1. Developing a local guideline for the management of cow’s milk protein intolerance GP Study day 9 th June 2010

2. Overview Why develop a local guideline? Why develop a local guideline? Diagnosis of CMPA Diagnosis of CMPA Symptoms of CMPA Symptoms of CMPA Managing CMPA in primary care Managing CMPA in primary care Managing CMPA in secondary care Managing CMPA in secondary care Controversies in guideline development Controversies in guideline development Discussion Discussion

3. Why develop a local guideline No widely accepted, national guidelines No widely accepted, national guidelines Significant problem (2-3% babies) Significant problem (2-3% babies) Some confusion (eg with lactose intolerance) Some confusion (eg with lactose intolerance) Wide variety in current practice Wide variety in current practice Often crosses professional boundaries Often crosses professional boundaries Better evidence base than for many other treatments that are currently recommended eg for “colick” Better evidence base than for many other treatments that are currently recommended eg for “colick”

4. Diagnosing CMPA Can be a challenge Can be a challenge Symptoms often non-specific, Symptoms often non-specific, difficult to quantify objectively difficult to quantify objectively Symptoms: Symptoms: should be consistent and related to feeds should be consistent and related to feeds typically within first month of life or within 1 week of switching to formula feed typically within first month of life or within 1 week of switching to formula feed Often affect more than one body system Often affect more than one body system History/family history of atopy increase likelihood but not diagnostic History/family history of atopy increase likelihood but not diagnostic

5. Physiology IgE mediated (SPT/RAST) IgE mediated (SPT/RAST) Urticaria, swelling, wheezing, vomiting, anaphylactic symptoms Immediate Can be life threatening Non IgE mediated – at least 50% (no tests available) Non IgE mediated – at least 50% (no tests available) Gut or skin symptoms more likely Delayed Is there a role for allergy tests?

6. Symptoms of CMPA Gastrointestinal 50-60% pts Vomiting/regurgitation Colic* Gastro-oesophageal reflux* Diarrhoea Abdominal discomfort Constipation* Blood in stools Skin 50-60% pts Rash Urticaria Eczema* Angio-oedema Swollen lips Respiratory 20-30% pts Rhinitis Chronic cough Wheezing General Food refusal Poor growth Iron-deficient anaemia Irritability/poor sleep (cying/irritable for >3hr/day for 3 days/week over a 3 week period)

7. Diagnosing CMPA in primary care Red flags? Red flags? Positive history Positive history Exclusion diet for 2 – 4 weeks Exclusion diet for 2 – 4 weeks Bottle-fed : extensively hydrolysed formula Bottle-fed : extensively hydrolysed formula Breast fed : maternal diary free diet (with calcium supps) Breast fed : maternal diary free diet (with calcium supps) Rechallenge with CMPA after 4 weeks Rechallenge with CMPA after 4 weeks No role for “allergy tests” No role for “allergy tests”

8. Management of CMPA in primary care Proven when symptoms resolve on CMP-free diet and recur on challenge. Proven when symptoms resolve on CMP-free diet and recur on challenge. Restart CMP-free diet for 6 months or until aged 1 year (whichever later). Restart CMP-free diet for 6 months or until aged 1 year (whichever later). Refer to paed dietitians for weaning advice Refer to paed dietitians for weaning advice Rechallenge with CMP at 12 months of age and every 6 months until passes or aged 3 Rechallenge with CMP at 12 months of age and every 6 months until passes or aged 3 Refer to paeds if persistent symptoms aged 3yrs Refer to paeds if persistent symptoms aged 3yrs

9. Management of CMPA in secondary care Likely to be more severe cases – eg faltering growth, blood in stools, severe reflux Likely to be more severe cases – eg faltering growth, blood in stools, severe reflux Includes those not responding to primary care management Includes those not responding to primary care management SPT/RAST? SPT/RAST? Go straight for amino-acid based formula (eg neocate). Go straight for amino-acid based formula (eg neocate). Do not re-challenge after 4 weeks Do not re-challenge after 4 weeks Consider alternative diagnosis if not improving Consider alternative diagnosis if not improving

10. Controversies in developing guideline Extensively-hydrolysed or amino acid based? Extensively-hydrolysed or amino acid based? Evidence is that 10% pts will not tolerate EHF and will need amino acid feed Evidence is that 10% pts will not tolerate EHF and will need amino acid feed If severe symptoms this rises to 50% If severe symptoms this rises to 50% Agreed that EHF appropriate (& cheaper) for those managed in primary care, amino acid feeds for those requiring secondary care Agreed that EHF appropriate (& cheaper) for those managed in primary care, amino acid feeds for those requiring secondary care Any role for partially hydrolysed formula? Any role for partially hydrolysed formula?

11. Controversies in developing guideline Re-challenge at 4 weeks or not? Re-challenge at 4 weeks or not? Some suggest re-challenge, others say not, others say try EHF rather than amino acid feed Some suggest re-challenge, others say not, others say try EHF rather than amino acid feed Agreed to re-challenge in primary care where more likely to be “temporary” feed issues which resolve with time rather than treatment. Agreed to re-challenge in primary care where more likely to be “temporary” feed issues which resolve with time rather than treatment. Not to re-challenge in secondary care as more likely to have significant symptoms and re-challenge more harmful (& harder to sell to parents) Not to re-challenge in secondary care as more likely to have significant symptoms and re-challenge more harmful (& harder to sell to parents) Role of SPT/RAST? Role of SPT/RAST?

12. Discussion Thoughts and comments welcome