Nutritional Management of Cow s Milk Allergy (CMA) Croydon University Hospital Dietetic Department

Nutritional Management of Cow s Milk Allergy (CMA) Croydon University Hospital Dietetic Department

Outline Types of CMA Cow s milk allergy vs. lactose intolerance Nutritional considerations in diagnosing CMA Formula and alternative milk choice Age-appropriate milk substitutes Dietetic management of CMA Meeting calcium requirements on a milk-free diet

Types of CMA

Case Study - Mira 10 weeks old Fed with Cow & Gate standard from birth Developed symptoms of reflux from 4 weeks of age 10 episodes of reflux a day Parents changed formula to Cow & Gate Comfort but symptoms have not improved Mira is very unsettled between feeds and it causing lots of anxiety for parents Mira is growing well and her weight it tracking 9 th centile Is this cow s milk allergy?

GOR or CMA Symptoms of gastro-oesophageal reflux (GOR) Unexplained feeding difficulties (refusing to feed, gagging or choking) Vomiting Regurgitation Distressed behaviour Faltering growth Chronic cough Hoarseness Single episode of pneumonia Symptoms suggestive of CMA in infants with GOR Blood in stool Chronic diarrhoea Infants and children with, or at high risk of atopy Infants whose GOR and/or GORD has not responded to the initial management Gastro-oesophageal reflux disease in children and young people: diagnosis and management, NICE guidelines, 2015

Simple reflux Management of GOR Use the following step-cared approach: Review the feeding history, Then reduce the feed volumes only if excessive for the infant's weight Then offer a trial of smaller, more frequent feeds (while maintaining an appropriate total daily amount of milk) (150ml/kg), unless the feeds are already small and frequent, Then offer a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum). If the stepped-care approach is unsuccessful stop the thickened formula and offer alginate therapy Gastro-oesophageal reflux disease in children and young people: diagnosis and management, NICE guidelines, 2015

OTC Thickened Formulas Thickening agent: Carob bean gum Thickening agent: Carob bean gum Thickening agent: corn starch Suitable for vegetarians Halal approved Thickening agent: Carob bean gum Trial for 1-2 weeks Do not prescribe

Case Study - Leo 3 months old Exclusively breastfed since birth Developed symptoms of frequent, loose stools 3 weeks ago Leo s weight has reduced from 50 th to the 25 th centile since birth Mum says that Leo is experiencing a lot of pain Mum also reports that 3 year old sister Skye had milk intolerance as a baby Is this CMA or lactose intolerance?

CMA or Lactose Intolerance Common age of onset Prognosis Dietary management CMA Infancy, usually between 3-6 months (rarely after 12 months) IgE-mediated allergy usually resolves by 5 years Non-IgE-mediated allergy usually resolves sooner Cow s milk protein exclusion Primary lactose intolerance Rarely before 2-5 years Usually lifelong Low lactose diet Secondary lactose intolerance Infancy and early childhood Usually resolves in 2-4 weeks Lactose-free diet for 2-4 weeks

Allergy-focused clinical history An individual and family history of atopic disease (such as asthma, eczema or allergic rhinitis) or food allergy is more likely in food allergy Allergy-focused clinical history (NICE CG116) Details of any foods that are avoided and the reasons why An assessment of presenting symptoms and other symptoms that may be associated with food allergy including questions about age at symptom onset, speed of onset, duration of symptoms, severity of reaction, frequency of occurrence, setting of reaction, reproducibility of symptoms Cultural and religious factors that affect the foods they eat Who has raised the concern and suspects the food allergy What the suspected allergen is The child or young person's feeding history, including age weaned commenced, whether type of feeding, details of any previous treatment and the response to this, any response to the elimination and reintroduction of foods NICE Food Allergy in Under 19s Assessment and Diagnosis CG116 NICE Quality standard: Food Allergy 2016 [QS118] statement 1

