What to feed a 1 year old with milk allergy

A baby with intoleranceusually experiences less severe reactions than one with an allergy. As with a milk allergy, symptoms of lactose intolerance can include diarrhoea, vomiting, and stomach cramps but not generally hives or breathing difficulties. Another difference is that a lactose intolerance won’t show up in a blood or skin-prick test. Still, your baby’s reaction will be noticeable, if not as severe as that of an allergy. If your baby is less than a year ancient, you might discover it useful to enter their symptoms into ourBaby Symptom Checker, as this gives some useful advice and suggestions for next steps.

There are two main types of lactose intolerance.

The first is primary lactose and is caused by a deficiency in the enzyme lactase. It normally affects Hispanic, Asian and American Indian populations, but is unusual in Europeans – also, the condition doesn’t often cause symptoms in the first year of life. But it doesn’t mean that lactose has to be removed from the diet entirely: depending on the individual, those with primary lactose intolerance can often tolerate a certain quantity of lactose.

Secondary lactose intolerance is generally caused by damage to the gut, after a severe stomach bug, for example. But this form of the condition is generally until the gut heals.

In extremely severe cases, lactose may need to be removed from the diet for a few weeks, but should only be done so on the advice of a healthcare professional.

Before you worry too much about milk allergies and intolerances, it’s worth remembering that babies and little children often pick up common bugs when they come into contact with other children, which can own similar unpleasant effects. But if your baby’s symptoms persist or you notice a pattern occurring, you should seek advice from your doctor.

If your kid has an allergy to milk, you may own heard that numerous children outgrow these allergies.

When does this occur? And, importantly, is your kid truly allergic to milk in the first place?


Differential diagnosis

With such a wide range of symptoms that can be caused by CMPA, the differential diagnosis is extensive, and includes other food allergies, non-food allergies such as pollen, animal dander, other gastrointestinal disorders, pancreatic insufficiency such as in cystic fibrosis, and infections — eg urinary tract infection.


Epidemiology[2, 3]

CMPA affects about 7% of formula-fed babies but only about 0.5% of exclusively breast-fed babies, who also tend to own milder reactions.

Exclusive breast-feeding may also protect babies from developing an allergy to cow’s milk protein after they are weaned[4].

There are a number of diverse proteins in cows milk: there are five protein components in each of the casein and whey fractions of milk. A kid can be allergic to one or more components within either group.

CMPA is more likely in children who own other atopic conditions such as asthma, eczema or hay fever, or if shut family members own those conditions. The presence of atopic eczema is a predictor for sensitisation to common food allergens.

The earlier the eczema starts and the more severe it is, the higher the risk of food allergy[5].

If there are other food allergies, it is more likely that CMPA will persist into later childhood.

Some work has been done looking at the development of food allergies and whether this can be prevented by feeding infants at risk with hydrolysed formula. However, the results own so far not been clear[6, 7].


Management [10]

Allergen avoidance

The management of CMPA generally consists of avoidance of the allergen.

If CMPA is the cause of the symptoms then they should resolve within two weeks of stopping cow’s milk.

If the kid is formula-fed, they can be given extensively hydrolysed milk formula such as Nutramigen®, Aptamil Pepti® or Pepti Junior®. These are based on cow’s milk but the proteins are broken below into smaller peptides that are less likely to trigger an allergic reaction.

Babies who own CMPA may own their growth and development impaired by the disorder; however, hydrolysed formula is shown to provide balanced nutrition and to restore normal growth and development[12, 13].

If the symptoms persist on hydrolysed formula but a suspicion of CMPA remains, then attempt an amino acid formula.

These include Nutramigen AA® and Neocate LCP®. Hydrolysed milks are cheaper and are also generally better tolerated, although the flavour and tolerability varies[14].

If the kid is breast-fed and the mom wishes to continue breast-feeding, she must eliminate milk and milk products from her diet. This will include checking ingredients for anything derived from milk, such as casein, whey and lactose.

The mom should make certain she is still getting adequate calcium in her diet. It is recommended that she be offered calcium and vitamin D tablets; however, calcium can also come from tinned fish, pulses, almonds, kale, oranges and soya products such as soya milk and tofu[8].

Babies who are being weaned, and older children with persisting CMPA, will need to follow a cow’s milk-free diet as above. Parents must be advised about how to check the ingredients of processed foods for milk-derived constituents.

What to feed a 1 year ancient with milk allergy

Children should be referred to a paediatric dietician for advice about maintaining a balanced diet while excluding allergens.

