Nutritional Management of Cow’s Milk Allergy (CMA) Croydon University Hospital Dietetic Department

Outline Types of CMA Cow’s milk allergy vs. lactose intolerance Nutritional considerations in diagnosing CMA Formula and alternative milk choice Age-appropriate milk substitutes Dietetic management of CMA Meeting calcium requirements on a milk-free diet

Types of CMA

Is this cow’s milk allergy? Case Study - Mira 10 weeks old Fed with Cow & Gate standard from birth Developed symptoms of reflux from 4 weeks of age  10 episodes of reflux a day Parents changed formula to Cow & Gate Comfort but symptoms have not improved Mira is very unsettled between feeds and it causing lots of anxiety for parents Mira is growing well and her weight it tracking 9th centile Is this cow’s milk allergy?

GOR or CMA Symptoms of gastro-oesophageal reflux (GOR) Symptoms suggestive of CMA in infants with GOR Unexplained feeding difficulties (refusing to feed, gagging or choking)  Blood in stool Vomiting   Chronic diarrhoea Regurgitation Infants and children with, or at high risk of atopy Distressed behaviour Infants whose GOR and/or GORD has not responded to the initial management Faltering growth Chronic cough Hoarseness  Single episode of pneumonia    Gastro-oesophageal reflux disease in children and young people: diagnosis and management, NICE guidelines, 2015

Management of GOR Use the following step-cared approach: Review the feeding history, Then reduce the feed volumes only if excessive for the infant's weight Then offer a trial of smaller, more frequent feeds (while maintaining an appropriate total daily amount of milk) (150ml/kg), unless the feeds are already small and frequent, Then offer a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum). If the stepped-care approach is unsuccessful stop the thickened formula and offer alginate therapy Simple reflux Gastro-oesophageal reflux disease in children and young people: diagnosis and management, NICE guidelines, 2015

OTC Thickened Formulas Thickening agent: Carob bean gum Thickening agent: corn starch Suitable for vegetarians Halal approved Trial for 1-2 weeks Do not prescribe

Is this CMA or lactose intolerance? Case Study - Leo 3 months old Exclusively breastfed since birth Developed symptoms of frequent, loose stools 3 weeks ago Leo’s weight has reduced from 50th to the 25th centile since birth Mum says that Leo is experiencing a lot of “pain” Mum also reports that 3 year old sister Skye had “milk intolerance as a baby” Is this CMA or lactose intolerance?

CMA or Lactose Intolerance Primary lactose intolerance Secondary lactose intolerance Common age of onset Infancy, usually between 3-6 months (rarely after 12 months) Rarely before 2-5 years Infancy and early childhood Prognosis IgE-mediated allergy usually resolves by 5 years Non-IgE-mediated allergy usually resolves sooner Usually lifelong Usually resolves in 2-4 weeks Dietary management Cow’s milk protein exclusion Low lactose diet Lactose-free diet for 2-4 weeks

Allergy-focused clinical history An individual and family history of atopic disease (such as asthma, eczema or allergic rhinitis) or food allergy is more likely in food allergy Allergy-focused clinical history (NICE CG116) Details of any foods that are avoided and the reasons why  An assessment of presenting symptoms and other symptoms that may be associated with food allergy including questions about age at symptom onset, speed of onset, duration of symptoms, severity of reaction, frequency of occurrence, setting of reaction, reproducibility of symptoms  Cultural and religious factors that affect the foods they eat   Who has raised the concern and suspects the food allergy   What the suspected allergen is   The child or young person's feeding history, including age weaned commenced, whether type of feeding,  details of any previous treatment and the response to this, any response to the elimination and reintroduction of foods NICE Food Allergy in Under 19s Assessment and Diagnosis CG116 NICE Quality standard: Food Allergy 2016 [QS118] statement 1 

