GP Patient Pathway for Infants under 1 year of age with Cows Milk Protein Allergy (Non IgE Mediated) Infant suspected with (non IgE) after an allergy focused clinical history has been completed (see appendix 1). Start infant on a hydrolysed infant formula and milk free diet if appropriate. If infant breast fed, mum will require a milk free diet (mum might also require Calcium and Vitamin D to be supplemented). Please refer to prescribing guidelines for infant formula choice and further guidance. Consider rechallenge if response** / diagnosis is unclear OR refer to paediatrician if symptoms do not fully resolve Dietitian Dietetic Telephone review * Milk free Group Education * Note: Cow s Milk Protein Allergy now includes those previously described as having Cow s Milk Protein Intolerance GP to complete Referral pro-forma to Paediatric Dietetics (appendix 2) (appenservice Diagnosis confirmed and/or no medical concerns Infant responded to 2-6 week trial of cow s milk elimination diet Specialist Paediatric Dietitian (RDH) to assess pro-forma Complex History and Diagnosis or not fully responded to hydrolysed cows milk free infant formula Requires Consultant Paediatrician assessment Refer back to GP/Health Visitor for advice e.g. Lactose intolerance, overfeeding, mild reflux, colic, general infant feeding advice Refer directly to consultant paediatrician if infant has: -severe faltering growth, -severe reflux, -unclear presentation Refer to Paediatric Allergy clinic (RDH) if: -multiple food allergy -anaphylactic reaction -Significant IgE mediated Telephone review at one year old* and discharge if appropriate Consultant Paediatrician appointment Telephone review at 14-18 months old (if required) and Discharge back to GP* Ongoing consultant paediatrician hospital care with dietetic support if required Note * Dietitian Date can refer produced: back to June consultant 2016 (updated paediatrician March 2018) at any point in pathway Review date: March 2020 ** Please see Author appendix Paediatric 4 for CIG patient (Infants advice Dietetics on Dept) rechallenge to confirm diagnosis if required Version 7.0 THIS PATHWAY SHOULD BE USED IN CONJUNCTION WITH THE GUIDANCE ON THE APPROPRIATE USE AND PRESCRIBING OF INFANT FORMULA IN PRIMARY CARE
Appendix 1 Allergy Focused History The most important part in diagnosis of allergy is the history. This requires taking an Allergy focused history: Please ask for occurrence of all of these symptoms. IgE mediated (acute onset) Skin Pruritus Erythema Acute urticaria (localised/ generalised) Acute angioedema (face, eyes, lips) Gastrointestinal Angioedema of lips/tongue/palate Oral pruritus Colicky abdominal pain Vomiting and diarrhoea Respiratory Upper respiratory (nasal itching, sneezing, rhinorrhoea, congestion) Lower respiratory (cough, wheeze, chest tightness, shortness of breath) Non IgE mediated (Delayed onset) Skin Pruritus and erythema Atopic eczema Gastrointestinal Gastro-oesophageal reflux disease Loose/frequent stools Blood and/or mucus in stools Abdominal pain Infantile colic Constipation Food refusal or aversion Peri-anal redness Pallor/ tiredness Faltering growth (with one or more of above) The timings of any reactions or symptoms need to be recorded in relation to possible allergen exposure. The following should also be identified: Identify allergen - e.g. Food, cow s milk -?first exposure?previous exposure - known allergen, other allergies Identify atopic tendency Wheeze, eczema, Identify strong family history parents, first degree relatives with asthma, hay fever, food allergies, other known allergies. Diagnosis can be diagnosed by a suggestive history and the following: IgE mediated/ immediate onset: Exclusion of cow s milk from diet leads to cessation of symptoms Typical symptoms can be confirmed by skin prick test weal size >3mm (these can be arranged by referral paediatric allergy clinic). There is no need to take routine bloods (e.g. specific IgE levels for milk) to aid in diagnosis unless there is uncertainty about diagnosis or symptoms appear atypical. In such cases a referral to paediatric allergy clinic may be indicated for further assessment. Non IgE mediated/ delayed onset symptoms: GI symptoms - milk exclusion for at least 2 weeks and assess symptoms which should improve Severe eczema and treatment resistant eczema with a clear history of milk being a likely contributing factor - Milk exclusion 2-6 weeks then reintroduction and assess symptoms on reintroduction.
Appendix 2 Incomplete referral forms will be rejected GP Referral Proforma for infants under 1 year of age with milk protein allergy (non IgE mediated) to Dietetic Service, Derbyshire Children s Hospital, Royal Derby Hospital Patient Details Name: Address: NHS no: DOB: Tel no: Family history of atopy or food allergies? Please give details Birth history. Please give details Medical and investigation history. Please give relevant details Onset of symptoms. Please tick, and give detail of frequency Reflux/vomiting Loose or frequent stools Blood and/or mucus in the stool Abdominal pain Infantile colic Constipation Perianal redness Eczema/itch Pallor and/or tiredness Faltering growth plus one gastrointestinal symptom above Note: If severe allergic reaction (IgE mediated) on contact of milk protein please refer directly to paediatric allergy clinic, Derbyshire Children s Hospital. If severe faltering growth, please refer directly to a paediatrician. Feeding History. Please give details
Please give details of the infants response to the trial period of cow s milk protein free infant formula (please refer to http://www.derbyshiremedicinesmanagement.nhs.uk/assets/clinical_guidelines/clinica l_guidelines_front_page/infant_feeding_guideline.pdf for information on suitable milk free infant formulas) Growth History Is the infant growing appropriately? Contact details Health Visitor Name Telephone no Are there any known safeguarding concerns? Referrer Details Referring GP Name: Address: Telephone No: Date: This form can be completed via choose and book under the following categories: Speciality: Dietetics, Clinic type: Food allergy and intolerance OR email to The Paediatric Dietitians, RDH at: dhft.kidsnutrition@nhs.net please remove email referral as a way of referral Contact: Paediatric Dietitians Dietetic Department Royal Derby Hospital Uttoxeter Road Derby DE22 3NE Tel 01332 785233 dhft.kidsnutrition@nhs.net
Appendix 3 Hypoallergenic infant formulas used to treat Nutramigen 1 with LGG (MJ Nutrition) Nutramigen 2 with LGG (MJ Nutrition) Aptamil Pepti 1 (Milupa, Danone) Aptamil Pepti 2 (Milupa, Danone) Neocate LCP (Nutricia) with severe faltering growth or multiple food allergies or infants who do not fully respond with a hydrolysed infant formula Extensively hydrolysed infant formula for under 6 months, available in 400g tin Contains no lactose Extensively hydrolysed infant formula for over 6 months, available in 400g tin Contains no lactose Extensively hydrolysed infant formula for under 6 months, available in 400g tin Contains lactose Extensively hydrolysed infant formula for over 6 months, available in 400g tin Contains lactose Amino based formula (elemental), available in 400g tin Nutramigen Puramino (MJ Nutrition) with severe faltering growth or multiple food allergies or infants who do not fully respond to a hydrolysed infant formula Amino acid based formula (elemental), available in 400g tin.
Appendix 4 This can be found at: https://www.allergyuk.org/assets/000/001/298/home_reintroduction_protocol_to_confirm_or_exclu de_diagnosis_original.pdf?1502805714
October 2016