Challenge test

The prognosis of CMPA is excellent with a remission rate of approximately 45-50% at 1 year, 60-75% at 2 years and 85-90% at 3 years[15].Children can own a challenge test every 6-12 months to see if they are capable to tolerate milk. It may take several days for the reaction to show, particularly for non-IgE allergy.

The challenge test can be carried out in stages, according to the ‘Milk Ladder’[16]. This is a hierarchy of milk-containing foods, beginning with those least likely to cause a reaction and gradually moving towards being capable to drink a glass of milk.

In baked form, such as muffins, cakes or malted milk biscuits, cow’s milk is less allergenic and may be tolerated sooner than unbaked milk. There is some evidence that including cooked milk in the diet may hasten the resolution of allergy to non-cooked milk[17, 18].

If the kid has had IgE type reactions, particularly if they own been severe, then a challenge test should be carried out under shut supervision.

Alternative milks

Soya formulas own been prescribed in the past for CMPA but soya is also a common allergen, so this is no longer routinely advised.

About 10-15% of children allergic to cow’s milk will also react to soya. Soya milk also contains isoflavones which own a feeble oestrogenic activity.

Other milks, such as pea, oat or coconut, may be used after the age of 2 years, depending on the child’s nutritional status and any other allergies they may own. A brand fortified with calcium should be used if available. Rice milk is not recommended for children aged under 4.5 years.

If the symptoms of CMPA persist into older childhood or beyond then patients need to continue to avoid milk and milk products.

The proteins in goat’s milk and other mammal milks which may be available are almost identical to those found in cow’s milk, so those are not suitable substitutes. It is significant to maintain an adequate calcium intake. Children who are avoiding cow’s milk for allergy reasons should be referred to a paediatric dietician for specialist advice.

New treatments

Immunotherapy, in which children are given a gradually increasing dose of milk over a period of several months, is one option which has been tried for children with persisting severe allergy.

The results own been extremely promising, although a Cochrane review concluded that further studies of higher quality were necessary before it can be recommended without reservation[19].


Diagnosis[8]

Allergic reactions can be immunoglobulin E (IgE)-mediated reactions or non-IgE-mediated reactions. Cow’s milk proteins can cause reactions of either type or both together, which can make them hard to diagnose.

IgE-mediated reactions

IgE-mediated reactions trigger histamine release and happen within two hours of milk being consumed.

They include skin reactions such as itching, erythema, urticaria and acute angio-oedema, most commonly of the face. There can be abdominal symptoms such as colicky pain, nausea, vomiting and diarrhoea. Respiratory symptoms can be upper or lower respiratory tract: nasal itching, sneezing, rhinorrhoea, congestion, cough, chest tightness or wheeze.

It is extremely rare for cow’s milk to trigger an anaphylactic reaction. Antihistamines can be used to treat the symptoms. Allergic reactions may be more severe in people with asthma, particularly if the asthma is poorly controlled[9].

This type of allergy can be diagnosed with a skin prick test or a blood test (specific IgE, previously known as RAST).

If this type of allergy is suspected, refer the kid to a paediatrician who will arrange for the test to be done in hospital.

Non-IgE-mediated reactions

Non-IgE-mediated reactions happen hours or days after consuming milk. Skin reactions such as atopic eczema are common, as well as itching and erythema. Abdominal symptoms include colicky pain (including infantile colic), reflux, blood or mucus in stools, constipation or diarrhoea. There may be lower respiratory tract symptoms such as cough, wheeze, breathlessness or chest tightness.The kid may be pale and tired, and growth may be faltering.

The best way to establish if cow’s milk is causing these symptoms is to exclude it from the diet.

There should be an improvement in symptoms within two weeks.


Lactose intolerance[20]

Many people confuse lactose intolerance with CMPA.

Lactose intolerance is an inability to digest lactose, due to an inadequate production of the digestive enzyme lactase. It is generally a condition of older childhood and adulthood. Worldwide it is extremely common, although it is less prevalent in northern European races.

It is unusual for babies and young children to be intolerant of lactose, although they do fairly commonly develop a transient lactose intolerance following an episode of gastroenteritis.

People with a lactose intolerance can often consume products such as yoghurt and cheese in which the lactose has been altered and they may be capable to own little amounts of milk without symptoms. They can generally tolerate lactose-free milk.