Dietary Management of Lactose Intolerance Babies under 1 year Can usually continue with their current milk (breast milk or formula) as symptoms should resolve in a few weeks OTC Lactose-free formulas are available but only need to be considered in higher-risk cases, such as infants younger than 3 months, or faltering growth Children over 1 year May require long-term low lactose diet if primary lactose intolerance OTC Lactose-free milk and dairy products Calcium-enriched alternative milks (non-organic soya, oat, coconut & nuts milks) Refer parents to NHS choices: Lactose intolerance for more information Lactose intolerance should be considered where patients present only with typical GI symptoms Refer children with primary lactose intolerance to the Dietitian to advise on the nutritional adequacy of the diet

OTC Lactose-Free Products Do not prescribe

Investigation of Suspected CMA in Exclusively Breastfed Infants Encourage Breastfeeding: Refer to breastfeeding advisor for support  if required Babies under 6 months (weaning not commenced) Trial a maternal cow’s milk protein exclusion for 4-6 weeks followed by challenge to confirm diagnosis Recommend OTC supplement for breastfeeding that contains 1000mg calcium and 10mcg Vitamin D. e.g. Pregnacare Incorporate OTC calcium-enriched, non-organic dairy alternatives into the maternal diet Babies over 6 months (or symptom onset with weaning) Trial a dietary cow’s milk exclusion for 2-6 weeks followed by challenge to confirm diagnosis Continue with breastfeeding and usual maternal diet Incorporate OTC calcium-enriched, non-organic dairy alternatives into the diet Patient information sheets are available from Allergy UK https://www.allergyuk.org/milk-allergy/milk-allergy and BDA https://www.bda.uk.com/foodfacts/milkallergy.pdf 

Investigation of Suspected CMA in Formula Infants Formula and mixed-fed infants: Babies under 1 year Trial an extensively hydrolysed formula for a period of 2 – 6 weeks followed by challenge to confirm diagnosis If no improvement in symptoms following trial consider other causes Babies over 1 year (rare) Trial a dietary cow’s milk exclusion with for 2-6 weeks followed by challenge to confirm diagnosis Recommend an OTC calcium-enriched, non-organic dairy alternative NICE Food Allergy in Under 19s Assessment and Diagnosis CG116 NICE Quality standard: Food Allergy 2016 [QS118] statement 3

Choice of Formula in CMA Extensively Hydrolysed Formula (eHF) should be used as first-line in infants up to 6 months of age If a baby does not settle on one EHF they may settle with another EHF with a different composition Patients unresponsive or partially responsive to a trial of two EHFs can be progressed to Amino Acid Formula Amino Acid Formula AAF should only be prescribed for severe IgE-mediated allergy Anaphylaxis There is emerging evidence that tolerance to cow’s milk occurs sooner on sustained exposure to eHF Berni Canani R. et all. . ISME J. 2016 Mar;10(3):742-50., Berni Canani R et all. J Pediatr. 2013 Sep;163(3):771-7. Over the counter (OTC ) Soya based formula (e.g. Wysoy®) can only be used first line from 6 months onwards Concomitant soya protein allergy only affects 1 in10 infants with CMA (BSACI 2014) Do not routinely prescribe eHF or AAF for children over 1 year of age 

Choice of Formula in infants <1y Caesin-based eHF Lactose-free Contains Lactose Whey-based eHF Contains MCT AAF First Line Second Line First line: should be initiated in primary care Second line: only initiate in primary care in severe CMA or Mild to moderate CMA unresponsive or partially responsive to EHF Not recommended: soya formula in babies under 6 month partially hydrolysed formulas: comfort formulas/SMA HA All children under 5 years of age require OTC vitamin D supplements unless they are taking > 500ml infant formula per day. 

Confirming Diagnosis of CMA Challenge to confirm the diagnosis of non-IgE-mediated cows’ milk allergy (with no history of severe delayed reactions) Challenge in Exclusively breast fed infants If symptoms improve on a milk free diet, the mother should revert to a normal diet including foods containing cows’ milk protein over a period of 1 week If symptoms do not return then the diagnosis is not CMA, or the CMA has been outgrown If symptoms return, exclude CMP from maternal diet again. If symptoms settle, this confirms the diagnosis of CMA. Challenge in Formula fed/mixed fed infants If symptoms improve on a milk free diet, reintroduce cows’ milk formula after 4-6 weeks If symptoms do not return then the diagnosis is not CMA If symptoms return, restart eHF again. If symptoms then settle, this confirms a diagnosis of CMA.  Suspected IgE-mediated cow’s milk allergy Positive milk RAST:  probable CMA – no challenge required Negative milk RAST: likely non-IgE-mediated CMA – challenge required. Confirmed CMA Refer to the Paediatric Dietitian NICE Food Allergy in Under 19s Assessment and Diagnosis CG116 NICE Quality standard: Food Allergy 2016 [QS118] statement 3

