Dietary Management of Cow s Milk Protein Allergy Amy Roberts Paediatric Dietitians September 2014
Objectives To increase confidence in diagnosing a cow s milk allergy To understand the difference between the range of formulas available To understand when to refer on to a paediatrician with an interest in allergy and/or a dietitian To understand when a prescribable formula can be stopped
The MAP guideline
The MAP Guideline
What are the options? Breast Milk Standard formula (Casein or Whey based) Lactose Free formula Soy-based formula Partially (PHF) or extensively hydrolyzed protein (EHF) formula Amino acid-based formula AAF
Removing the Protein Allergen Most Allergenic Whole protein Formulas (Dairy + Soy) Complete protein chain Hydrolysate Formulas Amino Acid-Based Formulas Least Allergenic Hydrolyzed Non-allergenic partial amino protein acid chain elements
Seven red flag indicators
Breast Milk Breast milk is the gold standard for feeding in infant nutrition Immunological and antiallergenic properties Lower incidence of CMPA in exclusively breast fed infants Breast milk contains allergens requiring dietary change for the mother
Case study 1 8 week old baby presents with history of vomiting, diarrhoea, excessive wind, crying for more than 3 hours per day and eczema which started from birth. Solely breast fed. You suspect CMPA. What would you advise?
Breast fed Infants: Treatment Maternal cow s milk exclusion for up to 2-4 weeks. Soya may also need to be eliminated (can be reintroduced after the 2-4 week trial) Cow s milk protein free diet for breastfeeding mum s diet sheet in the infant feeding guidelines If baby improves challenge by reintroducing milk into Mum s diet. If symptoms return you have confirmed the diagnosis. Daily supplement containing 1000mg calcium and 10mcg Vitamin D (usually recommend Pregnacare Breastfeeding as can be bought by parents) Cow s milk free weaning Referral to dietitian
What if 1. Mum asks for some formula to use as top ups. Which one would you prescribe? 2. Baby is still having symptoms despite maternal exclusion of cow s milk and soya? 3. Baby presented with these symptoms at weaning age after introducing yoghurts, cheese and milk, having had no symptoms during breast feeding?
Case Study 1 Answers 1. AAF In EHF the proteins have been hydrolysed to a similar level to breast milk 2. Referral to Paediatrician and Dietitian as Mum may need a multiple exclusion diet of milk, soya, eggs, nuts and wheat. AAF if top ups required. 3. Cow s milk free diet trial for baby. Mum may not need to remove cow s milk from her diet if symptoms improve. If formula top ups required trial EHF first.
Case study 2 26 week old baby presents with loose type 7 watery acidic stools with severe nappy rash. Windy and uncomfortable after formula feeds. Symptoms started after baby had diarrhoea and vomiting bug which lasted for around 2 weeks. 1. What diagnosis would you suspect?
Case Study 2 Answers Likely just lactose intolerance post diarrhoea and vomiting for more than 10 days. Lactose free formula to be bought by parents. Lactose free diet for 6 weeks then gradually reintroduce normal formula and lactose containing cow s milk products. If Mum is breastfeeding advise her to continue and not use a lactose free formula. Taking lactose out of Mum s diet will not change the lactose in her breast milk. The breast milk promotes gut healing.
Lactose Free Formula Indicators: +ve reducing substances Watery acidic stools usually with excoriated bottom Secondary lactose intolerance Nutritionally complete Palatable, cheap ( 5.49/430g), widely available Avoid food and drink containing lactose BUT Still contains Cow s Milk Protein
What if? 1. Would your diagnosis change if baby also had mild eczema, vomiting 1 hour after feeds and this was not post a diarrhoea and vomiting infection? 2. What formula would you consider?
Case Study 2 What If Answers 1. Consider CMPA with secondary lactose intolerance due to eosinophilic enteritis. 2. Baby will need a lactose and extensively hydrolysed formula trial such as Nutramigen Lipil 2 or Similac Alimentum. Challenge with cow s milk formula after a 2-4 week trial to confirm diagnosis. If diagnosis confirmed refer to dietitian. Cow s milk protein free weaning.
Case study 3 4 month old baby presenting with colic type symptoms. Parents report baby seems unsettled after feeding with back arching. In between feeds happy. Growing and gaining weight well. Parents have tried a range of formulas including lactose free, anti reflux formulas and soya formula with no improvement 1. When using the MAP guideline to diagnose a cow s milk allergy which formula would you use? 2. What would you advise about soya formula?
Case Study 3 Answers 1. EHF as first line - likely mild to moderate non IgE mediated. Challenge with cow s milk formula after a 2-4 week trial to confirm diagnosis. If diagnosis confirmed refer to dietitian. 2. Soya formula should not be used under the age of 6 months. If baby did not tolerate soya this should also be avoided during weaning.
What if? Baby has the same symptoms is now 9 months old and has been going back and forth to the GP since the age of 4 months. Parents are not happy with previous advice and you suspect CMPA. 1. Would your formula choice change?
