1. 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 mg/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

2. 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 Agreed at WECCG Medicine’s Optimisation Board October Review October 2019.