LET US DISCUSS KALPESH DIXIT 7/7/10

EXPERIENCE 1 AB, 5 DAYS OLD BLEEDING PR BREAST FED BABY 5-10 STOOLS PER DAY. UNSETTLED EXAMINATION NORMAL HAS REGAINED BIRTH WEIGHT ??? CAUSE

EXPERIENCE 2 6 WEEKS OLD BABY CRYING OFTEN EXPLOSIVE DIARRHOEA HV CHANGES MILK- SMA C&G APTAMIL MUM DECIDES TO TRY WYSOY NO RESPONSE VISITS GP EXAMINATION NORMAL ??? WHAT TO DO?

EXPERIENCE 3 3 MONTH OLD CRYING ARCHING AND VOMITING UNSETTLED FOR PROLONGED PERIODS CENTILES DROPPING POOR SLEEP FOR ALL EXAMINATION NORMAL ?? HOW WILL YOU PROCEED??

EXPERIENCE 4 6 MONTH OLD BABY SEVERE ECZEMA TRIED ALL POSSIBLE CREAMS, STEROIDS, ANTIFUNGAL AND ANTIBACTERIAL CREAMS REFERRAL TO DERMATOLOGY AWAITING 12-15 WEEK PERIOD FOR APPT. WHAT TO DO IN THE INTERIM?

Cows’ milk protein allergy – definition and incidence What is CMPA? "...an adverse reaction to cows' milk resulting from an immunologic hypersensitivity to one or more milk proteins“1 How many infants are affected? Most common food allergy in infancy Affects an estimated 2-7.5% of UK births1 – 5% would be 38,000 babies/year (imagine filling the 02 arena twice over) Generally resolves by 1-3 years of age2 1 Hill DJ et al. J Pediatr 1986; 109; 270-276. 2. Høst A. Ann Allergy Asthma Immunol 2002; 89 (6 Suppl 1): 33-37.

Allergy or intolerance? Hypersensitivity Involving the immune system Not involving the immune system Food allergy (allergic hypersensitivity) Food intolerance (non-allergic hypersensitivity) IgE mediated allergy Non-IgE mediated allergy Go to symptoms Adapted from Johansson SGO et al. 2004.

Allergic symptoms Body system affected Symptoms Oral tract • Itching and redness of mouth and lips Respiratory tract • Rhinitis • Asthma • Wheezing Skin • Urticaria • Angiodema • Atopic dermatitis Gastrointestinal tract • Vomiting • Abdominal pain • Diarrhoea

Breastfeeding is the gold standard in infant nutrition to 6 months Protection against chest infections and wheezing Protection against ear infections Breastmilk content per 100ml1 Protection against diarrhoea and upset stomach Vits & mins 0.173g Fat 3.4g Carbohydrates 6.7g Prebiotic OS 1.0g Better mental development Lower risk of diabetes Protein 1.2g Other 0.2g Less smelly nappies Less eczema 1. Jensen RG (ed) Handbook of Milk Composition. New York: Academic Press, 1995. 2. Vandenplas Y et al. Arch Dis Child. 2007; 92 (10): 902-908.

Diagnosis and management of CMPA in formula-fed infants* *Adapted from Vandenplas Y et al. Arch Dis Child. 2007; 92 (10): 902-908.

Diagnosis and management of CMPA in formula-fed Infants* Formula-fed infants suspected of suffering from severe cow’s milk protein allergy should be referred to a paediatric specialist. In the meantime, an elimination diet should be started and the child should preferably receive an amino-acid based formula. Amino-acid based formula is recommended because infants in this group fail to thrive, suffer from macronutrient deficiencies or have pain. In these cases, such a formula minimizes the risk of failure on an extensively hydrolyzed formula and further weight loss. Many of these children may need further diagnostic work-up to rule out other diagnoses. The decision concerning allergen challenge in cases with severe cow’s milk protein allergy should always be made by a specialist and performed in a hospital setting. In cases with a history of a life-threatening reaction, a food challenge may be contraindicated. *Adapted from Vandenplas Y et al. Arch Dis Child. 2007; 92 (10): 902-908. 11

MANAGEMENT IN BREAST FED INFANTS MILD TO MODERATE: CONTINUE BREAST FEEDING BUT ELIMINATION DIET IN MOTHER 2-4 WEEKS WITH CA SUPPLEMENT AND NO EGG IF IMPROVEMENT REINTRODUCE CMP AND CHECK SYMPTOMS –IF YES THEN eHF AFTER BF, SOLIDS WITHOUT CMP UNTIL 9-12 MONTHS AND ATLEAST FOR 6/12. EGG TO BE ADDED IF NO SYMPTOMS. SEVERE CMPA: REFER PAEDIATRICS AND IN MEANTIME ELIMINATION DIET IN MOTHER PLUS CA SUPPLEMENT VANDENPLAS: ADC OCT 2007,92, P 902-08