Case Study 3 What If Answers 1. Baby s taste is developing and EHF formulas taste very bitter. Older babies are likely to reject them. So long as you don t suspect secondary lactose intolerance you can trial Aptimil Pepti or Althera which contain lactose and therefore taste better. If you suspect secondary lactose intolerance Similac Alimentum tastes better and is lactose free. 2. So long as there is no history of anaphylaxis you can ask the parents to gradually introduce the new formula e.g. adding 1oz EHF to standard formula and increase amount of EHF over a week. We do occasionally advise adding a pinch of flavoured powder such as Nesquick to mask the bitter flavour. Once baby is established on the EHF this powder can be reduced and stopped.
Case study 4 Age 17 weeks at review and formula fed Treated for reflux: initially treated with Gaviscon and improved but symptoms returned. Ranitidine started but continues to vomit after feeds. Domperidone added. Still uncomfortable after meals and vomiting. Anti reflux formula trialed with no improvement. Weight: Below 25 th on referral Height: 75 th Centile 1. Why would you consider a diagnosis of CMPA? 2. Which formula would you consider prescribing?
Case Study 4 Answers 1. Treatment for GORD has been unsuccessful 2. AAF Baby is underweight for height which is an indicator for using AAF first. Challenge with cow s milk formula after a 2-4 week trial to confirm diagnosis. If diagnosis confirmed refer to dietitian.
Case Study 5 18 week old baby presents with chronic constipation. Laxatives have not resolved symptoms and baby is taking enough fluids. Bowels are opening every 4 days, type 4 with straining ++ 1. Why is this likely to be cow s milk protein allergy induced constipation? 2. What formula would you use?
Case Study 5 Answers 1. If baby has soft stool with straining and is taking the required volume of fluid this can be allergy induced constipation. If baby had hard type 1-3 stools this is a sign of inadequate fluids as the cause of constipation. 2. EHF first
Case study 6 14 month old presents to you on EHF for CMPA. They are taking soya yoghurts and soya milk in their foods. They are growing and gaining weight well. 1. What would you do with the formula prescription?
Case Study 6 Answers 1. Prescription can be stopped. Soya Junior 1 + milk is a suitable alternative to use as a drink as the child is gaining weight and growing well.
What if? 1. The child has faltering growth or reacts to soya products? 2. The child is also eating biscuits and cakes containing milk with no reaction?
Case Study 6 What If Answers 1. The EHF needs to be continued until 2 years of age to encourage catch up growth and weight gain. Ensure referral to dietitian has been made. 2. The child is tolerating milk that has been cooked at a very high temperature for over 30 minutes. Usually in conjunction with a dietitian the Milk Ladder can be used to reintroduce milk products. The child may not tolerate fresh cow s milk straight away as this has not been cooked.
Reintroduction of CMPA Reintroduction can be done at home so long as there is no history of immediate symptoms, wheezing, asthma, anaphylaxis, facial swelling or severe eczema. The Dietitian uses the MAP Milk Ladder to reintroduce cow s milk by starting with foods that are cooked at a high temperature for a long time and progressing to less cooked.
The Milk Ladder
Soy Formula Nutritionally Complete Palatable, cheap ( 6.19 per 430g), widely available Indicated for: Infants with CMPa/Intolerance who refuse EHF/PHF Vegan infants who do not/cannot breast feed BUT Not recommended for infants <6months 17-50% infants with CMP will also be allergic to Soy
How many tins of formula does the infant need? Refer to your infant feeding guidelines Age of child Under 6 months Number of tins 13 x 400g tins or 6 x 900g tins 6 12 months 7-13 x 400g tins or 3-6 x 900g tins Over 12 months 7 x 400g tins or 3 x 900g tins
Neocate products Neocate Advance : For infants above 1 year of age with just a diagnosis of CMPA and relying on formula as sole source of nutrition Neocate Active : For infants above 1 year of age and unable to take any dairy free alternative milks due to multiple allergies but is able to manage some foods orally Neocate Spoon : Hypoallergenic supplement for use in the dietary management of CMPA, multiple food protein allergies and other conditions requiring an amino acid based food. Used to supplement weaning when baby is not meeting requirements from AA formula.
Weaning Diet
To avoid cows milk in the weaning diet Obvious sources of cows milk (yogurt, cheese) and need to avoid goats/sheeps cheese etc. Need to read labels (casein, caseinates, whey) Common foods which contain cows milk chocolate, margarines, sausages, smiley faces, rusks, etc. Foods that don t have labels! Foods produced outside the EU Eating out
Are there alternatives? (Ensure Calcium enriched)
FAISG guidelines Do not introduce potential allergens before 6 months (wheat, eggs, soya, fish, nuts) Introduce one at a time starting with a small amount and leave at least 3 days between introductions Breast-feeding while introducing new foods may have some preventative effects Consult health professional before introducing nuts
Summary Use MAP guideline to decide on treatment plan Unless anaphylaxis, wheezing or severe symptoms, you can challenge to confirm the diagnosis Do not use soya formula under 6 months and ~17-50% will react to cow s milk and soya Do not use rice milk under 4 and ½ Refer to Dietitian in all cases for weaning advice, suitable alternatives and challenging
Thank-you Any questions? Amy.Roberts6@nhs.net Please email me with any questions you have after today.