Background information Patient information Key messages for this pathway When to suspect CMPA Symptoms of CMPA and assessing severity Symptoms of non IgE mediated CMPA Severe CMPA: urgent referral to paediatric allergy service or paediatrician with special interest Symptoms of IgE mediated CMPA: urgent referral to paediatrician or paediatric allergy service Exclusively breast milk fed infant Formula or mixed feeding 2 to 4 week trial maternal dairy and soya exclusion 2 to 4 week trial of extensively hydrolysed formula (ehf) Improvement: diagnosis confirmed if symptoms return on reintroduction of dairy to mother's diet efer to paediatric dietitian No improvement: CMPA less likely efer to paediatrician or paediatric allergy service if suspicion persists Improvement: diagnosis confirmed if symptoms return on reintroduction of cow's milk formula efer to paediatric dietitian No improvement: CMPA less likely efer to paediatrician or paediatric allergy service if suspicion persists Does the child have active eczema? Yes: check specific IgE or skin prick test to milk No: no need to check specific IgE or skin prick test to milk Positive: refer to paediatrics or paediatric allergy service for in hospital testing Negative eintroduction of cow's milk protein at home between age 12 and 18 months Page 1 of 5
1 Background information The incidence of CMPA confirmed by double blind placebo controlled trial is around 3%. 2 Key messages for this pathway This pathway has been locally developed for South West Hampshire. Key messages for this pathway: symptoms can be acute or delayed. Acute symptoms arise immediately after introduction of formula feeds, in previously exclusively breast fed babies. Formula fed babies may have recurrent symptoms symptoms may be IgE or non IgE mediated. Severe allergy or symptoms of IgE mediated CMPA ( especially urticarial rash, angioedema or runny nose and watery eyes) require urgent referral symptoms compatible with non IgE mediated CMPA (vomiting immediately after food, persistent, unsettled colic and fussiness, diarrhoea, bloody stools (especially breast fed babies) or constipation (especially with redness around the anus)) can be treated initially by exclusion diets in primary care Contributors to this pathway: Ms Felicity Beresfors, HHFT Dr Keith Foote, HHFT Ms Joan Gavin, UHS Dr Simon Hunter, WHCCG Dr Mich Lajeunesse, UHS Ms Sarah Paynton, Solent Healthcare Dr Derek Waller, UHS Ms ebecca Weeks, UHS 3 Patient information http://www.ndr-uk.org/ CMPA dietary advice for breast feeding mums Feeding the under 5s 4 When to suspect CMPA Symptoms can be: acute (within 30 minutes of ingestion of cows milk), when it is usually IgE mediated or delayed (hours to days after ingestion of cows milk), usually non IgE mediated Acute symptoms arise immediately after introduction of formula feeds, in previously exclusively breast fed babies. Formula fed babies may have recurrent symptoms. CMPA can arise in exclusively breast fed children if the mother has ingested cows milk. 5 Symptoms of CMPA and assessing severity Page 2 of 5
Symptoms of non IgE mediated CMPA include: vomiting immediately after food vomiting that may mimic GOD (see GOD in infants) persistent, unsettled colic and fussiness diarrhoea bloody stools (especially breast fed babies) constipation (especially with redness around the anus) Symptoms of IgE mediated CMPA include: urticarial rash angioedema vomiting immediately after food (but with other symptoms in this category) runny nose and watery eyes Symptoms of severe CMPA include: respiratory distress wheeze collapse or shock anaphylaxis persistent vomiting after food (leading to compromise) faltering growth anaemia oedema severe eczema 9 Exclusively breast milk fed infant CMPA may arise from maternal ingestion of cow's milk protein. 11 2 to 4 week trial maternal dairy and soya exclusion Advise the mother to exclude all dairy and soya products in her diet. Provide appropriate dietary advice to ensure nutritional adequacy of diet. Most symptoms should improve in 2 weeks of exclusion, however a 4 week exclusion may be needed if the main problem is eczema. If the mother is unable to consume the advised 1300 micrograms of calcium a day a supplement will be required. All mothers taking this diet require Vitamin D supplementation of 10 micrograms daily. 12 2 to 4 week trial of extensively hydrolysed formula (ehf) Use an extensively hydrolysed formula (ehf) such: Silmilac Alimentum (suitable from birth onwards) Nutramigen 1 in the under 6 months Nutramigen 2 in the over 6 months strictly dairy-free solids in weaned infants Pregestimil (Mead Johnson) may be used as an alternative Most symptoms should improve in 2 weeks, however 4 weeks exclusion may be needed if the main problem is eczema. Page 3 of 5
Calcium supplements may be required for the infant depending on their intake of formula and solids. Vitamin drops should be given to infants over 6 months who are breast fed or taking less than 500ml formula per day. 15 Improvement: diagnosis confirmed if symptoms return on reintroduction of cow's milk formula The infant should be given conventional formula and then observed for 30 minutes. Some symptoms may take up to 20 hours to recur but these will not be severe. 16 No improvement: CMPA less likely 90% of babies with CMPA respond to extensively hydrolysed formulas. The remaining 10% require an amino-acid based formula - ideally patients having this feed should be under a specialist team. 26 eintroduction of cow's milk protein at home between age 12 and 18 months Non IgE mediated CMPA resolves at around 14 months in most children. Soya protein is often tolerated before this age. Suggest reintroduction of soya from 9 months in age, milk and dairy products can be introduced between 12 and 18 months. If symptoms return, avoid for a minimum of 3 months before reintroduction. Page 4 of 5
Key Dates Published: 20-Nov-2014, by Southampton Area Valid until: 13-Oct-2017 Page 5 of 5