Prescribing Guidelines of Infant Formula for Infants with Cow s Milk Protein Allergy (CMPA) or Lactose Intolerance

Transcription

1 Background information Prescribing Guidelines of Infant Formula for Infants with Cow s Milk Protein Allergy (CMPA) or Lactose Intolerance Adverse reactions to foods, mainly cow s milk protein (CMP), are most common in the first year of life 1. In infancy, the main atopic symptoms are atopic dermatitis, gastrointestinal (GI) symptoms (diarrhoea, bloody stools, vomiting, abdominal distension and constipation) and recurrent wheeze. Most infants with cow s milk protein allergy (CMPA) develop symptoms before 1 month age, often within 1 week after introduction of CMP-based formula 2. CMP can induce both acute IgE-mediated reactions (within 2 hours) e.g. rash or urticaria, wheeze, vomiting and delayed reactions that may be either non IgE-mediated or mixed (> 2 hours) e.g. mildmoderate eczema, reflux. Severe CMP hypersensitivity symptoms may include anaphylaxis, severe eczema or faltering growth. 5-15% of infants show symptoms suggestive of an adverse reaction to cow s milk protein % of infants with gastro-oesophageal reflux (GOR) have (CMPA) % of CMPA individuals have cutaneous symptoms, 50-60% have GI symptoms and 20-30% respiratory symptoms 4. A remission rate is expected of 45-50% of infants at 1 year, 60-75% at 2 years and 85-90% at 3 years 4. Managing CMPA: Breast milk remains the ideal choice for the CMPA infant 5 If CMPA symptoms persist in the breast fed infant, a maternal exclusion diet i.e. milk-free diet, is indicated 5 for a minimum trial of 2 weeks. A referral should be made to a paediatric dietitian when suspicion of CMPA is raised and all infants on a cow s milk free diet should be referred to a paediatric dietitian. If the infant is seen privately, they should see a dietitian locally if it is not arranged privately. The mother will need a calcium supplement of 1000mg/day e.g. Sandocal 1000, if she follows a milk free diet herself whilst breastfeeding. The infant may need a calcium supplement depending on the formula used. For infants who are unable to receive breast milk, an appropriate hypoallergenic formula is required 6 see Flowchart 1. These formulae vary in palatability introduce as soon as possible and if possible transition the introduction with incremental mixing of the milks. It is advisable to prescribe a smaller amount on a trial basis. Lactose Intolerance See Flowchart 1 - symptoms include diarrhoea and colic.

2 Clinical presentation NICE clinical guidelines History If cows protein milk allergy is suspected, the GP or other healthcare professionals with the appropriate competencies should undertake an allergy focussed clinical history which includes: any personal history of atopic disease (such as eczema) any individual and family history of atopic disease (such as asthma, eczema, allergic rhinitis or food allergy) in parents or siblings details of any foods that are avoided and the reasons why

3 an assessment of presenting symptoms and other symptoms that may be associated with food allergy (see Box 1), including questions about: the age of the child or young person when symptoms first started speed of onset of symptoms following food contact duration of symptoms severity of reaction frequency of occurrence setting of reaction (for example, at school or home) reproducibility of symptoms on repeated exposure what food and how much exposure to it causes a reaction who has raised the concern and suspects the food allergy what the suspected food allergen is the child or young person s feeding history, including the age at which they were weaned and whether they were breastfed or formula fed. If the child is currently breastfed, consider the mother s diet details of any previous treatment, including medication for the presenting symptoms and the response to this any response to the elimination and reintroduction of foods cultural and religious factors that affect the foods they eat Physical examination Based on the findings of the allergy-focused clinical history, physically examine the child or young person, paying particular attention to: growth and physical signs of malnutrition signs indicating allergy-related co morbidities (atopic eczema, asthma and allergic rhinitis). References 1. Host A., Primary and secondary dietary prevention. Pediatr Allergy Immunol; 12 (suppl 14): Heine RG, Elsayed S, Hosking CS, Hill DJ. Cow s milk allergy in infancy. Curr Opin Allergy Clin Immunol 2002;2: Sicherer SH, Clinical aspects of gastrointestinal food allergy in childhood. Pediatrics; 111 (6): Host A., Frequency of cow s milk allergy in childhood. Ann Allergy Immunol; 89 (suppl): Host A Halken S. Hypoallergenic formulas; when, to whom and how long. Allergy 2004:59 (suppl78): Vandenplas Y, Brueton M Dupont C et al. Guidelines for the diagnosis and management of cow s milk allergy in infants. Arch Dis Child 2007; Food Allergy in Children NICE guideline 116 & NICE quick reference guide 2011