Management of cows’ milk allergy in the UK Effective management of CMPA within the NHS could lead to quicker improvement in symptoms and reduce the burden on NHS resources Management of cows’ milk allergy in the UK Sladkevicius & Guest, 2008 1,000 infants with CMPA analysed for treatment patterns and outcomes over first 12 months following initial presentation to a GP Mean age to be put on a diet after initially seeing a GP was 2.2 months Mean time to diagnosis = 3.6 months Time to symptom resolution = 2.9 months Average 18.2 GP visits over 12 months 42% of patients referred to a specialist physician Waiting time for referral = approx 3.7 months Mean 7.6 GP visits before referral Conclusion Consensus guidelines are required for the management of CMPA in order to shorten the time to treatment, diagnosis and symptom resolution and to decrease the consumption of healthcare resources MANAGEMENT OF COWS’ MILK ALLERGY IN THE UK (summary)   Objective To determine how infants with cow milk allergy (CMA) are managed in the UK and the time taken to achieve symptom resolution. Methods 1,000 infants with CMA were randomly selected from the Health Improvement Network (THIN) database, which comprises the longitudinal medical records of 5 million UK patients from the time they initially present to their GP. The records were analysed for treatment patterns and outcomes over the first 12 months following initial presentation to a GP. Results Patients presenting with a combination of gastrointestinal (GI) and atopic symptoms accounted for 55% of all patients. Those with GI symptoms alone and atopic symptoms alone accounted for a further 22% and 9% respectively. Those with acute IgE symptoms accounted for <10% of all patients. Patients’ age at the time of presentation was a mean 3.0 months. Treatments varied according to symptoms with the number of algorithms for each symptomatic group ranging from as little as one pathway for anaphylaxis to as many as 16 pathways for those presenting with a combination of atopic and GI symptoms. It took a mean 2.2 months to be put on a diet after initially seeing a GP. However, it took a mean 3.6 months from the initial GP visit for the CMA diagnosis to be made. 60% of all infants were initially treated with soy, 18% with an extensively hydrolysed formula (EHF) and 3% with an amino acid formula (AAF). A mean 9% of patients were intolerant of soy and 29% were intolerant of an EHF. Time to symptom resolution from the initial GP visit was a mean 2.9 months, however this varied from 3.4 months for those initially treated with an EHF to 2.6 months for those initially treated with an AAF. Patients had a mean 18.2 GP visits over the 12 months. A mean 42% of patients were referred to a specialist physician and the waiting time for a referral was a mean 3.7 months. Patients who saw a hospital physician had a mean 7.6 GP visits before the referral. Conclusion Consensus guidelines are required for the management of CMA in order to shorten the time to treatment, time to diagnosis and time to symptom resolution and to decrease the consumption of healthcare resources. (N.B: 2004–2007 England only: 2008 is UK and NI) Change in reporting structure Sladkevicius E & Guest J. Abstract presented at WCPGHAN, Brazil, August 2008: WCP-307.

Budget impact of managing cows’ milk allergy in the UK Effective management of CMPA within the NHS could lead to quicker improvement in symptoms and reduce the burden on NHS resources Budget impact of managing cows’ milk allergy in the UK Sladkevicius & Guest, 2008 Each infant with CMPA costs an estimated £1,289 to the NHS over the first 12 months after initial diagnosis For managing 18,350 infants in the UK this equate to an estimated annual cost of £23.6 million Conclusion Any strategy that can improve healthcare delivery and thereby shorten the time to diagnosis, treatment and symptom resolution should potentially decrease the burden CMPA imposes on the UK’s NHS Guest J & Sladkevicius E. Abstract presented at WCPGHAN, Brazil, August 2008: WCP-309. 14

Soya-based formulas Historically used for the management of food hypersensitivity (e.g. lactose intolerance and CMPA) Approximately 2% of formula-fed infants are fed a soya-based formula by 10-14 weeks¹ Sales of soya based infant formula accounted for 260,000kg in 2008, 0.9% of total infant formula sales¹ However, studies have shown that some 30-50% of infants given a soya-based formula for the management of CMPA present with concomitant soya protein allergy² 1. AC Nielsen/IMS. 2. ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2006; 42: 352-361. 15

Soya-based formulas Chief Medical Officer’s Statement on soya-based formulas¹ (Jan 2004) Soya-based formulas should not be first choice for the management of infants with proven cows’ milk sensitivity due to the potential risk from their high phytoestrogen levels Soya-based formulas should only be used in exceptional circumstances to ensure adequate nutrition, e.g. for vegans or infants who find alternatives unacceptable ESPGHAN are also in agreement and state that "Soya protein formula should not be used in infants with allergy during the first 6 months of life”. They also raise concerns over their use post 6 months and suggest that soya tolerance "should first be established by clinical challenge”2 1. Department of Health. CMO's Update 37 - January 2004. London: Department of Health, 2004. 2. ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2006; 42: 352-361. 16

Prescribable indications Product Indications Uses Cows’ milk protein intolerance ± secondary lactose intolerance Cows’ milk protein allergy/intolerance Disaccharide ± whole protein intolerance, or where amino acids and peptides are indicated for use with MCT Complex multiple food intolerances and malabsorption Disaccharide ± whole protein intolerance Cows’ milk protein allergy Cows' milk allergy, multiple food protein intolerance and other conditions where an elemental diet is indicated Severe cows’ milk allergy and multiple food intolerances 17

CONCLUSION CONSIDER CMPA EARLY- REMEMBER GOR IS AS COMMON AND DOES NOT NEED ELIMINATION DIET TREAT EARLY AVOID SOY BASED FORMULAE UNTIL ATLEAST 6 MONTHS. AVOID GOAT’S MILK, RICE MILK (ARSENIC) AS NOT APPROPRIATE CALORIES AND NUTRITION IF IN DOUBT DISCUSS WITH COLLEAGUES

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