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The importance of having a choice of eHF and AAF milks in the management of CMA

Cows' Milk Allergy

31/03/2021

Mother Reading A Book To Young Child In Nursery

During the last decade, the prevalence of allergic diseases in infants and children has increased significantly either through better awareness of the symptoms or through generally more children being affected.^1-3 Therefore, it is no surprise that the numbers of children presenting to clinics in district general hospitals has also increased.^4-5 Diagnosis of true milk allergy is key in resolving symptoms in this group of children. The cost of formula milks to the NHS as a whole is a contentious subject and various guidelines have been written to assist practitioners on diagnosing the condition and providing the correct formula milk in reasonable volumes.^6-9 In true milk allergy, a proportion of these children will have to try a range of different formulas to find the one that resolves their symptoms. The use of extensively hydrolysed formulas have been shown as key in preventing allergy progressing from non-IgE to IgE. However, in a small group of these children (10%) amino acid formulas are clinically indicated.⁹

Patient’s background/medical history/physical/diagnosis

Baby D was born at term +16 by emergency c section and passed meconium in the first 24 hours. She was admitted to the ward at day 8 with a 3 day history of not passing a stool. At this point she was on a standard whole protein formula. She had an episode of going red and holding her breath so was given laxatives and passed two stools overnight. She was then discharged home and re admitted on day 26 with vomiting. At this time she was diagnosed with overfeeding and parents were asked to reduce the amount they were giving. 3 days later she attended the ward again for investigation of pyloric stenosis and a 7 day history of forceful vomiting. Her weight gain had tailed off to 30g over the week. Ultrasound scan showed thickened pyloric muscle on either side so she was referred to a specialist hospital and an NGT was placed and she was fed via nasogastric tube.

Results

After surgical correction of the polyric stenosis, Baby D continues to be unsettled with repeated episodes of screaming and straining. There was no history of blood in the stools and still small amounts of vomiting. Diagnosis of cows’ milk protein allergy was made by the medical team and an extensive hydrolysed milk: Nutramigen 1 was recommended as a trial for a period of 1 month. Parents contacted the dietetic department after 20 days and reported that she seemed irritable. Baby D was still having issues with constipation and vomiting. The clinical decision was made to trial amino acid formula Neocate LCP. After 14 days baby D’s mother contacted the dietetic department as Baby D was was getting a widespread rash over her whole body during every feed. Clinically we agreed that Baby D should continue on an amino acid formula as her symptoms appeared to have resolved other than the rash. We then suggested changing her onto Alfamino® which appeared to relieve the symptoms of the CMPA within 24 hours and did not cause a rash. Weight gain throughout this period continued tracking the 50th centile. Dairy free weaning was commenced after the change to Alfamino®. The cause of the rash was unknown and may have been coincidental. Unfortunately, the child did not present for a skin prick test at 8 months so we have been unable to ascertain the outcome of her allergy.

Discussion

This mother was clearly concerned from the beginning about her child’s symptoms. Therefore the diagnosis of CMPA may have been made earlier if it had not been disguised by the pyloric stenosis. This case also highlights the importance of a multidisciplinary team approach in the diagnosis of CMPA and an understanding of the different milks available on the market. Anxiety over having to try different formulas is often common and parents should be reassured that correct choice is key in resolution of symptoms.

Conclusions

Extensively hydrolysed feed should always be the first line for children with mild to moderate cows’ milk protein allergy, however if not resolved then amino acid formula should be trialled. Amino acid formulas play an important role in those children with more severe CMPA and resolution of symptoms aids parental anxiety. The advantage of having different amino acid feeds available on the market is that it provides an alternative if one feed is not effective.^7-9

References: 1. ISAAC [web site]. International Study of Asthma and Allergies in childhood (http://isaac.auckland.ac.nz/, accessed 9 March 2007. 2. Jackson K et al. Trends in Allergic Conditions among Children: United stated, 1997-2011. National Center for Health Statistics Data Brief. 2013. Retrieved from www.cdc.gov.nchs/data/databriefs/db 10.htm. 3. World Health organization. White book on Allergy 2011-2012. Executive summary. By Prof. Ruby Pawankan, Prof Giorgio Walkter Canonica, and Prof. Stephen. 4. Hospital admissions for allergies up nearly eight per cent in a year, www.hscic.gov.uk. 5. Time trends in allergic disorders in the UK, R Gupa et al; Thorax 2007: 62:91-96. 6. BSACI guideline for the diagnosis and management of cow’s milk allergy, D Luyt et al; Clinical at Experimental Allergy, 44, 642-672. 7. CG116 Food allergy in children and young people, www.nice.org.uk. 8. Guidelines for the diagnosis and management of cow’s milk allergy in infants; Vanderplas et al, Arch Dis Child, 2007 Oct; 92(10): 902-908. 9. Diagnosis and management of non-IgE-mediated cow’s milk allergy in infancy- a UK primary care practical guide: MAP guidelines. Carina venter; Trevor Brown, Neil Shah, Joanne Walsh and Adam Fox. Clinical and translation allergy 2013, 3:23.

IMPORTANT NOTICE: Mothers should be encouraged to continue breastfeeding even when their infants have cows’ milk protein allergy. This usually requires qualified dietary counselling to completely exclude all sources of cows’ milk protein from the mothers’ diet. If a decision to use a special formula intended for infants is taken, it is important to give instructions on correct preparation methods, emphasising that unboiled water, unsterilised bottles or incorrect dilution can all lead to illness. Formula for special medical purposes intended for infants must be used under medical supervision.

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