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

2. 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

3. Types of CMA

4. Is this cow’s milk allergy?
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 9th centile
Is this cow’s milk allergy?

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

6. 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
Simple reflux
Gastro-oesophageal reflux disease in children and young people: diagnosis and management, NICE guidelines, 2015

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

8. Is this CMA or lactose intolerance?
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 50th to the 25th 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?

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

10. 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 

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

12. OTC Lactose-Free Products
Do not prescribe

13. 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)
Trial a maternal cow’s milk protein exclusion for 4-6 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, non-organic dairy alternatives into the maternal diet
Babies over 6 months
(or symptom onset with weaning)
Trial a dietary cow’s milk exclusion for 2-6 weeks followed by challenge to confirm diagnosis
Continue with breastfeeding and usual maternal diet
Incorporate OTC calcium-enriched, non-organic dairy alternatives into the diet
Patient information sheets are available from Allergy UK and BDA

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

15. 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 IgE-mediated 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 Mar;10(3): , Berni Canani R et all. J Pediatr 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 

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

17. 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

18. 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)

19. 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 

20. 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

21. 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

22. 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

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

24. Is this an age-appropriate milk intake?
Case Study- Niamh
15 month old girl 
Weight is tracking 50th- 75th 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?

25. Dietary reference values, COMA 1991
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
Adolescents
11-18
800 for girls
1000 for boys
13 Stars
17 Stars
Adults
19+
700
11 Stars
Dietary reference values, COMA 1991

26. Appropriate Milk Intake Beyond 1y
Milk is only required to meet calcium requirements
Calcium requirements reduce in the 2nd 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 ml (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 
Niamh is being prescribed 4 x 400g tins of Aptamil Pepti 2 every 28 days, this equals 838ml/day of formula
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

27. Calcium Content of Different Milks
% RNI for Ca in 1-3 year olds/100ml
* Higher Energy formula for children >1y– do not routinely prescribe. Seek advice from the Dietitian

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

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

30. 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 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

31. 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

33. 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
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)
Under 6
months
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
increased weaning and solid intake
9-12 months
600mls
6 x 400g (or 450g)
Over 12
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

34. Summary Confirmed CMA in infants under 1 year eHF
When to Prescribe
Confirmed CMA in infants under 1 year
eHF
Investigation of suspected CMA in infants under 1 year (trial only)
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