1. Dietary Treatment of Cows’ Milk Protein Allergy in Children Clare Thornton-Wood RD Debbie Evans RD (Paediatric Dietitians)

2. Aim To provide a brief overview of the dietary treatment of children with cow’s milk protein allergy Objectives  To provide details on formula milks available and their use  To provide information on cow’s milk free diet  To provide information on cow’s milk free alternatives  To provide a plan for reintroduction of cow’s milk/food challenge

3. Type of Allergy * only with other symptoms Cow’s milk protein allergy Lactose intolerance IgE-mediated (immediate onset<2 hrs) Non-Ige mediated (delayed onset) Mixed pattern: IgE/non-Ige mediated Pruritus Acute urticaria Acute angiodema Nausea Vomiting Lower/upper respiratory tract symptoms * Anaphylaxis Atopic eczema Gastro-oesophageal reflux disease Blood/mucus in stools Colic Constipation Lower respiratory tract symptoms *

4. Initial Assessment Symptoms (type, age of onset, severity, speed of reaction) Symptom link with food (eg change to formula/weaning/particular food) Personal/family history of atopic disease Feeding history (breastfed/formula/weaning) Assessment of growth Skin prick test/Specific IgE tests

5. Infant – breastfed from birth Advise mother to follow cows milk free diet (4-6 weeks initially) + egg free (Vandenplas, 2007) Mother will require 1000mg calcium (+ vit D ?) Infant will require vitamins from 6 months (Healthy Start) Mother will require dietary advice on milk free substitutes & overall dietary adequacy Review 4 weeks (if no improvement consider trial AA formula)

6. Formula fed Infant Choice of formula Calcium intake (RNI = 525mg <1yr, 350mg 1-3yrs) Overall nutritional completeness of diet Milk free weaning Vitamins if <500ml formula daily (Healthy Start or similar +? Calcium supplement)

7. Choice of Formula ? Extensively Hydrolysed Formula FormulaExamples Extensively hydrolysed formula (Casein based, lactose free) Nutramigen Lipil 1 Nutramigen Lipil 2 Pregestimil (contains MCT) Similac Alimentum Extensively hydrolysed formula (Whey based, contains lactose) Aptamil Pepti 1 Aptamil Pepti 2 Pepti Junior (contains MCT) Althera (Vitaflo) 1 st choice for mild to moderate non IgE CMA without faltering growth (Venter 2013)

8. Choice of Formula ? Amino Acid Formula FormulaExamples Amino Acid FormulaNutramigen AA Neocate LCP Amino Acid Formula 1 yr+Neocate Active 1 st choice for breast fed non IgE CMA, if EHF not tolerated, if severe non IgE symptoms including growth faltering, severe IgE CMA or allergic eosinophilic oesophagistis (Venter 2013)

9. Choice of Formula? Soya Infant Formula FormulaExamples Soya FormulaWysoy Infasoy NOT suitable for infants 6 months. More likely to be tolerated if IgE CMA.

10. Compliance Advise parents formula will taste/smell/look different Use in bottle/covered beaker If non IgE and symptoms not too severe titrate gradually with breast milk/cow’s milk formula Mask taste with vanilla extract/milkshake powder (wean off gradually) May change stool consistency/colour (AA formula)

11. Milk free diet Reading labels Substitute milks Cooking with alternatives Advice for nurseries/childminders

12. Substitute foods Rice milk not suitable for use <4.5 years (DOH, 2009) Use in cooking but not as main milk drink until 2 yrs of age Main milk and cooking from 1 yr

13. Follow up Check compliance Resolution of symptoms Change formula if no resolution, or consider not CMA or maybe multiple food allergy Change from stage 1 to stage 2 DIETARY ADEQUACY

14. Reintroduction of Cow’s Milk Food Challenge (not for IgE mediated except under hospital conditions) Suggested plan: 1. Milk in biscuit 2. Cooked in meal (e.g. fish pie with milk/cheese) 3. Custard, tinned rice 4. Uncooked cheese, yoghurt, ice cream 5. Cow’s milk heated 6. Cow’s milk not heated Keep trying! (80% infants grow out of CMP allergy by 4 years)

15. Using Resources Wisely (stopping prescriptions!) Use Alpro Soya 1+ from 1 yr of age Soya not tolerated – 1 sachet Neocate Active/day from 1yr of age Use other shop bought milks on cereal/cooking and extra drinks Reduce all prescribable milks between 3-4 yrs of age and use shop bought milks as drinks + recommend multivitamins daily Stop all prescribable milks by age 4!

16. Who are We ? 2 Registered Dietitians specialising in Paediatrics: Debbie Evans Clare Thornton-Wood “Registered Dietitian” = Protected Title All Health Professions Council (HPC) registered - statutory regulator protecting health & well-being of people using the services of health professionals Have to meet standards for professional skills, behaviour & health All members of British Dietetic Association (BDA)

17. Qualifications We have either a 4 year BSc honours degree in Nutrition & Dietetics or Nutrition degree followed by an 18 month postgraduate dietetics diploma We have post graduate Dietetic training in Paediatric dietetics Clare is working on her MSc. Debbie completed her post graduate paediatric training before the modules were MSc accredited...

18. How to contact us RSCH dietetic department 01483 464119 rsch.dietitians@nhs.net

19. Any Questions ?

20. References British Dietetic Association Paediatric Group: Paediatric Group Position Statement: Use of Infant Formulas based on Soy Protein for Infants (October 2010) www.bda.uk.com (accessed Jan 2012)www.bda.uk.com Department of Health Advice for Toddlers and Young Children (1 – 5 years) to Avoid Rice Drinks due to Risk of Exposure to inorganic Arsenic http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_0998 49.pdf (accessed Jan 2012) http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_0998 49.pdf Du Toit G, Meyer R et al. Identifying and managing cow’s milk protein allergy. Arch Dis Child 2010; 95:134-144 Fiocchi A, et al World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow’s Milk Allergy (DRACMA) Guidelines (2010) DRACMAhttp://www.worldallergy.org/publications/WAO_DRACMA_guidelines.pdf (accessed Jan 2012) NICE Clinical Guideline 116 (2011). Food Allergy in Children & Young People – Diagnosis & Assessment of Food Allergy in Children & Young People in Primary Care & Community Settings http://guidance.nice.org.uk/CG116 (accessed Jan 2012) http://guidance.nice.org.uk/CG116 RCPCH (Royal College of Paediatrics & Child Health (2011) Allergy Care Pathways for Children Food Allergy http://www.rcpch.ac.uk/sites/default/files/2011_RCPCH-CarePathway- RCPCHFoodAllergy_v6_(16.26).pdf.pdf (accessed Jan 2012)http://www.rcpch.ac.uk/sites/default/files/2011_RCPCH-CarePathway- RCPCHFoodAllergy_v6_(16.26).pdf.pdf Vandenplas, Y, Koletso S et al. Guidelines for the diagnosis and management of cow’s milk protein allergy in infants. Arch Dis Child 2007; 92:902-8 Venter C et al. Diagnosis and management of non IgE mediated cow’s milk allergy in infancy – a UK primary care practical guide. http://wwwctajournal.com/content/3/1/23http://wwwctajournal.com/content/3/1/23