MAP Home Challenge To CONFIRM THE DIAGNOSIS of Mild to Moderate Non-IgE Cow’s Milk Allergy after the milk exclusion Symptoms suggestive of CMA based on self-reports vary, and only about 1 in 3 children presenting with symptoms is confirmed to be CMA (BSACI 2014)

Dietetic Management of Confirmed CMA Strict avoidance of cows’ milk protein for at least 6 months or until the child is 9-12 months old Ensure optimal nutrition Milk-free weaning group (pilot) Enables parents of babies <1 year to receive dietary advice promptly 2h interactive group session to provide comprehensive milk-free weaning advice for babies with confirmed CMA Fast-track appointment ~1 month following attendance at group Access to fortnightly Fast-Track Dietetic review clinics How to refer:  Confirm diagnosis of CMA and refer to the Peadiatric Dietitian  as per existing referral pathway and local guidelines 

Practical advice on what foods and drinks to avoid, how to interpret food labels and alternative sources of nutrition to ensure adequate nutritional intake  Ensure weaning progression  Provide guidance on nutritional adequacy of diet  Dairy Free

Dietary avoidance of CMP Butter, butter oil, buttermilk Casein, caseinates, hydrolysed casein, sodium caseinate, calcium caseinate Cheese Cow’s milk: fresh, UHT, evaporated, condensed, dried, powdered Cream, artificial cream, ice cream Curd, ghee Lactalbumin, lactoglobulin Margarine Milk solids, non-fat milk solids, milk sugar, milk protein, milk powder, skimmed milk powder Whey, hydrolysed whey, whey powder, whey syrup sweetener Yogurt, fromage frais

The Milk Ladder Dietetic Review: Assess suitability of a home milk challenge to establish tolerance Usually following 6 months of cow's milk protein exclusion

COWS MILK ALLERGY Confirmed Cows Milk Allergy- Paediatric Pathway for CUH Dietetic Service Referral Triage Process Breast Fed Baby Formula  Fed Baby-  under 1 year  Formula Fed Baby-  over 1 year Urgent Clinic Initial Clinic Appointment COWS MILK ALLERGY  Invitation to Milk Free Weaning Group (pilot) Routine Initial Clinic Appointment Fast-Track review Appointment Routine review Appointment Further review appointments Discharge

Is this an age-appropriate milk intake? Case Study- Niamh 15 month old girl  Weight is tracking 50th- 75th centile CMA diagnosed at 4 months Mum is requesting 4 tins of Aptamil Pepti 2 a month Mum is concerned that Niamh is a very fussy eater BNO for 5 days with abdominal pain and straining  Is this an age-appropriate milk intake?

Dietary reference values, COMA 1991 Calcium Requirements Group Age (years) Age (years) Calcium (mg) per day Calcium stars per day Infants Under 1 525 9 Stars Children 1-3 4-6 7-10 350 450 550 6 Stars 7 ½ Stars Adolescents 11-18 800 for girls 1000 for boys 13 Stars 17 Stars Adults 19+ 700 11 Stars Dietary reference values, COMA 1991

Appropriate Milk Intake Beyond 1y Milk is only required to meet calcium requirements Calcium requirements reduce in the 2nd year of life to 350 mg Encourage 3 servings of calcium rich products per day (including all milk drinks) to meet requirements   Milk drinks should now be only 100-120ml (3-4 oz) and offered from a cup They should be limited to three times a day or less if cheese and yoghurt are eaten regularly. Milk intakes >500ml in children >1 year increase the risk of: Appetite suppression/fussy eating Compromised nutritional intake/dietary imbalance Iron deficiency  Constipation  Childhood obesity  Niamh is being prescribed 4 x 400g tins of Aptamil Pepti 2 every 28 days, this equals 838ml/day of formula Maslin et al, 2015 Department of Health (2012) National Diet and Nutrition Survey: Headline Results from Years 1, 2 and 3 (combined) of the Rolling Programme 2008/09 – 2010/11