4 Flow chart 1 - Prescription of infant formula in infants with suspected cow s milk protein (CMP) allergy or lactose intolerance Mild to moderate symptoms One or more of the following symptoms: Gastrointestinal: Frequent regurgitation, vomiting, diarrhoea, constipation, blood in stool, iron deficiency anaemia Persistent distress or colic ( 3 hrs per day wailing/ irritable), for at least 3 days/week over > 3 weeks Dermatological: Atopic dermatitis, swelling of the lips or eyelids (angio-oedema), urticaria unrelated to acute infections, drug intake or other causes. Suitable formula/ feeding Cow s milk protein free foods if weaning. Step 1: Breastfeeding If mum is breastfeeding consider CMP free diet for mum, with calcium supplements, for a minimum trial of 2 weeks. (1000mg/day e.g. Sandocal 1000) Step 2: Extensively hydrolysed formulas (EHF) Casein Based: Nutramigen 1 & 2 (Mead Johnson) Whey based: Pepti - contains lactose (Aptamil) Step 3: Amino acid based formulas (AAF) If symptoms do not improve after 2 weeks or the child persistently refuses EHF then: Neocate LCP Nutramigen AA Trial for a minimum of two weeks. Step 4: Soya Formula Can only be used in infants over 6 months who refuse above formulas. Use with caution as high incidence of soya allergy in children with References: CMP allergy Severe symptoms One or more of the following symptoms: Gastrointestinal: 1. FTT due to chronic diarrhoea and/or regurgitation/ vomiting and/ or refusal to eat. 2. Iron deficiency anemia due to occult or macroscopic blood loss 3. Protein losing enteropathy (hypoalbuminaemia) 4. Endoscopic/ histologically confirmed enteropathy or severe allergic or eosinophilic colitis Dermatological: Exudative or severe atopic dermatitis with hypoalbuminaemia, or FTT or Iron deficiency anaemia Respiratory: Acute laryngoedema or bronchial obstruction with difficultly breathing Systemic reactions: Anaphylactic shock needs immediate referral to hospital for management Suitable formula/ feeding Cow s milk protein free foods if weaning 1. Breastfeeding: Consider CMP free diet for mum, with calcium supplements, for a minimum trial of 2 weeks. 2. Amino acid based formulas (AAF) For a minimum trial of 2 4 weeks Neocate LCP Nutramigen AA 1. Vandenplas Y et al: Guidelines for the diagnosis and management of cow s milk protein allergy in infants Lactose Intolerance Includes: Diarrhoea Colic Symptoms are usually transient and 2 to GI insult e.g.: rotavirus infection Diagnosis: Clinical history Reducing substances in stool Treatment: Breastfed babies lactase drops (e.g. Colief, 4 drops/ feed) Formula: Low lactose formulas based on CMP e.g.: SMA LF; Enfamil O-Lac Weaned children would need to avoid solids containing lactose Soya is not recommended unless the above are not available and only in infants over 6 months. Note: Most children should be able to revert back to normal formula once GI insult has resolved within 4 6 weeks If symptoms do not improve after two weeks on lactose free diet, consider alternative diagnosis. Notes: Please refer ALL infants on cow s milk protein free diets to a paediatric dietitian. Please refer all patients with cow s milk protein allergy to the Paediatric Allergy/Gastrointestinal (for gastro symptoms) Clinic at St Georges Hospital. These patients will need ongoing management including advice regarding the possibility of multiple food allergies, and the timing of introductions and challenges. Prescription for infant formula will be required up until 2 years of age (if allergy persists), and beyond for older patients who are unable to tolerate commercial milk substitutes.

5 2. Host A et al: Joint statement of ESPACI Committee on hypoallergenic formulas and ESPGHAN committee on nutrition. Arch Dis Child 1999; 81: Zeiger RF et al: Soy allergy in infants and children with IgE associated cow s milk allergy. J Pediatr 1999; 134: Powell GK: Milk and soy induced enterocolitis of infancy. Clinical features and standardization of challenge. J Pediatr 1978; 93: D De Boissieu et al: Allergy to extensively hydrolysed cow milk proteins in infants: identification and treatment with an amino acid-based formula. J Pediatr 1997; 137: J A Vanderhoof et al: Intolerance to protein hydrolysate infant formulas: An under recognised cause of gastrointestinal symptoms in infants. J Pediatr 1997; 131: DJ Hill et al: The natural history of intolerance to soy and extensively hydrolysed formula in infants with multiple food protein intolerance. J Pediatr 1999;135: Kanabar D et al: Improvement of symptoms in infant colic following reduction of lactose load with lactase. J Hum Nutr Dietet 2001; 14: Kanavar D: Lactose Intolerance a common cause of colic? Clin Nutr 2003; Davidson GP et al: Incidence and duration of lactose malabsorption in children hospitalised with acute enteritis: Study in a well-nourished urban population. J Pediatr 1984; 105:

6 Referral to Community Paediatric Dietitian Has this referral been agreed with the child s parent/guardian? YES/NO Is an interpreter required? YES/NO If YES, what language? Child s Family name: Child s First name: Child s date of birth: Home address: M/F Name of Parent/Guardian: Ethnic group (of child): NHS No: Name & address of General Practitioner: Telephone number: Name & address of School/Nursery: Telephone number: Child s height: cm, weight: kg Current medication: Principal diagnosis (if applicable): Reason for referral: Describe what recent changes have occurred in the child s condition (e.g. on-going problem, recent weight change) Medical information: (including name of other teams involved) Name of referrer and post title: Contact address: Date of referral: Telephone number: Please ensure all sections are completed. Incomplete or illegible referrals will be returned Send to: Community Paediatric Dietitian, Queen Mary s Hospital, Roehampton Lane, London SW15 5PN Tel: /32 Fax: