Cow’s Milk Protein Allergy (CMPA) in Children

 

This summary on cow's milk protein allergy (CMPA) in infants is taken from EKPG Appropriate prescribing of specialist infant formula and should be read in conjunction with the full guidance

.

Symptoms and diagnosis

Symptoms differ if the allergy is IgE-mediated or non-IgE mediated and can include:

  • Skin symptoms (pruritis, erythema, urticaria, atopic dermatitis)
  • Acute angioedema of the lips and face, tongue and palate, and around the eyes
  • GI symptoms (diarrhoea, bloody stools, nausea and vomiting, abdominal distension and /or colicky pain, constipation, GORD)
  • Recurrent wheeze or cough, nasal itching, sneezing, rhinorrhoea or congestion
  • Anaphylaxis
  • Faltering growth

.

NICE recommends further investigation with a skin prick test or specific IgE antibody blood test if IgE-mediated allergy is suspected

When non-IgE mediated allergy is likely, trial elimination for 2 to 6 weeks of the suspected allergen is advised

Most infants with CMPA develop symptoms within 1 week of introduction of CMP-based formula

.

Different presentations on children with suspected cow's milk allergy

The following diagram is taken from the article by Venter et al 'Diagnosis and management of non-IgE-mediated cow’s milk allergy in infancy - a UK primary care practical guide' from the Clinical and Translational Allergy journal

.

Primary care management of mild to moderate non-IgE cow's milk allergy

The following diagram is taken from the article by Venter et al 'Diagnosis and management of non-IgE-mediated cow’s milk allergy in infancy - a UK primary care practical guide' from the Clinical and Translational Allergy journal

.

.

Referral Criteria

NOTE Most infants with CMPA can be managed in primary care until weaned

Referral to a paediatric dietitian should be made prior to weaning for all infants who will require a cow’s milk free diet. Breastfeeding mothers following a milk free diet should be referred to the paediatric dietitian who will advise on both the mother’s and the child’s diet

Refer to secondary or specialist care if any of the following apply:

  • Faltering growth with one or more gastrointestinal symptoms
  • Acute systemic reactions or severe delayed reactions
  • Significant atopic eczema where multiple or cross-reactive food allergies are suspected by the parent or carer
  • Possible multiple food allergies
  • Persisting parental suspicion of food allergy despite a lack of supporting history (especially where symptoms are difficult or perplexing)

.

Treatment

  1. Breast milk is the ideal choice for most infants with CMPA
  2. If symptoms persist in the exclusively breast-fed infant, a maternal milk free diet is indicated for a minimum trial of 2 weeks
  3. Breastfeeding mothers on a milk free diet may require supplementation with 1000mg calcium per day
  4. If breastfeeding is not occurring, extensively hydrolysed formulae (EHF) are the first choice, unless the infant has a history of anaphylactic symptoms
  5. Amino acid formulae (AAF) should normally be started in secondary or specialist care. They are suitable only when EHF does not resolve symptoms and/or there is evidence of severe (anaphylactic) allergy
  6. If breastfeeding mothers do not wish to or are unable to follow a milk free diet, or are following a milk free diet and symptoms persist, an AAF will be needed if top-ups are required and can be prescribed in primary care
  7. If a patient has a history of anaphylactic reaction to cow’s milk, AAF may be started in primary care, with immediate onward referral to secondary or specialist care

.

The following diagrams are taken from the article by Venter et al 'Diagnosis and management of non-IgE-mediated cow’s milk allergy in infancy - a UK primary care practical guide' from the Clinical and Translational Allergy journal.

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

Have a question or query?

Get in touch