Clinical Editor’s comments (October 2017)
Dr Hayley Willacy recommends the recently released international Milk Allergy in primary care guideline[1]. The guideline includes updated recommendations on presentation and recognition of cow’s milk allergy (CMA); diagnosis; management of mild-to-moderate confirmed non-IgE-mediated CMA within primary care; suspected severe non-IgE-mediated CMA and referral.

A number of additional resources own been developed alongside the guideline to support parents and carers, including an initial factsheet for parents; a home reintroduction protocol to confirm diagnosis; a milk ladder and milk ladder recipes.

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Protect yourself this autumn.

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  • Hill DJ, Hosking CS; Food allergy and atopic dermatitis in infancy: an epidemiologic study. Pediatr Allergy Immunol.

    2004 Oct15(5):421-7.

  • Boyano-Martinez T, Garcia-Ara C, Pedrosa M, et al; Accidental allergic reactions in children allergic to cow's milk proteins. J Allergy Clin Immunol. 2009 Apr123(4):883-8. doi: 10.1016/j.jaci.2008.12.1125. Epub 2009 Feb 20.

  • Liao SL, Lai SH, Yeh KW, et al; Exclusive breastfeeding is associated with reduced cow's milk sensitization in early childhood.

    What to feed a 1 year ancient with milk allergy

    Pediatr Allergy Immunol. 2014 Aug25(5):456-61. doi: 10.1111/pai.12247.

  • Boyle RJ, Ierodiakonou D, Khan T, et al; Hydrolysed formula and risk of allergic or autoimmune disease: systematic review and meta-analysis. BMJ. 2016 Mar 8352:i974. doi: 10.1136/bmj.i974.

  • Bloom KA, Huang FR, Bencharitiwong R, et al; Effect of heat treatment on milk and egg proteins allergenicity. Pediatr Allergy Immunol. 2014 Dec25(8):740-6. doi: 10.1111/pai.12283. Epub 2014 Dec 18.

  • Venter C, Brown T, Meyer R, et al; Better recognition, diagnosis and management of non-IgE-mediated cow's milk allergy in infancy: iMAP-an international interpretation of the MAP (Milk Allergy in Primary Care) guideline.

    Clin Transl Allergy. 2017 Aug 237:26. doi: 10.1186/s13601-017-0162-y. eCollection 2017.

  • Cows milk protein allergy in children; NICE CKS, June 2015 (UK access only)

  • Agostoni C, Terracciano L, Varin E, et al; The Nutritional Worth of Protein-hydrolyzed Formulae. Crit Rev Food Sci Nutr. 201656(1):65-9. doi: 10.1080/10408398.2012.713047.

  • Yeung JP, Kloda LA, McDevitt J, et al; Oral immunotherapy for milk allergy. Cochrane Database Syst Rev. 2012 Nov 1411:CD009542. doi: 10.1002/14651858.CD009542.pub2.

  • Host A, Halken S; Cow's milk allergy: where own we come from and where are we going?

    Endocr Metab Immune Disord Drug Targets. 2014 Mar14(1):2-8.

  • Dupont C, Hol J, Nieuwenhuis EE; An extensively hydrolysed casein-based formula for infants with cows' milk protein allergy: tolerance/hypo-allergenicity and growth catch-up. Br J Nutr. 2015 Apr 14113(7):1102-12. doi: 10.1017/S000711451500015X. Epub 2015 Mar 17.

  • Leonard SA, Nowak-Wegrzyn AH; Baked Milk and Egg Diets for Milk and Egg Allergy Management. Immunol Allergy Clin North Am. 2016 Feb36(1):147-59. doi: 10.1016/j.iac.2015.08.013.

  • Vandenplas Y, De Greef E, Devreker T; Treatment of Cow's Milk Protein Allergy.

    What to feed a 1 year ancient with milk allergy

    Pediatr Gastroenterol Hepatol Nutr. 2014 Mar17(1):1-5. doi: 10.5223/pghn.2014.17.1.1. Epub 2014 Mar 31.

  • The Milk Ladder; MAP Guideline

  • Osborn DA, Sinn J; Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants. Cochrane Database Syst Rev. 2006 Oct 18(4):CD003664.

  • Vandenplas Y, Koletzko S, Isolauri E, et al; Guidelines for the diagnosis and management of cow's milk protein allergy in infants. Arch Dis Kid. 2007 Oct92(10):902-8.

  • Ludman S, Shah N, Fox AT; Managing cows' milk allergy in children. BMJ. 2013 Sep 16347:f5424.

    What to feed a 1 year ancient with milk allergy

    doi: 10.1136/bmj.f5424.