Calcium Content of Different Milks % RNI for Ca in 1-3 year olds/100ml * Higher Energy formula for children >1y– do not routinely prescribe. Seek advice from the Dietitian

Cow’s milk vs. soya milk Energy (kcal) CHO (g) Sugars (g) Fat (g) Protein (g) Cal (mg) B2 (mg) B12 (ug) Vit D (ug) Cow’s milk (whole) 66 4.5 3.9 3.3 120 0.23 0.9 Trace Cow’s milk (semi) 50 4.8 1.8 3.6 124 0.22 0.8 Alpro Soy milk (Growing Up) 64 8.3 2.5 2.2  0.21  0.38  1.5

Calcium fortified products Quantity Calcium (mg) Stars (1 star= 60mg) Calcium enriched, non-organic milk alternatives e.g. Oat/ Soya/Coconut etc. 200ml 240 **** Soya bean curd/ tofu (only if set with calcium chloride (E509) or calcium sulphate (E516), not nigari) 60g 200 *** Calcium fortified soya yoghurt/ dessert/ custard 125g 150 ** Calcium enriched orange juice 250ml 195 Calcium fortified infant cereals 30g serving 137 Calcium fortified instant hot oat cereal 1 tbsp. dry cereal (15g) Calcium- fortified bread 1 slice (40g) 191 * To ***

Other non-dairy sources of Calcium Quantity Calcium (mg) Stars (1 star= 60mg) Sardines (with bones) ½ tin(60g) 258 **** Pilchards (with bones) 1 Serving (60g) 150 ** Tinned Salmon (with bones) ½ tin(52g) 47 * Whitebait 1 small portion (50g) 130 ******* Scampi in breadcrumbs 6 pieces (90g) 190 *** White bread 2 large slices (100g) 100 Wholemeal bread 54 Pitta bread/ chapatti 1 portion (65g) 60 Orange 1 medium (120g) 75 Broccoli, boiled 2 spears (85g) 34 Spring greens 1 serving (75g) 56

Management of Excessive Milk Intake in Children >1y Reduce milk intake <300ml Stop night time milk Stop bottles and offer milk in a beaker/cup Educate on optimum dietary Ca sources Educate on risks of high milk intake Further advice: Health Visiting Service British Dietetic Association Calcium food fact sheet Infant & Toddler Forum factsheets: 10 steps for healthy toddlers (includes advice on portion sizes) Fussy eating and faddy eating factsheets

Suggested Quantities of Formula To Prescribe To avoid waste prescribe maximum of 1 week supply (2-3 tins) until tolerance and compliance is established. Age of child Average total volume feed per day (estimated) Number of tins required for 28 days complete nutrition Department of Health recommendations (based on average weight for age) Under 6 months 1000mls 10 x 400g (or 450g) Exclusively formula fed based on 150mls/kg/day of a normal concentrated formula 6-9 months 800mls 8 x 400g (or 450g) Requiring less formula with increased weaning and solid intake 9-12 months 600mls 6 x 400g (or 450g) Over 12 300mls Should no longer routinely prescribe, unless under advice of specialist or dietician. Generally infants of this age require 300ml of milk or milk substitute per day

Summary Confirmed CMA in infants under 1 year eHF When to Prescribe Confirmed CMA in infants under 1 year eHF Investigation of suspected CMA in infants under 1 year (trial only) When to recommend OTC products CMA in children over 1 year Calcium-enriched alternative milks (non-organic) Lactose intolerance Lactose-free formula in infants under 1 year Lactose-free milks in children over 1 year Thickened formulas for GOR When to refer to the Dietitian Confirmed CMA Primary lactose intolerance