Cows Milk Allergy How to follow a milk free diet. Janet Purves Paediatric Dietitian March 2015

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1 Cows Milk Allergy How to follow a milk free diet Janet Purves Paediatric Dietitian March 2015

2 Summary of main topics Principles of a milk free diet Hypoallergenic formulas Weaning the cows milk allergic infant Milk substitutes for the older child Milk free foods Calcium and vitamins Milk reintroduction

3 Cow s Milk Protein Allergy Allergy to milk proteins (Casein, Whey) Most common food allergy in children < 3yrs Most symptoms present before 6months of age Prevalence % in infancy, 2-3% population Prevalence in exclusively breast fed infants % Lactose intolerance may be confused with non-ige mediated cows milk allergy as symptoms overlap Most children outgrow cows milk protein allergy during childhood Luyt et al (2014)

4 Practical dietary management of cows milk allergy Allergen avoidance Labelling Obvious and hidden sources Milk substitutes/milk free foods +/- Vitamin and mineral supplementation Growth monitoring Texture progression in infants Resources Diet sheets, recipes, websites, support groups, supermarket free from lists Reintroduction advice

5 Milk Free Diet Free of both milk protein and lactose Excludes: Milk cow, sheep, goat Cheese Yogurt Butter, margarine Cream Hidden milk

6 Hidden Milk Non-fat milk solids, Buttermilk, Ghee, Whey, whey solids, Hydrolysed whey protein, Hydrolysed whey sugar, Casein (curds), Caseinate, Hydrolysed casein, Lactose, Milk protein, Milk sugar, Milk solids, Lactoglobulin, Lactoalbumin

7 New Allergen Labelling Law Dec14 Previous law - covered 14 allergens in pre-packed food: cereals containing gluten, crustaceans, eggs, fish, peanuts, soybeans, milk, nuts, celery (and celeriac), mustard, sesame, sulphur dioxide, lupin, molluscs New law -14 allergens+ allergen information also to be provided for foods sold non- prepacked or prepacked for direct sale multimedia/pdfs/publication/allergyleaflet.pdf

8 Hidden Milk

9 Hypoallergenic formula Definition of hypoallergenic for EU labelling - immunoreactive protein <1% of total nitrogen containing substance Tolerated by at least 90% of patients with CMPA Degree of hydrolysis varies between brands Only amino acid formulas considered to be nonallergic Host et al (1999)

10 Extensively hydrolysed formula Althera (Vitaflo) Aptamil Pepti 1 & 2 (Danone) Nutramigen Lipil 1 & 2 (Mead Johnson) Pregestimil (Mead Johnson) Peptijunior (Cow & Gate) Similac Alimentum (Abbott) Hydrolysed whey (+lactose) Hydrolysed whey (+lactose) Hydrolysed casein Hydrolysed casein (+MCT) Hydrolysed whey (+MCT) Hydrolysed casein (+MCT)

11 Extensively Hydrolysed formula

12 Amino acid formula Neocate LCP (0-12mths) Nutricia SHS Neocate Active (>12mths) Nutricia SHS Neocate Advance (>12mths) Nutricia SHS Alfamino Vitaflo Nutramigen AA Mead Johnson Neocate Spoon (weaning supplement) Nutricia SHS Amino acids Amino acids Amino acids Amino acids Amino acids Amino acids

13 Amino Acid formula/supplements

14 Product Reformulation

15 ehf and AAF in clinical practice Infant presents with IgE or non IgE mediated symptoms on exposure to cows milk protein Breastfed infant Standard formula fed infant Symptoms present whilst breastfeeding despite maternal CMP avoidance Symptoms present on introduction of standard formula Extensively hydrolysed formula Severe + multiple symptoms e.g. blood in stools, extensive eczema, severe vomiting + diarrhoea with faltering growth Extensively hydrolysed formula Symptoms persist Symptoms persist Amino acid formula Adapted from: Meyer, R (2007) Diagnosis and Management of Cows Milk Protein Allergy in Infants. A case for developing UK-relevant guidelines. Complete Nutrition Volume 7 No 6 p

16 Practical issues formula acceptance Taste, smell, stool colour/frequency Depends on age, taste experience and individual baby Introduction: Straight swop Mix with EBM/existing formula (non-ige mediated) Flavouring eg vanilla essence

17 Soya formula Not for use under 6 months of age

18 Soya formula Indications for use: infants with CMPA who refuse ehf/aaf formula vegan mothers who are unable or do not wish to breast feed Not for CMPA in infants <6 months of age phytoestrogen content risk of soya sensitisation

19 SMA HA Infant Milk Not for CMPA treatment Not prescribable

20 Key Points Extensively hydrolysed formula (ehf) suitable for most infants and children with CMPA Degree of hydrolysis varies between brands Soya formula should not normally be used < 6 months of age Use Amino acid formula if severe and multiple symptoms, symptoms remain on ehf or in breastfed infant despite maternal milk avoidance, faltering growth or refusal to take ehf

21 Weaning The Cow s Milk Allergic Infant 26 weeks not before 17wks DH If breastfeeding, continue to breastfeed whilst introducing solids Start with low allergenic foods- root vegetables eg carrot, potato, parsnip; fruit eg apple, pear, plum, peach When high allergenic foods are introduced give singly in small amounts over 3 days Introduce earlier in the day rather than in the evening in case medical advice is needed Appropriate texture progression

22 Milk substitutes for the older child Soya milk Rice milk Oat milk Coconut milk Hemp milk

23 Milk substitutes for the older child

24 Comparison Of Milk Substitutes Energy (kcal/100ml) Protein (g/ 100ml) Calcium (mg/100ml) Vitamin D (ug/100ml) Cows milk Oat Milk Rice milk Coconut milk trace Soya milk u/s Organic milk substitutes usually have no added calcium.

