Cow's Milk Protein Allergy Flashcards
Define Cow’s Milk Protein Allergy
A reproducible immune-mediated allergic response to one or more proteins in cow’s milk (inc. casein, whey, and 20 other potentially sensitising proteins)
What is the difference between IgE mediated CMPA and non-IgE mediated CMPA
IgE: development of serum-specific IgE Abs after exposure and sensitisation → mast cell + basophil involvement → histamine → immediate and consistently reproducible symptoms
Non-IgE: cell-mediated (T cell), delayed reaction (2-72h)
What are the risk factors for CMPA
Male sex (2 fold higher risk)
Known food allergy
PMHx atopic conditions e.g. asthma, atopic eczema
FHx food allergy or atopy
Epidemiology of CMPA
One of the most common presentations of food allergy seen in early childhood, second to egg allergy
Most common presentation is mild-to-moderate non-IgE-mediated allergy
Almost all cases present before one year of age, with a prevalence between 1.8-7.5% of infants
10% will also be intolerant to soya milk
What are the symptoms of IgE-mediated CMPA
Rapid onset after ingestion
Skin: pruritus, erythema, urticaria, swelling, eczema flare-up
GI: nausea, colicky abdo pain, vomiting, diarrhoea
Resp: cough, chest tightness, wheezing, SOB, sneezing
Other: faltering growth, irritability
What are the symptoms of non-IgE-mediated CMPA
Delayed onset (2-72h)
Skin: pruritus, eczema
GI: GORD, vomiting, loose/frequent stools, abdo pain/discomfort, infantile colic, irritability, blood/muscous in stools
Resp: cough, wheezing, SOB
Other: faltering growth
What are the differentials for CMPA
Food intolerance e.g. lactose
Colic
GORD
Coeliac disease
Constipation
IBD
Pancreatic insufficiency e.g. CF
Infection e.g. gastroenteritis
Intussusception, small bowel obstruction
What are the signs of CMPA on examination
Weight and height
* Plot on growth chart and assess growth
General
* Any signs of clinical reaction
* Urticaria/erythema
* Angio-oedema
ABCDE
Exclude anaphlaxis
What investigations should be done for CMPA
Clinical diagnosis + cow’s milk protein elimination (4 week trial + re-introduction)
Consider:
- Stool sample for occult blood
- Serum specific IgE allergy testing (RAST)
- Skin prick testign
What is the management for Cow’s milk protein allergy
Trial elimination of all cow’s milk for 2-4 weeks
- Clear improvement → home reintroduction into mother’s/infant’s diet to confirm diagnosis
Diagnosis confirmed:
Exclude all cow’s milk from diet (at least 6 months) form both mother and infant until 9-12 months older
- Consider supplements for breastfeeding mothers who must stop drinking milk: 1000mg calcium, 10ug vit D
- Replace milk-based formula with hypoallergenic infant formula - extensively hydrolysed formula/amino acid formula
What is the follow up for CMPA
Regularly monitor growth
Re-evaluate every 6-12 months to assess for tolerance - involved re-introduction
Give examples of cow’s milk substitutes
- Extensively hydrolysed formula (eHF)
a. Whey or Casein-based
b. use when breastfeeding stops, until 12 months of age and at least for 6 months - Amino acid formula (AAF)
Reserved for children with severe symptoms or Hx of anaphylaxis, those who have ongoing symptoms with eHFs or symptoms that do not respond to maternal avoidance
Do NOT recommend milk alternatives as they have poor nutritional value
Lactose-free still contains CMP - do not recommend
How should milk be re-introduced into children with CMPA
Milk ladder
1. Cookie/biscuit
2. Muffin
3. Pancake
4. Cheese
5. Yoghurt
6. Milk
+ oral antihistamines at home in case
Symptoms return → cow’s milk-free diet → re-evaluated after 6-12 months
What are the complications of CMPA
Food protein induced enterocolitis syndrome (FPIES)
Cow’s milk induced enteropathy
Proctocolitis
Eosinophilic oesophagitis
Heiner’s syndrome: milk-induced pulmonary disease
Stress and anxiety
Reduced QOL
Faltering growth
Cross-reactivity with other mammalian milks
Anaphylaxis
What is the prognosis for CMPA
IgE: >50% develop tolerance within a year, 80% by 16yo
Non-IgE: faster resolution rate, almost100% tolerant after a year