Dietary Management of Lactose Intolerance Babies under 1 year Children over 1 year Can usually continue with their current milk (breast milk or formula) as symptoms should resolve in a few weeks May require long-term low lactose diet if primary lactose intolerance OTC Lactose-free formulas are available but only need to be considered in higherrisk cases, such as infants younger than 3 months, or faltering growth OTC Lactose-free milk and dairy products Lactose intolerance should be considered where patients present only with typical GI symptoms Calcium-enriched alternative milks (nonorganic soya, oat, coconut & nuts milks) Refer children with primary lactose intolerance to the Dietitian to advise on the nutritional adequacy of the diet Refer parents to NHS choices: Lactose intolerance for more information

OTC Lactose-Free Products Do not prescribe

Investigation of Suspected CMA in Exclusively Breastfed Infants Encourage Breastfeeding: Refer to breastfeeding advisor for support if required Babies under 6 months (weaning not commenced) Babies over 6 months (or symptom onset with weaning) Trial a maternal cow s milk protein exclusion for 4-6 weeks followed by challenge to confirm diagnosis Trial a dietary cow s milk exclusion for 2-6 weeks followed by challenge to confirm diagnosis Recommend OTC supplement for breastfeeding that contains 1000mg calcium and 10mcg Vitamin D. e.g. Pregnacare Incorporate OTC calcium-enriched, nonorganic dairy alternatives into the maternal diet Continue with breastfeeding and usual maternal diet Incorporate OTC calcium-enriched, nonorganic dairy alternatives into the diet Patient information sheets are available from Allergy UK https://www.allergyuk.org/milk-allergy/milk-allergy and BDA https://www.bda.uk.com/foodfacts/milkallergy.pdf

Investigation of Suspected CMA in Formula Infants Formula and mixed-fed infants: Babies under 1 year Babies over 1 year (rare) Trial an extensively hydrolysed formula for a period of 2 6 weeks followed by challenge to confirm diagnosis Trial a dietary cow s milk exclusion with for 2-6 weeks followed by challenge to confirm diagnosis If no improvement in symptoms following trial consider other causes Recommend an OTC calciumenriched, non-organic dairy alternative If no improvement in symptoms following trial consider other causes NICE Food Allergy in Under 19s Assessment and Diagnosis CG116 NICE Quality standard: Food Allergy 2016 [QS118] statement 3

Choice of Formula in CMA Extensively Hydrolysed Formula (ehf) should be used as first-line in infants up to 6 months of age If a baby does not settle on one EHF they may settle with another EHF with a different composition Patients unresponsive or partially responsive to a trial of two EHFs can be progressed to Amino Acid Formula Amino Acid Formula AAF should only be prescribed for severe IgEmediated allergy Anaphylaxis There is emerging evidence that tolerance to cow s milk occurs sooner on sustained exposure to ehf Berni Canani R. et all.. ISME J. 2016 Mar;10(3):742-50., Berni Canani R et all. J Pediatr. 2013 Sep;163(3):771-7. Over the counter (OTC ) Soya based formula (e.g. Wysoy ) can only be used first line from 6 months onwards Concomitant soya protein allergy only affects 1 in10 infants with CMA (BSACI 2014) Do not routinely prescribe ehf or AAF for children over 1 year of age

Choice of Formula in infants <1y First Line Caesinbased ehf Lactosefree Wheybased ehf Contains Lactose Caesinbased ehf Contains Lactose Second Line AAF Contains MCT AAF Contains MCT AAF First line: should be initiated in primary care Not recommended: Second line: only initiate in primary care in severe CMA or Mild to moderate CMA unresponsive or partially responsive to EHF All children under 5 years of age require OTC vitamin D supplements unless they are taking > 500ml infant formula per day. soya formula in babies under 6 month partially hydrolysed formulas: comfort formulas/sma HA