  • Miraglia Del Giudice M, D'Auria E, Peroni D, et al; Flavor, relative palatability and components of cow's milk hydrolysed formulas and amino acid-based formula. Ital J Pediatr. 2015 Jun 341:42. doi: 10.1186/s13052-015-0141-7.

  • Vandenplas Y; Lactose intolerance. Asia Pac J Clin Nutr. 201524 Suppl 1:S9-13. doi: 10.6133/apjcn.2015.24.s1.02.

Prevalence of CMA

Population based studies report that the prevalence of Cow’s Milk Allergy (CMA) ranges from 1.9 – 4.9% in young children[2].

What to feed a 1 year ancient with milk allergy

UK data from 2008 indicated 2.3% of 1–3 year olds suffer from CMA, the majority of these presenting with non-IgE-mediated CMA[3]. A meta-analysis by Rona et al.[4] reported that Cow’s milk (CM) is one of the most common foods which is responsible for allergic reactions in European children. In general, the prognosis for CMA is excellent, with up to 80-90% of children developing tolerance before three years of age[12]. However, CMA may persist up to school age and may be associated with the later development of other allergic diseases such as asthma, rhinoconjunctivitis, and atopic dermatitis[13], as well as other disease manifestations such as recurrent abdominal pain[14].

It is also well-known that perceived prevalence may be much higher[4, 12] than that confirmed by appropriate tests. Cow’s milk formula or cow’s milk containing foods frolic an significant role in the nutritional intake of children particularly in early infancy. Onset after infancy has also been uncommonly reported[3].

Nomenclature

The first step in making the correct diagnosis and managing infants and children with cow’s milk allergy is to own a excellent understanding of the immune mechanisms involved. According to the European Academy for Allergy and Clinical Immunology (EAACI) and the World Allergy Organisation (WAO)[15], a hypersensitivity reaction to cow’s milk can be referred to as cow’s milk allergy if it involves the immune system.

Non-allergic cow’s milk hypersensitivity (lactose intolerance) on the other hand, does not involve the immune system. Cow’s milk allergy is further divided into IgE-mediated cow’s milk allergy and non-IgE-mediated cow’s milk allergy[7]. There is however clinical overlap between some presentations of cow’s milk allergy as indicated by the US food allergy guidelines[10].

Lactose intolerance[20]

Many people confuse lactose intolerance with CMPA.

Lactose intolerance is an inability to digest lactose, due to an inadequate production of the digestive enzyme lactase.

What to feed a 1 year ancient with milk allergy

It is generally a condition of older childhood and adulthood. Worldwide it is extremely common, although it is less prevalent in northern European races. It is unusual for babies and young children to be intolerant of lactose, although they do fairly commonly develop a transient lactose intolerance following an episode of gastroenteritis.

People with a lactose intolerance can often consume products such as yoghurt and cheese in which the lactose has been altered and they may be capable to own little amounts of milk without symptoms.

They can generally tolerate lactose-free milk.

Clinical Editor’s comments (October 2017)
Dr Hayley Willacy recommends the recently released international Milk Allergy in primary care guideline[1]. The guideline includes updated recommendations on presentation and recognition of cow’s milk allergy (CMA); diagnosis; management of mild-to-moderate confirmed non-IgE-mediated CMA within primary care; suspected severe non-IgE-mediated CMA and referral. A number of additional resources own been developed alongside the guideline to support parents and carers, including an initial factsheet for parents; a home reintroduction protocol to confirm diagnosis; a milk ladder and milk ladder recipes.

Flu vaccination.
Protect yourself this autumn.

Find out if you are eligible for a free NHS flu vaccination.

Check eligibility

Prevalence of CMA

Population based studies report that the prevalence of Cow’s Milk Allergy (CMA) ranges from 1.9 – 4.9% in young children[2].

UK data from 2008 indicated 2.3% of 1–3 year olds suffer from CMA, the majority of these presenting with non-IgE-mediated CMA[3]. A meta-analysis by Rona et al.[4] reported that Cow’s milk (CM) is one of the most common foods which is responsible for allergic reactions in European children. In general, the prognosis for CMA is excellent, with up to 80-90% of children developing tolerance before three years of age[12]. However, CMA may persist up to school age and may be associated with the later development of other allergic diseases such as asthma, rhinoconjunctivitis, and atopic dermatitis[13], as well as other disease manifestations such as recurrent abdominal pain[14].

It is also well-known that perceived prevalence may be much higher[4, 12] than that confirmed by appropriate tests. Cow’s milk formula or cow’s milk containing foods frolic an significant role in the nutritional intake of children particularly in early infancy. Onset after infancy has also been uncommonly reported[3].

