PRESENTATION AND MANAGEMENT OF GASTRO-OESOPHAGEAL REFLUX (GOR) and COWS MILK ALLERGY (CMA) 1. Child presents with history of non-forceful vomiting in first 3 months 2. Take a full allergy-focused clinical history using "Reflux and Cow's Milk Allergy Assessment Form“ (form currently being updated) Health Visitor responsibility Uncomplicated infant: Regurgitation (often asymptomatic) Weigh infant & record weight Reassurance & practical advice Avoid over-feeding. Burp (wind) baby frequently before, during and after feeding. Keep baby upright after feeds for at least 30 minutes. Avoid nappies tight around the abdomen. Avoid laying flat - tip the cot, nappy changing etc. Avoid exposure to smoke e.g. tobacco/other (irritant). Improved (By 2 weeks) Improvement Continue for 3 months or until weaning is established Not responding Consider 2 week trial of over the counter (OTC) feed thickener e.g. Carobel® or OTC comfort / anti-reflux formula Not responding Refer to GP Presentation and Management of Gastro Oesophageal Reflux Disease (GORD) GP responsibility Complicated infant: Regurgitation (with symptoms) Weigh infant & record weight 4 week trial of ranitidine if symptoms mild. If severe, discontinue and trial omeprazole See Box 1 for doses Improved Continue for 3 months or until weaning is established, adjust dose to increasing weight Refer to “reflux and Cow’s Milk Allergy Assessment Form” (form currently being updated). Predominately upper GI symptoms without red flags can be treated as GORD. Red flags Jet black stools, Bilious vomit, eczema (less than 3months old), persistent blood/mucus in stools, faltering growth. Refer (consider same day) to Secondary Care Not responding Consider CMA- NB 40% of children with moderate- severe GORD have CMA Box 1: Medication doses: Ranitidine dose: Neonate: 2mg/kg 3 times daily but absorption unreliable; max. 3mg/kg 3 times daily. 1 to 6 months: 1mg/kg 3 times daily, max 3mg/kg 3 times daily. 6 months to 3 years: 2 to 4mg/kg twice daily. Omeprazole dose: Neonate: 700mcg/kg once daily, increased if necessary after 7 to 14 days to 1.4mg/kg (some neonates may require up to 2.8mg/kg once daily). 1 month to 2 years: 700mcg/kg once daily, increased to 3mg/kg (max 20mg) once daily. Body weight between 10 and 20kg: 10mg once daily increased if necessary to 20mg once daily (in severe reflux oesophagitis, max. 12 weeks at higher dose). Dissolvable Losec MUPS or if weaned capsules can be opened and the contents mixed with fruit juice or yogurt. Presentation of Cow’s Milk Allergy (CMA) Adapted from iMAP guidelines ‘Presentation of Suspected Cow’s Milk Allergy (CMA) in the 1st Year of Life’ (Dec 2016). Guideline for Primary Care and ‘First Contact’ Clinicians. Having taken an Allergy focused Clinical History and Physically Examined. Mild to Moderate Non IgE mediated CMA Mostly 2 to 72 hrs. after ingestion of Cow’s Milk Protein (CMP) Formula fed, exclusively breast fed or at onset of mixed feeding Usually several of these symptoms will be present Treatment resistance e.g. to atopic dermatitis or reflux, increases likelihood of allergy Gastrointestinal Irritability - ‘Colic’ Vomiting - ‘Reflux’ - GORD Food refusal or aversion Diarrhoea-like stools - loose and/or more frequent Constipation – especially soft stools, with excessive straining Abdominal discomfort, painful flatus Blood and/or mucus in stools in an otherwise well infant Skin Pruritus (itching), Erythema (flushing) Non-specific rashes Moderate persistent atopic dermatitis Severe Non IgE mediated CMA Mostly 2 to 72 hrs. after ingestion of Cow’s Milk Protein (CMP) Formula fed, exclusively breast fed or at onset of mixed feeding One or more of these Severe and Persisting symptoms: Gastrointestinal Diarrhoea, vomiting, abdominal pain, food refusal or food aversion, significant blood and/or mucus in stools, irregular or uncomfortable stools +/- Faltering growth Skin Severe atopic dermatitis +/- Faltering Growth Mild to Moderate IgE mediated CMA Mostly within minutes (may be up to 2 hrs.) after ingestion of Cow’s Milk Protein (CMP) Mostly formula fed or at onset of mixed feeding One or more of these symptoms: Skin – one or more usually present Acute pruritus, erythema, urticaria, angioedema Acute ‘flaring’ of persisting atopic dermatitis Gastrointestinal Vomiting, diarrhoea, abdominal pain/colic Respiratory Acute rhinitis and/or conjunctivitis Cow’s Milk Free Diet Initial 1st. Choice Extensively Hydrolysed Formula - eHF*1 Soy may be used in some settings if not sensitised Or- Advise exclusively breast feeding mother to exclude all Cow’s Milk Protein from her own diet and to take daily supplements of calcium and Vit D*3 Initial IgE testing needed If diagnosis confirmed (which may require a Supervised Challenge in a minority of cases) : Follow up with serial IgE testing and later Planned Challenge to test for acquired tolerance Cow’s Milk Free Diet Amino Acid Formula AAF*2 Or- Advise exclusively breast feeding mother to exclude all Cows Milk Protein from her own diet and to take daily supplements of calcium and Vit D*3 Severe IgE CMA ANAPHYLAXIS Immediate reaction with severe respiratory and/or CVS signs and symptoms. (Rarely a severe gastrointestinal presentation) Cow’s Milk Free Diet Extensively Hydrolysed Formula – eHF*1 Or – Advise exclusively breast feeding mother to exclude all CMP from her own diet and to take daily Calcium and Vit D*4 See Management Algorithm (Page 2) Ensure: Urgent referral to secondary Care Emergency Treatment and Admission Refer to West Essex Community Allergy Service *1 eHF e.g .Similac Alimentum *2 AAF e.g. SMA Alfamino