Confirming Diagnosis of CMA Challenge to confirm the diagnosis of non-ige-mediated cows milk allergy (with no history of severe delayed reactions) Challenge in Exclusively breast fed infants If symptoms improve on a milk free diet, the mother should revert to a normal diet including foods containing cows milk protein over a period of 1 week If symptoms do not return then the diagnosis is not CMA, or the CMA has been outgrown If symptoms return, exclude CMP from maternal diet again. If symptoms settle, this confirms the diagnosis of CMA. Challenge in Formula fed/mixed fed infants If symptoms improve on a milk free diet, reintroduce cows milk formula after 4-6 weeks If symptoms do not return then the diagnosis is not CMA If symptoms return, restart ehf again. If symptoms then settle, this confirms a diagnosis of CMA. Suspected IgE-mediated cow s milk allergy Positive milk RAST: probable CMA no challenge required Negative milk RAST: likely non-ige-mediated CMA challenge required. Confirmed CMA Refer to the Paediatric Dietitian NICE Food Allergy in Under 19s Assessment and Diagnosis CG116 NICE Quality standard: Food Allergy 2016 [QS118] statement 3

MAP Home Challenge To CONFIRM THE DIAGNOSIS of Mild to Moderate Non-IgE Cow s Milk Allergy after the milk exclusion Symptoms suggestive of CMA based on self-reports vary, and only about 1 in 3 children presenting with symptoms is confirmed to be CMA (BSACI 2014)

Dietetic Management of Confirmed CMA Strict avoidance of cows milk protein for at least 6 months or until the child is 9-12 months old Ensure optimal nutrition Milk-free weaning group (pilot) Enables parents of babies <1 year to receive dietary advice promptly 2h interactive group session to provide comprehensive milk-free weaning advice for babies with confirmed CMA Fast-track appointment ~1 month following attendance at group Access to fortnightly Fast-Track Dietetic review clinics How to refer: Confirm diagnosis of CMA and refer to the Peadiatric Dietitian as per existing referral pathway and local guidelines

Practical advice on what foods and drinks to avoid, how to interpret food labels and alternative sources of nutrition to ensure adequate nutritional intake Ensure weaning progression Provide guidance on nutritional adequacy of diet Dairy Free

Dietary avoidance of CMP Butter, butter oil, buttermilk Casein, caseinates, hydrolysed casein, sodium caseinate, calcium caseinate Cheese Cow s milk: fresh, UHT, evaporated, condensed, dried, powdered Cream, artificial cream, ice cream Curd, ghee Lactalbumin, lactoglobulin Margarine Milk solids, non-fat milk solids, milk sugar, milk protein, milk powder, skimmed milk powder Whey, hydrolysed whey, whey powder, whey syrup sweetener Yogurt, fromage frais

The Milk Ladder Dietetic Review: Assess suitability of a home milk challenge to establish tolerance Usually following 6 months of cow's milk protein exclusion

Confirmed Cows Milk Allergy- Paediatric Pathway for CUH Dietetic Service Referral Triage Process Breast Fed Baby Formula Fed Babyunder 1 year Formula Fed Babyover 1 year Urgent Clinic Initial Clinic Appointment Invitation to Milk Free Weaning Group (pilot) Routine Initial Clinic Appointment Fast-Track review Appointment Routine review Appointment Further review appointments Discharge

Case Study- Niamh 15 month old girl Weight is tracking 50 th - 75 th centile CMA diagnosed at 4 months Mum is requesting 4 tins of Aptamil Pepti 2 a month Mum is concerned that Niamh is a very fussy eater BNO for 5 days with abdominal pain and straining Is this an age-appropriate milk intake?

