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Twins with cows’ milk allergy step down from AAF to EHF

Cows' Milk Allergy

31/03/2021

The case:
16 weeks old, female twins were identified on EMIS search at a GP practise by an Oviva community dietitian for review. They were not already under the care of a dietitian and had both been started on Neocate LCP^® for suspected cows’ milk allergy (CMA) at 6 weeks old by a paediatrician. The dietitian successfully switched both twins to SMA Alfamino and later stepped them down to SMA Althera.

Initial EMIS review at 4 months by community dietitian:

	Twin 1	Twin 2
Antropometry	Weight: 5.49kg (>9^th centile)-increasing Length (6 weeks old)=50cm (0.4^th C)	Weight: 5.21kg (>9^th centile)-increasing Length (6 weeks old)=49cm (0.4^th C)
Biochemistry	Nil relevant	Nil relevant
Clinical	Heart murmur investigated by Paediatric team
Feeding hx	Exclusively BF from birth, started combination feeding at 4 weeks and now currently being exclusively formula fed	Exclusively BF from birth, found to have tongue tie and told to put onto formula so started at 4 weeks. Currently being exclusively formula fed
Symptoms	Reflux, colic, dry skin patches and loose and mucous stools	Similar to Twin 1
Overview	When started on formula symptoms started. When explained to Paediatrician (1.5 months old) he advised likely CMA and recommended to start on Neocate LCP^®. When started on Neocate LCP^® symptoms resolved within 3-4 days and they were much happier	Similar to Twin 1
Family hx	Older sister had lactose intolerance (had Wysoy) but had outgrown it. Her symptoms were similar to the twins so possible CMA mis-diagnosis)	Similar to Twin 1
Born	37+1 weeks	Same as Twin 1

Initial assessment at 4 1/2 months by community dietitian:

	Twin 1	Twin 2
Bowels	BO x 3 per day (still sometimes mucousy)	BO x 1 per day Explosive and loose (leaks through nappy)
Feeding	5 x 5 ounce bottles 750ml (Req>830ml)	5 x 5 ounce bottles but doesn’t usually drink full amount 750ml (Req>780ml)
Symptoms	Doing well and a lot better than Twin 2 who is on Neocate LCP^®. Is happy, drinking well and weight increasing	For the last 2 weeks symptoms have returned- cries when being fed, refusing feeds, posseting, seems really uncomfortable and back arching

Growth:
Growth Chart - Twin 1 & 2

Intervention by community dietitian:

Intervention:

Sample of SMA Alfamino to trial (first line AAF) for both twin 1 and twin 2
Twin 2-trial Infant Gaviscon
Cows' milk free weaning education

Follow Up:

Signed up to Oviva app
Sent BDA Food Allergy Specialist Group (FASG) ‘Cows' Milk Free Diet for Infants and Children’
Follow up the next week through Oviva app

Oviva app follow up: 1 week after:
Messages via smartphone app

Both twins were doing really well on SMA Alfamino
Twin 2 symptoms have improved significantly and now seems ‘like a happy baby’
Twin 2 did not have any Infant Gaviscon as they did not require it

5 ½ months old:
Phone call to check weaning and formula tolerance

Started to wean onto solids i.e. mashed banana, butternut squash puree
Tolerating SMA Alfamino well and meeting fluid requirements
Weight tracking on centile chart
No concerns with diet or questions on milk free weaning

Intervention
1) Discussed about allergen introduction

7 months of age:
Phone call to review weaning:

Twin 1

Weight increasing, mother describes her as ‘text book baby’
Started on stage 2 textures; 3 meals (baby rice, branded baby food kitchen pouches, avocado/peas mashed)
810ml of formula and 90ml of water per day (meeting requirements of 830ml); accidentally given a tsp of yoghurt by another family member-stools looser

Twin 2

Struggling with weaning-was doing well on stage 1 but when tried to increase texture is not taking well. Seems to be choking and spitting out
Mother concerned that ‘something is not right’ - eating only about ¼ of lunch and dinner meals compared to twin 2

Both

Had not tried introducing soya, fish or eggs and had not received any follow up appointments with paediatrician

Intervention:
1) Organised health visitor (HV) to observe feeding and if concerns consider speech and language therapist (SLT) referral
2) Discussed other allergen introduction
3) Emailed paediatrician about follow up appointment
4) Try softer finger foods for Twin 2
5) Get weighed

HV assessment at 7 months of age
Feedback from parent on HV visit:
The HV came yesterday and suggested that Twin 2 may just have strong gag reflexes. That there’s no concern that her struggle with lumps is holding her development back
The HV simply feels Twin 2 is ready to move up to finger foods and when we tried toast and strips of banana she reacted well
This morning both the twins had toast for breakfast and really enjoyed it

8 months of age:
Phone call:

Tried soya yoghurts but it seemed to make them uncomfortable and stools looser
Have given them fish-tolerate and have included regularly into their diet
Tried with coconut yoghurts and scrambled eggs-seem to tolerate but do not like very much
Having peanut butter on toast
Fussy with chicken and meat
Start using Oat milk in foods

Intervention:

Milk Ladder education given to start once they turn 9 months old

9 ½ months of age:

Message from mother and phone call from pharmacist that the pharmacy did not have SMA Alfamino
Girls both doing well on milk ladder-tolerating baked milk products so therefore decided to step down to SMA Althera

Results: Nothing significant but a change in colour of nappies from greenish to brown and Twin 2 reflux increased for a few days but then this subsided

11 months:

‘Dip in progress’
Mother continued up the milk ladder and was giving yoghurt and starting milk in breakfast and noticed Twin 2 stools getting looser, reflux, uncomfortable and looking like not putting on weight
Twin 1 increase in dry skin/eczema

Intervention:
1) Go back to baked milk products to determine if moving up the milk ladder too quickly or changing to SMA Althera have resulted in the symptoms
2) Get weighed
3) Provide the Oviva high energy weaning guide

12 months:
Phone call:

Returning to baked milk helped with symptoms
Moving to the next step on the milk ladder caused symptoms to return
Unable to get weighed

Intervention:

Continue with baked milk and not to progress with the milk ladder for the time being and await paediatrician appointment

Where we are at now after the paediatrician appointment:

Both twins having baked cheese i.e. lasagne and tolerating. Slowly increasing up milk ladder
Weight tracking and length increasing
Twin 2-emollients and Aveeno bath oil from paediatrician Transitioning onto Oatly Barista milk as main drink

What the dietitian learnt from the case:

One of the first times stepping down from AAF to EHF and now feel more comfortable doing it in practice
Importance of still utilising MDT even though working quite independently in the community

What went well:

The use of smartphone app to communicate especially with a busy mother
Combination of messages and phone calls
Stepping down to EHF from AAF

What made the case challenging:

Twins-mother wanting to do the same for both and comparing one/another
HV service and getting weights
Up and down on milk ladder

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.

16 weeks old, female twins were identified on EMIS search at a GP practise by an Oviva community dietitian for review. They were not already under the care of a dietitian and had both been started on Neocate LCP® for suspected cows’ milk allergy (CMA) at 6 weeks old by a paediatrician. The dietitian successfully switched both twins to SMA Alfamino and later stepped them down to SMA Althera.

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