Nomenclature

The first step in making the correct diagnosis and managing infants and children with cow’s milk allergy is to own a excellent understanding of the immune mechanisms involved. According to the European Academy for Allergy and Clinical Immunology (EAACI) and the World Allergy Organisation (WAO)[15], a hypersensitivity reaction to cow’s milk can be referred to as cow’s milk allergy if it involves the immune system.

Non-allergic cow’s milk hypersensitivity (lactose intolerance) on the other hand, does not involve the immune system. Cow’s milk allergy is further divided into IgE-mediated cow’s milk allergy and non-IgE-mediated cow’s milk allergy[7]. There is however clinical overlap between some presentations of cow’s milk allergy as indicated by the US food allergy guidelines[10].

Lactose intolerance[20]

Many people confuse lactose intolerance with CMPA.

Lactose intolerance is an inability to digest lactose, due to an inadequate production of the digestive enzyme lactase.

It is generally a condition of older childhood and adulthood. Worldwide it is extremely common, although it is less prevalent in northern European races. It is unusual for babies and young children to be intolerant of lactose, although they do fairly commonly develop a transient lactose intolerance following an episode of gastroenteritis.

People with a lactose intolerance can often consume products such as yoghurt and cheese in which the lactose has been altered and they may be capable to own little amounts of milk without symptoms.

They can generally tolerate lactose-free milk.

Clinical Editor’s comments (October 2017)
Dr Hayley Willacy recommends the recently released international Milk Allergy in primary care guideline[1]. The guideline includes updated recommendations on presentation and recognition of cow’s milk allergy (CMA); diagnosis; management of mild-to-moderate confirmed non-IgE-mediated CMA within primary care; suspected severe non-IgE-mediated CMA and referral. A number of additional resources own been developed alongside the guideline to support parents and carers, including an initial factsheet for parents; a home reintroduction protocol to confirm diagnosis; a milk ladder and milk ladder recipes.

Flu vaccination.
Protect yourself this autumn.

Find out if you are eligible for a free NHS flu vaccination.

Check eligibility

  • Hill DJ, Hosking CS; Food allergy and atopic dermatitis in infancy: an epidemiologic study.

    Pediatr Allergy Immunol. 2004 Oct15(5):421-7.

  • Boyano-Martinez T, Garcia-Ara C, Pedrosa M, et al; Accidental allergic reactions in children allergic to cow's milk proteins. J Allergy Clin Immunol. 2009 Apr123(4):883-8. doi: 10.1016/j.jaci.2008.12.1125. Epub 2009 Feb 20.

  • Liao SL, Lai SH, Yeh KW, et al; Exclusive breastfeeding is associated with reduced cow's milk sensitization in early childhood. Pediatr Allergy Immunol. 2014 Aug25(5):456-61. doi: 10.1111/pai.12247.

  • Boyle RJ, Ierodiakonou D, Khan T, et al; Hydrolysed formula and risk of allergic or autoimmune disease: systematic review and meta-analysis.

    BMJ. 2016 Mar 8352:i974. doi: 10.1136/bmj.i974.

  • Bloom KA, Huang FR, Bencharitiwong R, et al; Effect of heat treatment on milk and egg proteins allergenicity. Pediatr Allergy Immunol. 2014 Dec25(8):740-6. doi: 10.1111/pai.12283. Epub 2014 Dec 18.

  • Venter C, Brown T, Meyer R, et al; Better recognition, diagnosis and management of non-IgE-mediated cow's milk allergy in infancy: iMAP-an international interpretation of the MAP (Milk Allergy in Primary Care) guideline. Clin Transl Allergy. 2017 Aug 237:26. doi: 10.1186/s13601-017-0162-y. eCollection 2017.

  • Cows milk protein allergy in children; NICE CKS, June 2015 (UK access only)

  • Agostoni C, Terracciano L, Varin E, et al; The Nutritional Worth of Protein-hydrolyzed Formulae.

    Crit Rev Food Sci Nutr. 201656(1):65-9. doi: 10.1080/10408398.2012.713047.

  • Yeung JP, Kloda LA, McDevitt J, et al; Oral immunotherapy for milk allergy. Cochrane Database Syst Rev. 2012 Nov 1411:CD009542. doi: 10.1002/14651858.CD009542.pub2.

  • Host A, Halken S; Cow's milk allergy: where own we come from and where are we going? Endocr Metab Immune Disord Drug Targets. 2014 Mar14(1):2-8.