Calcium Requirements Group Age (years) Age (years) Calcium (mg) per day Calcium stars per day Infants Under 1 525 9 Stars Children 1-3 4-6 7-10 350 450 550 6 Stars 7 ½ Stars 9 Stars Adolescents 11-18 800 for girls 1000 for boys 13 Stars 17 Stars Adults 19+ 700 11 Stars Dietary reference values, COMA 1991

Appropriate Milk Intake Beyond 1y Milk is only required to meet calcium requirements Calcium requirements reduce in the 2 nd year of life to 350 mg Encourage 3 servings of calcium rich products per day (including all milk drinks) to meet requirements Milk drinks should now be only 100-120ml (3-4 oz) and offered from a cup They should be limited to three times a day or less if cheese and yoghurt are eaten regularly. Milk intakes >500ml in children >1 year increase the risk of: Appetite suppression/fussy eating Compromised nutritional intake/dietary imbalance Iron deficiency Constipation Childhood obesity Maslin et al, 2015 Department of Health (2012) National Diet and Nutrition Survey: Headline Results from Years 1, 2 and 3 (combined) of the Rolling Programme 2008/09 2010/11

% RNI for Ca in 1-3 year olds/100ml Calcium Content of Different Milks 35% 30% 25% 20% 15% 10% 5% 0% * Higher Energy formula for children >1y do not routinely prescribe. Seek advice from the Dietitian

Cow s milk vs. soya milk Cow s milk (whole) Cow s milk (semi) Alpro Soy milk (Growing Up) Energy (kcal) CHO (g) Sugars (g) Fat (g) Protein (g) Cal (mg) B2 (mg) (ug) B12 Vit D (ug) 66 4.5 4.5 3.9 3.3 120 0.23 0.9 Trace 50 4.8 4.8 1.8 3.6 124 0.22 0.8 Trace 64 8.3 2.5 2.2 2.5 120 0.21 0.38 1.5

Calcium fortified products Calcium enriched, nonorganic milk alternatives e.g. Oat/ Soya/Coconut etc. Soya bean curd/ tofu (only if set with calcium chloride (E509) or calcium sulphate (E516), not nigari) Calcium fortified soya yoghurt/ dessert/ custard Calcium enriched orange juice Calcium fortified infant cereals Quantity Calcium (mg) Stars (1 star= 60mg) 200ml 240 **** 60g 200 *** 125g 150 ** 250ml 195 *** 30g serving 137 ** Calcium fortified instant hot oat cereal 1 tbsp. dry cereal (15g) 200 *** Calcium- fortified bread 1 slice (40g) 191 * To ***

Other non-dairy sources of Calcium Quantity Calcium (mg) Stars (1 star= 60mg) Sardines (with bones) ½ tin(60g) 258 **** Pilchards (with bones) 1 Serving (60g) 150 ** Tinned Salmon (with bones) ½ tin(52g) 47 * Whitebait 1 small portion (50g) 130 ******* Scampi in breadcrumbs 6 pieces (90g) 190 *** White bread 2 large slices (100g) 100 * Wholemeal bread 2 large slices (100g) 54 * Pitta bread/ chapatti 1 portion (65g) 60 * Orange 1 medium (120g) 75 * Broccoli, boiled 2 spears (85g) 34 * Spring greens 1 serving (75g) 56 *

Management of Excessive Milk Intake in Children >1y Reduce milk intake <300ml Stop night time milk Stop bottles and offer milk in a beaker/cup Educate on optimum dietary Ca sources Educate on risks of high milk intake Further advice: Health Visiting Service British Dietetic Association Calcium food fact sheet Infant & Toddler Forum factsheets: 10 steps for healthy toddlers (includes advice on portion sizes) Fussy eating and faddy eating factsheets

