NHSGGC Guideline for the Management of non IgE Cows Milk Allergy in Infants

Warning

Objectives

Despite the low incidence of non IgE CMPA there is a rather disproportional number of national and international guidelines for its diagnosis and management.  

This could be explained by the complexity in the diagnosis and management of this type of food intolerance. Its signs and symptoms maybe a variant of normal or as a result of other common conditions and since there is no available diagnostic test this type of intolerance can only be confirmed by exclusion of cow’s milk and subsequently planned reintroduction. In addition parental anxiety around infant’s symptoms could lead to multiple visits to primary and secondary care especially to A+E.  

Therefore when managing an infant that is frequently unsettled and regurgitates, health professionals need to consider and exclude other causes (if any) before diagnosing CMPA. 

 

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Summary of key points for assessment and management of non IgE mediated CMPA

  • Non IgE mediated CMPA can present with a wide range of symptoms which are common in infants and can be related to causes other than allergy, e.g. Irritability (colic), gastro-oesophageal reflux, rashes and atopic dermatitis.  
  • In breast fed infants the incidence of CMPA is less than 0.5% compared to 3-5% in formula fed infants567
  • Healthcare professionals should reinforce the importance of breast feeding, in line with the World Health Organisation Guidelines8 , and be aware of the negative psychological effect of an elimination diet. Unnecessary elimination of food allergens may adversely impact on the quality of life and nutritional status of the breast feeding mother. 
  • The diagnosis should only be made:
    1. after undertaking a thorough allergy focused history and consideration of other first line management e.g general infant feeding advice,  management GORD and eczema
    2. after exclusion of milk and milk products for 2-4 weeks followed by a planned reintroduction 
    3. reoccurence of the symptoms when milk and milk products are reintroduced after a 2-4 week period of strict exclusion 
  • Cow’s milk allergy will resolve in the majority of children by around 12 months of age and infants should be reassessed by a dietitian at 6-12 monthly intervals after diagnosis to consider reintroduction cow’s milk/milk products using the milk ladder.
  • Extensively hydrolysed formulas (eHFs) are the recommended therapeutic choice and are tolerated by the majority of infants and children (90%) with cow's milk protein allergy. 
  • The choice of amino acid formulas (AAF) instead of eHF should be made based on the history and combination of symptoms rather than on absolute indication (based on a single condition or a specific symptom). AAF should be offered when eHF fails, in growth faltering babies, in particular those with multisystem involvement (gastrointestinal tract and / or skin), multiple food eliminations and history of anaphylaxis. The initiation of an AAF formula ideally should be discussed with the general paediatric and / or dietetic team.

Hypoallergenic formula for management of cow's milk allergy in children

The latest version of the formulary is hosted on the Greater Glasgow & Clyde Medicines site > Non-medicines Formularies

Editorial Information

Last reviewed: 01/09/2021

Next review date: 01/10/2023

Author(s): Dr George Raptis, Paediatric Allergy Consultant, Anne Maclean, Dietetic Manager - Paediatrics, David Inglis, Digital Health Practice Development Dietitian.

References
  1. Royal College of Paediatrics and Child Health. Allergy Care Pathways for Children: Food Allergy 2011        

  2. NICE Guideline: Cow's milk allergy in children. 2019 

  3. Meyer R, Lozinsky AC, Fleischer D, Viera M, Du Toit G . Diagnosis and management of Non‐IgE gastrointestinal allergies in breastfed infants—An EAACI Position Paper. Allergy 2020; 75: 14-32 

  4. Koletzko S, Heine RG, Grimshaw KE, Beyer K, Grabenhenrich L, Keil T, Sprikkelman AB, Roberts G. Non‐IgE mediated cow's milk allergy in Euro Prevall. Allergy 2015;70(12):1679‐1680. 

  5. Høst A, Husby S, Osterballe O. A prospective study of cow’s milk allergy in exclusively breast-fed infants. Incidence, pathogenetic role of early inadvertent exposure to cow’s milk formula, and characterization of bovine milk protein in human milk. Acta Paediatr Scand. 1988;77(5):663–70. 

  6. Høst A. Frequency of cow’s milk allergy in childhood. Ann Allergy Asthma Immunol. 2002;89(6 Suppl 1):33–7. 

  7. Jakobsson O, Lindberg T. A prospective study of cow’s milk protein intolerance in Swedish infants. Acta Paediatr Scand. 1979;68(6):853–9. 

  8. World Health Organisation https://www.who.int/health-topics/breastfeeding

  9. Fox A, Brown T, Walsh J. An update to the Milk Allergy in Primary Care guideline. Clin Transl Allergy 2019; 9, 40 

  10. Munblit D, Perkin MR, Palmer D. Assessment of Evidence About Common Infant Symptoms and Cow’s Milk Allergy: JAMA Pediatr. 2020; 174(6):599-608                        

  11. Rosen R, Vandenplas Y, Singendonk M, Cabana M, DiLorenzo C, Gottrand F, Gupta S, Langendam M, Staiano A, Thapar N, Tipnis N, Tabbers M. Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition: (JPGN 2018;66: 516–554).    

  12. Luyt D, Makwana N, Green MR, Bravin K, Nasser SM, Clark AT.. BSACI guideline for the diagnosis and management of cow’s milk allergy; Clinical & Experimental Allergy. 2014; Volume 44, Issue 5, Pages: 642-672  

  13. Meyer R, Groetch M, Venter C. When Should Infants with Cow's Milk Protein Allergy Use an Amino Acid Formula? A Practical Guide 2018, 6 (2); 383-399