25 Arsenic and rice milk Children between 1 and 4.5 years old should not have rice drinks as a replacement for cows milk, breast milk, or infant formula. This is because they will then drink a relatively large amount of it, and their intake of arsenic will be greater than that of older children and adults relative to their bodyweight. FSA April 2009 Ref: Meharg et al 2008

26 Milk free alternatives Available from health food shops, supermarkets, mail-order Dairy free margarine - soya, sunflower Soya yoghurts, desserts, ice cream, cheese Soya, oat creams Milk free chocolate Vegan products

27 Milk free products

28 Price Comparison -Milk Free Digestives 175g 400g

29 Calcium requirements Daily requirements: - <12 months 525mg years 350mg years 450mg years 550mg - Breastfeeding 1250mg (10ug vitamin D) RNI Figures

30 Meeting daily calcium requirements Age 1 year 600ml Nutramigen2 =564mg calcium (RNI=350mg) Age 4 years 300ml Alpro soya milk plus 1 pot of soya yogurt =510mg calcium (RNI = 450mg)

31 Calcium Supplements Osteocare Liquid: 5ml = 150mg Calcium Gluconate 1g 1 tab = 89mg* Adcal (chewable):1 tab = 600mg* Cacit (fizzy): 1 tab = 500mg* Calcichew: 1 tab = 500mg* Calcichew Forte 1 tab = 1000mg* Sandocal1000(fizzy)1 tab =1000mg* *BNF

32

33 Healthy Start Children s Vitamins Dose: 5 drops per day: Vitamin A - 233ug (700iu) Vitamin C - 20mg Vitamin D -7.5ug (300iu) Banana flavour Free from milk, egg, gluten, soya and peanut Suitable for vegetarians 10ml bottles each of which contains just over 56 daily doses

34 Diagnosis in non-ige mediated CMPA Natural History Hospital reintroduction: Any moderate to severe reaction, less severe reaction to trace exposure, regular asthma preventative treatment, multiple or complex allergies, parents unable to understand protocol (BSACI)

35

36 Non-IgE mediated CMPA diagnosis 4 week trial milk exclusion: Breast fed infant maternal milk exclusion assess maternal diet re Calcium, Vitamin D Formula fed infant - milk substitute +milk free solids if weaning Reintroduction: Breast fed - gradual reintroduction into mother s diet Formula fed - staged reintroduction into infant s diet 1oz cow s milk formula added to milk substitute progressing in daily 1oz increments

37 Natural History Around 85% of children are likely to outgrow milk allergy by 3 years of age Heine et al (2002) Skripak et al (2007) 807 patients-19% resolution by 4 years of age, 42% by 8 years, 64% by 12 years, 79% by 16 years. Higher IgE levels, co-existing asthma or allergic rhinitis predictive of persistent allergy. Some developed tolerance in adolescence

38 Home Reintroduction-Milk Ladder Stage 1 Baked Milk Products Malted milk biscuit/brioche or cake-start with 1tsp on the first day then double up every day until 1 biscuit or small piece cake given every day for at least 5 days Stage 2 Boiled Milk Boil milk and allow to cool or use cooked milk/cheese in custard or cheese sauce. Start with 1 tsp then double up the quantity every day for at least 5 days Stage 3 Yogurt/Fromage Frais/hard cheese (eg white cheddar/edam/gouda daily) Start with a ½ tsp then double up the quantity every day for at least 5 days Stage 5 Uncooked pasteurised cows milk Start with 1 tsp added to foods then double up each day The challenge is complete when tolerating 150ml of uncooked pasteurised milk daily for at least 5 days

39 Published CMPA - Guidelines A number of guidelines have been published including: Vandenplas et al. Guidelines for the diagnosis and management of cow's milk protein allergy in infants. Arch Dis Child 2007 Oct 1;92(10): Caffarelli et al. Cow's milk allergy in children: a practical guide. J Pediatr 2010;36(5). Fiocchi et al. Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines. World Allergy Organisation Journal 2010;April: Kemp et al. Guidelines for the use of infant formulas to treat cows milk protein allergy: an Australian consensus panel opinion. Med J Aust 2008;188: Koletzko et al. Diagnostic Approach and Management of Cow's-Milk Protein Allergy in Infants and Children: ESPGHAN GI Committee Practical Guidelines. J Pediatr Gastroenterol Nutr 2012 Aug;55(2): Venter et al. Diagnosis and management of non-ige-mediated cow's milk allergy in infancy - a UK primary care practical guide. Clin Transl Allergy Jul 8;3(1):23 (MAP) Luyt et al. BSACI guideline for the diagnosis and management of cow s milk allergy. Clin Experimental Allergy May 44,

40 References 1. Department of Health (DH) Report of the Panel on Dietary Reference Values of the Committee on Medical Aspects of Food Policy (COMA) Dietary Reference Values for Food Energy and Nutrients for the United Kingdom. Report on Health and Social Subjects 41. London: HMSO, Host et al (1999) Dietary products used in infants for treatment and prevention of food allergy Arch Dis Child 1999; 81: Luyt et al (2014) BSACI guideline for the diagnosis and management of cow s milk allergy. Clin Experimental Allergy May 44, Meharg et al 2008 Inorganic arsenic levels in rice milk exceed EU and US drinking water standards Journal of Environmental Monitoring;10: Heine et al (2002) Cow milk allergy in infancy. Current Opinion in Allergy and Clinical Immunology, 2(3), National Institute for Health and Clinical Excellence (2011) Clinical guideline 116 Food allergy in children and young people: Diagnosis and assessment of food allergy in children and young people in primary care and community settings 7.Skripak et al (2007) The natural history of IgE- mediated cow s milk allergy J Allergy Clin Immunol;120:1172-7

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