CHOOSING THE APPROPRIATE TYPE OF FORMULA FOR CMPA Note: a large fraction of infants with CMPA have a mixed delayed and acute presentation. Treatment should follow the guidance for acute presentation in these cases Onset of symptoms after ingestion of cow s milk protein Delayed onset generally with 2-72hrs Majority of cases milk protein Acute onset generally within the hour, rarely delayed - Minority of cases YES Infant Being Exclusively Breast Feeding? NO Anaphylaxis/Severe symptoms URGENT REFERRAL TO PAEDIATRIC EMERGENCY DEPARTMENT NO Urgent Referral via paediatric hotline for further management Trial exclusion of cow s milk containing foods from maternal diet for 4-6 weeks and continue breastfeeding. Mother to be advised to consider Vitamin D 400 units plus calcium 1000mg/day supplements. If top up formula required prescribe extensively hydrolysed formula (ehf). (see 1 st line choice) Symptoms resolved? YES Provide advice on MAP home challenge. If symptoms return, challenge to be STOPPED and mum to return to full milk exclusion diet. Refer to dieticians. If no symptoms occur, YES mother to continue drinking/eating cow s milk containing products, e.g. cheese and yoghurt. If symptoms return later on introduction of formula milk or on weaning, refer to dieticians. First line formula feeds Initiate Trial Extensively Hydrolysed Formula (EHF) Trial (minimum of 4 weeks). Prescribe 1-2 tins of 400g initial until tolerance has been established. If initial EHF does not improve symptoms, try an alternative EHF Mild to Moderate CMPA symptoms e.g. gastrointestinal colic, diarrhoea, reflux or vomiting. Aptamil Pepti 1 from birth to 6 mths. Aptamil Pepti 2 from 6 to 12 mths Severe CMPA symptoms e.g. severe eczema, multiple food allergies, strong family history of allergies:- Nutramigen 1 from birth to 6 mths. Nutramigen 2 for 6 to 12 mths. Review: Review at 4-6 weeks after change in diet or starting EHF. Provide advice on MAP home challenge. If symptoms return continue with EHF. Quantities to prescribe see prescribing guidance. If symptoms do not return with challenge - CMPA is ruled out. IF NO IMPROVEMENT: If infant on EHF and CMPA still suspected prescribe AAF. Refer to paediatric outpatients and the paediatric dieticians. Urgently treat symptoms Immediately refer to specialist Prescribe 1-2 tins of Amino Acid Formula (AAF) 400g milk initially to establish tolerance. SMA Alfamino or Nutramingen Puramino. Refer to paediatric dietician for dietary advice. If breastfed exclude cow s milk containing food from maternal diet for 2-4 weeks. Do not home challenge. Advise mother of the need to take: Calcium carbonate 1.25g and Vitamin D (cholecalciferol) 10mcg supplements Ongoing Management on resolution of symptoms Continue to review weight and adjust prescribing of EHF/AAF in line with child s age (see page2). Refer if concerns of faltering growth. Refer to dieticians for follow up advice on cow s free exclusion diet and re-challenge (see page 4) Prescriptions for EHF should NOT routinely be continued beyond age of 12 months. Prescribing infant formula for cow s milk protein allergy in primary care v 2.0 01.05.2017

Suggested Quantities of Formula To Prescribe To avoid waste prescribe maximum of 1 week supply (2-3 tins) until tolerance and compliance is established. Age of child Under 6 months Average total volume feed per day (estimated) Number of tins required for 28 days complete nutrition Department of Health recommendations (based on average weight for age) 1000mls 10 x 400g (or 450g) Exclusively formula fed based on 150mls/kg/day of a normal concentrated formula 6-9 months 800mls 8 x 400g (or 450g) Requiring less formula with 9-12 months 600mls 6 x 400g (or 450g) increased weaning and solid intake Over 12 months 300mls Should no longer routinely prescribe, unless under advice of specialist or dietician. Generally infants of this age require 300ml of milk or milk substitute per day

Summary When to Prescribe Confirmed CMA in infants under 1 year ehf Investigation of suspected CMA in infants under 1 year (trial only) ehf When to recommend OTC products CMA in children over 1 year Calcium-enriched alternative milks (non-organic) Lactose intolerance Lactose-free formula in infants under 1 year Lactose-free milks in children over 1 year Thickened formulas for GOR When to refer to the Dietitian Confirmed CMA Primary lactose intolerance