely prescribe soya formulae (SMA Wysoy ) for those with CMPA or secondary lactose intolerance. Not to be used at all in infants under 6 months due to the high phytoestrogen content Do not suggest milk or formulae made from goat, sheep or mammalian milks for infants with CMPA or secondary lactose intolerance or other conditions covered in this guideline Do not suggest rice milk for children under 5 years due to the high arsenic content Do not prescribe low lactose/lactose free formulae in children with secondary lactose intolerance over 1 year who previously tolerated cow s milk, since they can use supermarket full fat lactose free milk e.g. Lactofree brand 7

8 National and Local Spend These guidelines consider both clinical and cost effectiveness in its recommendations. Some products may not be the least expensive but are considered the most appropriate first line product for the condition. By using the first line CMPA product (ie an EHF and not an AAF) could save over 18 million nationally annually. This represents the biggest cost saving in the guidelines. Acknowledgements, References and Appendices: Please refer to the full document: Hertfordshire Guidelines on Specialist Infant Feeds (HMMC) Feb

9 Appendix 1 CMPA Frequently Asked Questions Cow s Milk Protein Allergy (CMPA) Frequently Asked Questions Q: Can goat s milk formula be used as a treatment for CPMA A: No: Goat s milk and sheep s milk are not advised due to cross reactivity with cow s milk Q: What happens when an infant reaches 1 year of age and is still CMPA? A: - If soya is tolerated: Children over 1 year of age can use Alpro Junior 1+ soya milk instead of formula (this can be used in cooking from 6 months). Available to purchase in supermarkets. - If soya is not tolerated: Continue with specialist formula (ensure child has review appointment with the paediatric dietician and, if necessary, the specialist paediatrician). Q: What happens when an infant reaches 2 years of age and still has a cow s milk protein and soya allergy? A: The specialist formula milk should no longer be required and the child can go onto a supermarket milk substitute i.e. oat, coconut, almond, hazelnut or hemp milk. Rice milk is not suitable for children under 5 years due to the high arsenic content Further advice and support can be sought from the paediatric dietician. Q: Are vitamin and mineral supplements required? A: The Department of Health recommends that a supplement containing vitamin A, C and D in the form of vitamin drops is given to: All breastfed infants from 6 months of age Infants under 1 year of age who are taking less than 500ml of formula daily All children from 1 5 years The Health Visitor can provide advice on vitamin drops and where to get them. The child will be entitled to free vitamin drops if the family is eligible for the Healthy Start scheme. Q: What are Neocate Active and Neocate Advance? A: These are highly specialised hypoallergenic amino acid products and should only be initiated and advised by secondary care. They should not be prescribed in infants under the age of 1 year. They are not designed as follow on from Neocate LCP and will not be required automatically by all infants over 1 year on an amino acid formula. Neocate Active is a high calorie formula and is not suitable as sole source of nutrition. Neocate Advance is a high calorie product and is used as a sole source of nutrition for tube fed infants aged 1-10 years. Q: What is Neocate Spoon? A: This is a hypoallergenic amino acid based food. It is not to be used as a drink/formula. It is suitable for infants from 6 months of age who have multiple food allergies. It should only be initiated and used under the direction of a paediatric dietician. A: Why is soya formula not routinely advised? Q: Soya formula is no longer indicated for cow s milk allergic infants under the age of 6 months due to its phytooestrogen content and the increased risk of sensitisation to soya protein (as per Chief Medical Officer Statement, 2004). Parents wishing to feed their infant (over the age of 6 months) on a soya based formula should be advised of the risks and advised to purchase the formula over the counter. Soya formula (Wysoy ) is available from pharmacies and supermarkets at a similar cost to standard infant formula. Q: Can lactose free products be used in CMPA? A: No: These products contains cow s milk protein and are therefore not suitable. 9

10 Appendix 2 Patient Information Initial advice for those needing a milk free diet Patient Information Initial advice for those needing a milk free diet If you (if you are breastfeeding) or your child needs a milk free diet because of cow s milk protein allergy or lactose intolerance, the following foods should be avoided: Milk cow s, goat s, sheep s All types of cheese Yogurt Milk powder Butter Cream Milk drinks Margarine Ice cream Artificial cream Crème fraiche Fromage frais Food labels that list any of the ingredients below should also be avoided, as this indicates that the food contains milk: Caseins Skimmed milk powder Whey syrup Caseinates Milk solids Milk sugar Hydrolysed casein Ghee Butter fat Sodium caseinate Non-fat milk solids Lactose Skimmed milk Whey Buttermilk Lactoglobulin Whey solids Hydrolysed whey Whey powder Whey sugar Whey syrup sweetener The following foods are examples (not a complete list) of processed foods which may contain milk and will need to be checked: Breakfast cereals Baked goods, e.g. rolls Soups Pancakes, batters Baby foods Ready made meals Processed meats, e.g. luncheon meat, sausages Puddings and custards Pasta and pizzas Cakes, biscuits, crackers Instant mashed potato Chocolate/confectionery Sauces and gravies Crisps ALWAYS CHECK FOOD LABELS CAREFULY. IF IN DOUBT, LEAVE IT OUT! If your child has cow s milk allergy, a special infant formula may be prescribed (e.g. Similac Alimentum, Nutramigen LGG ). These are made from extensively hydrolysed (broken down to small particles) milk protein which should not cause an allergic reaction. If your child has lactose intolerance, a milk free diet may be needed for a few weeks until this resolves. A lactose free formula may be recommended for you to purchase from pharmacies if your child is below 1 year of age. If your child is over 1 year, you are recommended to use a lactose free milk (Lactofree ) which can be purchased from most supermarkets. 10

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13 Appendix 4 MAP milk ladder guidance to parents to re-introduce milk at home and to determine tolerance 13

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