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Cow’s Milk Protein Allergy

 

Affects at least 2 - 3% of UK infants

Important to distinguish whether reaction IgE or non-IgE mediated (see Food Allergy)

 

IgE Mediated CMPA:

Children with IgE mediated reactions should be referred to the Allergy Clinic

  • Advise total milk avoidance. If breastfeeding mother she should avoid milk products, but breastfeeding continuation should be advocated.
  • Antihistamine advised- Cetirizine PRN if over 1 year of age, Chlorphenamine if under 1 year of age (see BNFc for doses)
  • Adrenaline autoinjectors x2 if required due to anaphylaxis or known diagnosis of asthma requiring daily preventative steroid inhalers
  • Advise continuation of baked milk 3x/week if already tolerated
  • Please do not use Milk Ladder for IgE mediated Milk Allergy

 

Non-IgE mediated CMPA:

Non-IgE mediated CMPA can be manged in Primary Care

  • Please use the iMAP guideline on the Allergy UK website- https://gpifn.org.uk/imap where there are additional resources such as information sheets for professionals and families.
  • Note that there is no test for suspected non-IgE mediated CMP allergy apart from elimination and re-introduction, and most do not need Paediatric Allergy referral.
  • Dietetic referral is often more appropriate in the first instance.

 

 

Refer to Dietitians if:

·       Mild-moderate confirmed non-IgE CMP allergy (Routine)

·       Faltering growth associated with proven milk allergy (Urgent)

NB – Refer cases of blood in an infant’s stool (even if thought to be to CMP allergy) as same-day referral to Paediatric observation unit due to differential diagnosis.

 

Overall Prognosis of Milk Allergy:

IgE mediated - some 80% of children grow out of this in childhood, although if severe tends to take longer so more important to monitor in allergy clinic using skin prick tests/specific IgE as child grows up.

Non IgE mediated – mean age of resolution sooner but can persist in some.

 

 

Appropriate Milks – Summary for different ages

Please refer to KCCG Formulary and information sheet for milk choices:

https://www.eclipsesolutions.org/UploadedFiles/355_KCCG_Specialist%20Infant%20Formula%20Prescribing%202018.pdf

 

*Always the added calcium versions and ideally unsweetened.

*Vitamin drops A, C and D are recommended once talking under 17oz/500mls formula or if consuming calcium fortified plant based milk substitute for children under 5 years

*Advise to look for around 2-3g protein/100mls and at least 40-50 calories/100mls from plant based milk substitute (NOTE: almond milk is low in calories and has a very low protein content).

 

Paediatric Dietetics Guidelines available here
 

Lactose Intolerance:

  • Congenital Lactose intolerance with symptoms from birth is extremely rare and presents with copious diarrhoea (patients are usually in hosptial as a result)
  • Primary lactose intolerance usually presents in teens, not toddlers or younger children under the age of 6. It is more common in younger children in some ethnic groups.
  • Secondary lactose intolerance is common after a gastroenteritis but usually resolves within a few weeks without need for lactose – free milk

Parents often think that lactose intolerance is milk allergy and vice-versa

There is no need to refer possible lactose intolerance to the Allergy, Dietetic or General Paediatric Service.

 

Lactose – free milks are not on the KCCG prescribing formulary and should not be used in milk allergy

A very good information sheet can be found at http://www.patient.co.uk/health/Lactose-Intolerance.htm

 



Date 
                                          January 2022

Review Date                              January 2023

Authors:                                    Simon Bedwani, Consultant Paediatrician, RCHT

                                                   Dr S Burns RMS GP