  • Dupont C, Hol J, Nieuwenhuis EE; An extensively hydrolysed casein-based formula for infants with cows' milk protein allergy: tolerance/hypo-allergenicity and growth catch-up.

    Br J Nutr. 2015 Apr 14113(7):1102-12. doi: 10.1017/S000711451500015X. Epub 2015 Mar 17.

  • Leonard SA, Nowak-Wegrzyn AH; Baked Milk and Egg Diets for Milk and Egg Allergy Management. Immunol Allergy Clin North Am. 2016 Feb36(1):147-59. doi: 10.1016/j.iac.2015.08.013.

  • Vandenplas Y, De Greef E, Devreker T; Treatment of Cow's Milk Protein Allergy. Pediatr Gastroenterol Hepatol Nutr. 2014 Mar17(1):1-5. doi: 10.5223/pghn.2014.17.1.1. Epub 2014 Mar 31.

  • The Milk Ladder; MAP Guideline

  • Osborn DA, Sinn J; Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants.

    Cochrane Database Syst Rev. 2006 Oct 18(4):CD003664.

  • Vandenplas Y, Koletzko S, Isolauri E, et al; Guidelines for the diagnosis and management of cow's milk protein allergy in infants. Arch Dis Kid. 2007 Oct92(10):902-8.

  • Ludman S, Shah N, Fox AT; Managing cows' milk allergy in children. BMJ. 2013 Sep 16347:f5424. doi: 10.1136/bmj.f5424.

  • Miraglia Del Giudice M, D'Auria E, Peroni D, et al; Flavor, relative palatability and components of cow's milk hydrolysed formulas and amino acid-based formula. Ital J Pediatr. 2015 Jun 341:42. doi: 10.1186/s13052-015-0141-7.

  • Vandenplas Y; Lactose intolerance.

    Asia Pac J Clin Nutr. 201524 Suppl 1:S9-13. doi: 10.6133/apjcn.2015.24.s1.02.

Methodology

The NICE guideline was written to direct the diagnosis of every food allergies. CMA is however, the most clinically complicated individual food allergy and therefore causes significant challenges in both recognising the numerous differing clinical presentations and also the varying approaches to management, both at primary care and specialist level.

A subgroup of the clinicians on the NICE guideline development group (CV, JW, ATF, TB) felt that there was therefore a specific need to extend this into a more practical guideline for cow’s milk allergy for UK Primary Care use. This need was further emphasized by the publication of international and European guidelines on cow’s milk allergy[2, 7–9]. This subgroup, with the additional expertise of a paediatric gastro-enterologist (NS) has produced a UK Primary Care Guideline in the form of practical algorithms.

Prior to the development of this Primary Care Guideline, the group discussed significant questions that they wanted to address and which clear, practical messages they wanted to convey to UK primary care.

These were:

  1. How to distinguish between:

    Methodology

    The NICE guideline was written to direct the diagnosis of every food allergies. CMA is however, the most clinically complicated individual food allergy and therefore causes significant challenges in both recognising the numerous differing clinical presentations and also the varying approaches to management, both at primary care and specialist level.

    A subgroup of the clinicians on the NICE guideline development group (CV, JW, ATF, TB) felt that there was therefore a specific need to extend this into a more practical guideline for cow’s milk allergy for UK Primary Care use. This need was further emphasized by the publication of international and European guidelines on cow’s milk allergy[2, 7–9]. This subgroup, with the additional expertise of a paediatric gastro-enterologist (NS) has produced a UK Primary Care Guideline in the form of practical algorithms.

    Prior to the development of this Primary Care Guideline, the group discussed significant questions that they wanted to address and which clear, practical messages they wanted to convey to UK primary care.

    These were:

    1. How to distinguish between:

    2. 1)

      IgE-mediated and non-IgE-mediated presentations of CMA.

    3. 2)

      Severe and mild to moderate clinical expressions of CMA.

    4. To provide guidance on formula choice in the initial diagnosis of CMA based on the current international guidelines.

    5. Give guidance about the ongoing management of mild to moderate non-IgE-mediated CMA in primary care.

    A literature search was conducted to ensure that every major food allergies and cow’s milk allergy guidelines published in the past five years were included.

