Cows milk protein intolerance Flashcards
What is the prevalence of Cow’s milk protein intolerance/allergy (CMPI/CMPA)?
CMPI/CMPA occurs in about 3-6% of all children and typically presents in the first 3 months of life.
What are the differences between CMPA and CMPI?
CMPA refers to immediate, IgE mediated reactions. CMPI refers to mild-moderate delayed, non-IgE mediated reactions.
What are common features of CMPI/CMPA?
Features include regurgitation, vomiting, diarrhoea, urticaria, atopic eczema, ‘colic’ symptoms (irritability, crying), wheeze, chronic cough, and rarely, angioedema and anaphylaxis.
What diagnostic methods are used for CMPI/CMPA?
Diagnosis may be clinical (e.g., improvement after cow’s milk protein elimination), skin prick/patch testing, and measurement of total and specific IgE (RAST) for cow’s milk protein.
What is the first-line management for formula-fed infants with CMPI/CMPA?
The first-line replacement formula for mild-moderate symptoms in formula-fed infants is extensive hydrolysed formula (eHF).
What formula is recommended for severe cases of CMPA or no response to eHF?
For severe CMPA or no response to eHF, an amino acid-based formula (AAF) is recommended.
How is CMPI/CMPA managed in breastfed infants?
Management involves continuing breastfeeding, eliminating cow’s milk protein from the maternal diet, and possibly supplementing with calcium.
What is the prognosis for children with CMPI/CMPA?
Most children with CMPI resolve the intolerance by age 3, while about 55% of those with IgE mediated intolerance resolve it by age 5. A challenge test may be performed in a hospital setting due to the risk of anaphylaxis.
summarise
Cow’s milk protein intolerance/allergy
Cow’s milk protein intolerance/allergy (CMPI/CMPA) occurs in around 3-6% of all children and typically presents in the first 3 months of life in formula-fed infants, although rarely it is seen in exclusively breastfed infants.
Both immediate (IgE mediated) and delayed (non-IgE mediated) reactions are seen. The term CMPA is usually used for immediate reactions and CMPI for mild-moderate delayed reactions.
Features
regurgitation and vomiting
diarrhoea
urticaria, atopic eczema
‘colic’ symptoms: irritability, crying
wheeze, chronic cough
rarely angioedema and anaphylaxis may occur
Diagnosis is often clinical (e.g. improvement with cow’s milk protein elimination). Investigations include:
skin prick/patch testing
total IgE and specific IgE (RAST) for cow’s milk protein
Management
If the symptoms are severe (e.g. failure to thrive) refer to a paediatrician.
Management if formula-fed
extensive hydrolysed formula (eHF) milk is the first-line replacement formula for infants with mild-moderate symptoms
amino acid-based formula (AAF) in infants with severe CMPA or if no response to eHF
around 10% of infants are also intolerant to soya milk
Management if breastfed
continue breastfeeding
eliminate cow’s milk protein from maternal diet. Consider prescribing calcium supplements for breastfeeding mothers whose babies have, or are suspected to have, CMPI, to prevent deficiency whilst they exclude dairy from their diet
use eHF milk when breastfeeding stops, until 12 months of age and at least for 6 months
Prognosis
CMPI usually resolves in most children
in children with IgE mediated intolerance around 55% will be milk tolerant by the age of 5 years
in children with non-IgE mediated intolerance most children will be milk tolerant by the age of 3 years
a challenge is often performed in the hospital setting as anaphylaxis can occur.
A 12-week-old baby is bought to his GP by his mother. She reports he has had regurgitation and vomiting after most feeds and ongoing diarrhoea which contains significant amounts of mucus. She is particularly concerned about his crying, as she finds it very hard to settle him and she has noted that he often pulls his legs up to his chest during these episodes.
He was born at full term and was a healthy weight at birth (although he has recently trailed off of his centile). He is formula-fed. Other than his apparent gastrointestinal problems, his only past medical history is some eczema managed with emollients.
What is the next step in management?
Creon
Gaviscon
Omeprazole
Pyloromyotomy
Trial of extensively hydrolysed formula
Trial of extensively hydrolysed formula
If a formula-fed baby is suspected of having mild-moderate cow’s milk protein intolerance then a extensive hydrolysed formula should be tried
Trial of extensively hydrolysed formula is the best option here as the baby’s symptoms of vomiting mucus stool and ‘colic’-type episodes fit most with cow’s milk protein allergy. If the extensively hydrolysed formula resolves the symptoms then this essentially confirms this diagnosis and must be continued instead of normal formula milk. If it does not, amino acid-based formula (AAF) may be trialled and/or further investigations may be required.