Management of Mild to Moderate Non-IgE Cow’s Milk Allergy (CMA) Adapted from the iMAP guideline for Primary Care and ‘First Contact’ Clinicians. (no initial IgE Skin Prick Tests or Serum Specific IgE Assays necessary) Exclusively Breastfeeding *3 Formula Feeding or ‘Mixed Feeding’ (Breast and Formula)*3 Strict exclusion of cow’s milk containing foods from maternal diet and maternal daily supplements of calcium and Vit D*4. Refer mother to EPUT adult dietitian- a maternal substitute milk should be advised. If atopic dermatitis or more severe gut symptoms – consider egg avoidance as well. An agreed Elimination Trial of up to 4 weeks with a minimum of 2 weeks No Clear Improvement Clear Improvement- need to confirm Diagnosis Strict cow’s milk protein free diet Formula feeding only- Trial of an Extensively Hydrolysed Formula (eHF) Mixed feeding- If symptoms only with introduction of top-up feeds Replace with eHF top ups. Mother can continue to consume cow’s milk containing foods in her diet. If weaned, may need advice and support from dietitian. An agreed Elimination Trial of up to 4 weeks- with a minimum of 2 weeks Clear Improvement - need to confirm Diagnosis No Clear Improvement But CMA still suspected: Consider excluding other maternal foods e.g. egg CMA no longer suspected: Return to usual maternal diet. Consider referral to local general paediatric service if symptoms persist Home Reintroduction: Mother to revert to normal diet containing cow’s milk foods over period of 1 week *5- to be done usually between 2 to 4 weeks of starting Elimination Trial Home Reintroduction: Using cow’s milk formula*5 To be done usually between 2 to 4 weeks of starting Elimination Trial But- CMA still suspected: Consider initiating a trial of an Amino Acid Formula (AAF) CMA no longer suspected: Unrestricted diet again. Consider referral to local general paediatric service if symptoms persist Refer to West Essex Community Allergy Service No return of symptoms NOT CMA - normal feeding Return of Symptoms Return of symptoms No return of symptoms NOT CMA- normal feeding Refer to West Essex Community Allergy Service Exclude cow’s milk containing foods from maternal diet again. If symptoms clearly improve: CMA NOW CONFIRMED If top up formula feeds should later be needed- eHF may well be tolerated: If not replace with AAF Return to the eHF again If symptoms clearly improve: CMA NOW CONFIRMED Symptoms do not settle Symptoms do not settle Cow’s milk free diet until 9 to 12 months of age and for at least 6 months – with support of dietitian. A planned Reintroduction or Supervised Challenge is then needed to determine if tolerance has been acquired. Performing a Reintroduction versus a Supervised Challenge is dependent on the following: Does the child have Current Atopic Dermatitis or ANY history at ANY time of immediate onset symptoms? Refer to West Essex Community Allergy Service Cow’s milk free diet until 9 to 12 months of age and for at least 6 months – with support of dietitian. A planned Reintroduction or Supervised Challenge is then needed to determine if tolerance has been acquired. Performing a Reintroduction versus a Supervised Challenge is dependent on the following: Does the child have Current Atopic Dermatitis or ANY history at ANY time of immediate onset symptoms? Refer to West Essex Community Allergy Service No Current Atopic Dermatitis And no history at any time of immediate onset symptoms (No need to check Serum Specific IgE or perform Skin Prick Test) Reintroduction at Home – using a MILK LADDER*6 and milk ladder recipes*7 To test for Acquired Tolerance History of immediate onset symptoms at any time Serum Specific IgE or Skin Prick Test needed Negative Positive or Liaise with local Allergy Service Tests not available Re: Challenge Current Atopic Dermatitis   Check Serum Specific IgE or Skin Prick Test to cow’s milk Negative Positive And still no history at any stage of immediate onset symptoms Reintroduction at Home- using a MILK LADDER*6 and milk ladder recipes*7 To test for Acquired Tolerance Refer to secondary care (A Supervised Challenge may be needed) Guidance for prescribing infant formula 1st Line infant formula options: Extensively Hydrolysed Formula (eHF): Similac Alimentum Amino Acid Formula (AAF): SMA Alfamino Appropriate Quantities Under 6months: 13 x400g; 12 x 450g or 6 x 900g tins 6-12months: 7-13 x 400/450g or 3-6 x 900g tins 12months - 2 years: 7 x 400g; 6 x 450g or 3 x 900g tins Prescribe 1-2 tins initially to check tolerance AAF/ eHF should not be prescribed after 2yrs of age, unless recommended and under review by a dietitian*8 Do not prescribe soya/ lactose free/ goats milk or anti reflux formula’s. Information leaflets to provide to parents/ carer *3 Provide iMAP initial fact sheet *4 Provide Milk free diet advice *5 Provide iMAP Milk challenge *6 Provide iMAP Milk Ladder *7 Provide iMAP Milk ladder recipes *8 Provide Suitable milks for over 2years Produced by WECCG Medicines Optimisation Team October 2017. Agreed at WECCG Medicine’s Optimisation Board October 2017. Review October 2019.