    These included the World Allergy Organisation’s Guidelines on Cow’s Milk Allergy[2], the NIAID Food Allergy Guidelines from the US[10], the UK NICE Guideline on Food Allergy in Children and Young People[6], the ESPGHAN guidelines on the diagnosis and management of cow’s milk allergy[7]and the Australian consensus statement on the diagnosis and management of cow’s milk allergy[11]. Every these papers were informed by extensive systematic reviews of the literature and the group (CV, TB, JW, NS, ATF), felt that they were rigorous enough to build this proposed additional practical guideline on.

    It is intended to complement the NICE Food Allergy Guideline.

    The diverse manifestations of CMA

    According to the UK NICE guideline[6], food allergy can manifest as a number of diverse clinical presentations, mainly affecting the skin, gastro-intestinal tract and respiratory systems.

    The NICE guideline[6] emphasises that food allergies should be particularly considered 1) in infants where there is a family history of allergic disease (but the absence of a family history of allergy does not exclude the possibility of becoming allergic), 2) in infants where symptoms are persistent and affecting diverse organ systems and 3) in infants who own been treated for moderate to severe atopic eczema, gastro-oesophageal reflux disease (GORD) or other persisting gastrointestinal symptoms (including ‘colic’ , loose stools, constipation), but own not responded to the usual initial therapeutic interventions.

    In Figure 2 of the algorithms, we own divided IgE and non-IgE-mediated CMA into “mild-moderate presentations” and “severe presentations” to aid in the diagnostic process, management of CMA and appropriate onward referral.

    Therefore, most importantly, Figure 2 gives a clear message about which infants can be safely diagnosed and managed in UK primary care without any onward referral to secondary or tertiary care.

    Diagnosis of Cow’s milk allergy

    History taking

    Taking an allergy focused history forms the cornerstone of the diagnosis of food allergies including CMA and the UK NICE guideline[6] recommends that questions should be asked regarding:

    1. Any personal history of early atopic disease.

    2. The infant’s feeding history.

    3. Any family history of atopic disease in parents or siblings.

    4. Presenting symptoms and signs that may be indicating possible CMA.

    5. Details of previous management, including any medication and the perceived response to any management.

    6. Was there any attempt to change the diet and what was the outcome?

    An EAACI task force also dealt with the significant questions that should be asked during an allergy focused diet history, and will be available later this year.

    Following on from these questions is the significant step to attempt to differentiate between possible IgE and non-IgE -mediated allergies (Figure 2) and which “tests” to do.

    IgE-Mediated CMA

    For the diagnosis of IgE-mediated CMA, the use of skin prick tests (SPT) or specific serum IgE tests are recommended, but these should only be performed by those capable to interpret the tests[16].

    It is significant to understand that a positive SPT or specific serum IgE test merely indicates sensitisation and does not confirm clinical allergy. However, a positive test coupled with a clear history of a reaction should generally be sufficient to confirm a diagnosis. Although a diagnostic oral food challenge (after a short period of cow’s milk avoidance) may not be required in most of these cases, if such a challenge is conducted, it may need to be performed in a supervised setting in the majority of cases.

    Liasion with or referral to a local paediatric allergy team is recommended (see Figure 3).

    Non-IgE -Mediated CMA

    There are no validated tests for the diagnosis of non-IgE CMA, apart from the planned avoidance of cow’s milk and cow’s milk containing foods, followed by reintroduction as a home challenge to confirm the diagnosis[17]. Home reintroduction/challenges may not be acceptable in children with severe forms of non-IgE- mediated cow’s milk allergy, and these children should be referred to secondary/tertiary care[6].

    The role of dietary interventions in the diagnosis of IgE and non-IgE-mediated CMA

    Maternal avoidance of cow’s milk in the case of breast fed infants, or choosing an appropriate formula for bottle fed/partially bottle fed infants are crucial steps in the diagnosis of CMA.

    Mothers excluding cow’s milk from their diet should be supplemented with calcium and vitamin D[18] (Figure 2).

    Choosing the most appropriate formula (Figure 3, Figure 4; Table 1) for the baby based on the clinical presentation is debated with clear differences between countries. This choice is really a clinical decision which should be based on clinical presentation and the nutritional composition and residual allergenicity of the proposed hypoallergenic formula.

    The problem clinicians face is that it may appear there is a large body of evidence about alternatives to cow’s milk formulae, but most of the research is of low quality and there are a relatively little number of studies about each type of formula.

    There are extremely few studies comparing the diverse formulae in RCTs head to head and the clinical profiles of the patients who improved and did not improve are often extremely poorly described. This puts the physician and dietitian in a extremely hard position when choosing the most appropriate formula for a specific clinical presentation. In some cases choosing a soya or an extensively hydrolysed formula (eHF), which the baby may also react to, may lead to a untrue negative diagnosis.