Creon would be an option if the symptoms were due to pancreatic insufficiency causing malabsorption (such as in cystic fibrosis) but, other than diarrhoea, there are no other symptoms to suggest this. This would not, therefore, be the next appropriate step in management.
Gaviscon would be a management option for a baby suffering from gastroesophageal reflux disorder however the mucus stools and diarrhoea make this a less likely diagnosis and thus not the best next step in management.
Omeprazole would also be a management option for a baby suffering from gastroesophageal reflux disorder however the mucus stools and diarrhoea make this a less likely diagnosis and thus not the best next step in management.
Pyloromyotomy would be a management option for an infant suffering from pyloric stenosis however this would generally present at a younger age and with forceful vomiting (often of curdled milk), weight loss, reduced bowel movements and significant dehydration so is not a likely diagnosis.
Which one of the following statements regarding cow’s milk protein intolerance/allergy in infants is true?
An adrenaline pen should be given to all parents
It is more common in breastfed infants
Green-coloured stools are common
Around 1-2% of infants are affected
The majority of cases resolve before the age of 5 years
The majority of cases resolve before the age of 5 years
A 5-week-old boy is brought into the GP by his mother with diarrhoea and vomiting for the past 4 days. He also has a new rash that is irritating him and has developed a runny nose. There is no history of any weight loss, pyrexia, or other family members being unwell.
On further questioning, she reports that she has tried to wean him from breast to bottle this week as she is going away with work in 3 weeks time and is anxious about him not feeding well if there is a sudden change. The GP suspects that the infant may have cow’s milk protein intolerance.
What is the next most appropriate feed to trial in this infant?
Amino acid based formula
Extensively hydrolysed formula
High-protein formula
Lactose free formula
Soy based formula
Extensively hydrolysed formula
If a formula-fed baby is suspected of having mild-moderate cow’s milk protein intolerance then a extensive hydrolysed formula should be tried
This infant is suspected to have a mild-moderate cow’s milk protein intolerance - he is having frequent regurgitations, diarrhoea, and has recently been swapped to a formula feed. If he had more severe features, such as failure to thrive, severe atopic dermatitis, or laryngo-oedema: this would be suggestive of severe cow’s milk protein intolerance. With the GP’s suspicion, he should be trialled on an extensively hydrolysed formula. This formula is tolerated by 90% of infants with cow’s milk protein intolerance. In this formula, the proteins that trigger allergy are hydrolysed into peptides which make them less allergenic.
Amino acid-based formula is appropriate for infants with severe cow’s milk protein intolerance. This formula is less palatable, however, it is appropriate for those with severe intolerance as it is composed of free amino acids only.
High protein formula has been used to manage pre-term infants. This is becoming an increasingly specialised use as there are increasing studies showing that high-protein feed (even in prematurity) is associated with increased long-term obesity risk.
Lactose-free formula would be appropriate if the child was considered to be lactose intolerant. The features pointing towards cow’s milk protein intolerance are the rash and runny nose. Infants with lactose intolerance will usually have GI symptoms only.
Soy based formula is not typically recommended for infants due to its high phyto-oestrogen content which could potentially give hormonal side effects.
Charlie is a 7 month old baby boy who presents to you with poor weight gain (50th to 10th centile), on examination he has an erythematous, blanching rash over his abdomen, colicky abdominal pain and vomiting after feeds. He has been breast feeding with top ups of ‘Aptamil’ formula. What is the most likely diagnosis?
Pyloric stenosis
Eczema
Infantile colic
Cows’ milk protein intolerance
Reflux
Cows’ milk protein intolerance
The correct answer is cows’ milk protein intolerance.
The following clues in the history would suggest the diagnosis of cows’ milk protein intolerance:
Multi-system involvement
7 months would suggest the new introduction of top up feeds which correlates with the symptoms
Faltering growth along with the multi-system involvement would suggest cows’ milk protein intolerance
Charlie is older than the classical age of presentation for pyloric stenosis (2 to 8 weeks very rare above 6 months)
The presentation is unusual for eczema, infantile colic and reflux due to the multi-system involvement in the history making cows’ milk protein intolerance more likely.
References
Cows’ milk protein allergy in children - NICE CKS http://cks.nice.org.uk/cows-milk-protein-allergy-in-children#!diagnosissub/-617759
Infantile Hypertrophic Pyloric Stenosis - Patient.co.uk - http://patient.info/doctor/infantile-hypertrophic-pyloric-stenosis
buzz words
poor weight gain
new erythematous, blanching rash over abdomen
colicky abdominal pain
vomiting after feeds
breast feeding
top ups of ‘Aptamil’ formula fed/bottle feeds
diarrhoea and vomiting
runny nose
<5 years
regurgitation and vomiting after most feeds
ongoing diarrhoea which contains significant amounts of mucus.
crying
pulls legs up to chest during these episodes.