    Alternatively, choosing an amino acid formula (AAF) when not indicated increases the cost burden of managing CMA and may affect development of tolerance (albeit the data is extremely preliminary at this time)[19, 20].

    Table 1 summarises the current international guidelines on the use of hypo-allergenic formulae in the diagnosis and management of CMA. It is accepted that the majority of children with CMA will improve on an extensively hydrolysed formula. It is therefore not surprising that in general, the guidelines propose the use of an AAF, as a first line treatment, only for more severe presentations of CMA such as a history of anaphylaxis, Heiner Syndrome, Eosinophilic Eosophagitis and severe gastro-intestinal and/or skin presentations, generally in association with faltering growth.

    They recommend the use of an eHF for every other clinical presentations.

    Unfortunately, apart from the ESPGHAN guidelines[21], none of the guidelines[2, 6, 10, 11, 22] discuss the use of formulae in two significant patient groups, namely those with multiple food allergies, and those infants who do not reply to maternal avoidance of cow’s milk (and other suspected allergens) despite a excellent clinical suspicion that these infants may be reacting to residual allergens. These cases own been reviewed by Hill et al.[23], Niggeman et al.[24] and Van den Plas et al.[8] with data suggesting that these groups may benefit from an AAF.

    The systematic review by Hill et al.[23] further suggested that those infants presenting with symptoms of CMA whilst exclusively breast fed, who may need a top-up formula or a replacement of breast milk may also benefit from an AAF.

    The use of soya formula in the diagnosis and management of CMA is also debated, with clear differences between the Australian consensus panel[11] and the ESPGHAN[7]/AAP[22, 25] guidelines. ESPGHAN and AAP acknowledge that only about 10-14% of infants with IgE- mediated CMA will also react to soya, but that this figure is much higher in infants with non-IgE- mediated CMA (25–60%).

    The two societies therefore recommend that cow’s-milk-based hypoallergenic formulae should ideally be chosen rather than soya formula in the management of CMA. In addition, soya formula contains phytate which may affect nutrient absorption and isoflavonoids in amounts that make soya milk unsuitable for use in every infants under six months of age. Soya can however be used in infants older than 6 months if eHF is not accepted or tolerated, if these hypoallergenic formulae are too expensive, or if there are strong parental preferences (e.g.

    vegan diet).

    In addition, there own been some questions raised regarding the use of hypoallergenic formulae containing lactose in the diagnosis and management of infants and young children with CMA. ESPGHAN[7] advises that adverse reactions to lactose in children with CMA is not reported in the literature and finish avoidance of lactose is not needed in the majority of cases, apart from those children who own an enteropathy with severe diarrhoea where there is a secondary lactose intolerance.

    Two randomised trials suggested that rice based hydrolysed formula is well tolerated by infants with CMA[26, 27] although there are some concerns about the effect of these formulae on weight gain[28].

    Therefore, to summarise the above discussion, taking into account the lack of excellent quality studies in this field:

    1. Breast-feeding is always the preferred way to feed any baby. In any case where there is a need to exclude cow’s milk from the maternal diet and a top-up formula is needed, we propose in agreement with Hill et al.[23] an amino acid based formula as the B-lactoglobulin levels and peptide sizes of cow’s milk protein in breast milk and those of eHF are similar to the ranges of B-lactoglobulin seen in breast milk[29–33].

    2. AAF is recommended as a first line of treatment for those infants with a history of anaphylaxis to cow’s milk, Heiner Syndrome, Eosinophilic Eosophagitis and severe gastro-intestinal and/or skin presentations, particularly in association with faltering growth.

    3. eHF is recommended as a first line of choice for infants with mild to moderate presentations of CMA e.g.

      colic, reflux, diarrhoea, vomiting, eczema in the absence of faltering growth.

      What to feed a 1 year ancient with milk allergy

      eHF containing whey may not be suitable as a first line of treatment of those infants with possible secondary lactose intolerance[7].

    4. Soya formula can be used in infants over 6 months of age who do not tolerate the eHF, particularly if they are suffering from IgE mediated CMA in the absence of sensitisation to soya.

    Are milk allergies common in babies?

    Only around 2–7.5% of babies under are allergic to cows’ milk1. By the age of three most children will own grown out of cows’ milk allergies, but for a it may final until they’re 6–8 years ancient. Occasionally, it can continue into adulthood – especially if there is a family history of allergies2.


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