Cow's milk protein allergy

Symptoms of mild to moderate CMPA

• Gastrointestinal: frequent regurgitation, vomiting, diarrhea, constipation (with/without perianal rash), blood in stool, iron deficiency anemia.
• Dermatological: atopic dermatitis.
• Gastric: persistent distress or colic (≥3h per day wailing/irritable) at least 3 days/week over a period of >3 weeks.

Symptoms of severe CMPA

• Gastrointestinal: failure to thrive due to diarrhea or regurgitation/vomiting, refusal to feed, moderate to large amounts of blood in stool with decreased hemoglobin, protein-losing enteropathy.
• Dermatological: failure to thrive and severe atopic dermatitis.
  
  

For Mild to Moderate CMPA

Four-week trial of Extensively Hydrolyzed Formula (EHF)

• First line: Aptamil Pepti 1.
• Second line: SMA Althera.

Evaluation

• Improvement:
  • Reintroduce CMP (restart usual formula).
    • If symptoms recur:
      • Continue EHF prescription.
      • Trial reintroduction of CMP at regular intervals.
    • If no symptoms:
      • Continue normal diet (formula).
      • Consider other diagnoses.
• No Improvement:
  • Two-week trial of Amino Acid Formula (AAF):
    • First line: Neocate LCP.
    • Second line: SMA Alfamino.
  • Improvement:
    • Reintroduce CMP (restart usual formula).
    • If symptoms recur:
      • Continue AAF prescription.
      • Trial reintroduction of CMP at regular intervals.
    • If no symptoms:
      • Continue normal diet (formula).
      • Consider other diagnoses.
  • No Improvement:
    • Consider other diagnoses.

For severe CMPA

• Immediate referral to paediatric dietician for diagnosis and treatment.
  
  

For Mild to Moderate CMPA

Continue breastfeeding

• Mother should follow an elimination diet, excluding CMP for 2 weeks (up to 4 weeks in case of atopic eczema or allergic colitis), plus calcium supplement.

Evaluation

• Improvement:
  • Reintroduce CMP into mother's diet.
    • If symptoms recur:
      • Maintain elimination diet in mother (plus calcium supplement).
      • Use eHF after breastfeeding finished and solid foods free of CMP at weaning until 9-12 months of age, and for at least 6 months..
• No Improvement:
  • Breast feeding can continue, topical treatment in case of atopic dermatitis
  • Resume normal diet in mother and/or consider other (allergic) diagnoses.

For severe CMPA

• Referral to paediatric dietician for diagnosis and treatment.
• In the meantime, mother should follow an elimination diet (no CMP) plus calcium supplement.
  
  

Refer to paediatric dietician

Refer urgently

• Infants with severe CMPA symptoms:
  • Gastrointestinal: failure to thrive because of diarrhea or regurgitation/vomiting, refusal to feed, moderate to large amounts of blood in stool with decreased hemoglobin, protein-losing enteropathy.
  • Dermatological: failure to thrive and severe atopic dermatitis.

Refer routinely

• Infants with mild to moderate CMPA who show no improvement after trials of EHF and AAF (for formula-fed infants) or after elimination diet in mother (for breastfed infants).
• Where expert support and advice would be helpful in a baby/child with suspected or confirmed CMPA.

Do not refer:

• Infants with mild to moderate CMPA who show improvement with EHF or AAF (for formula-fed infants).
• Infants who show improvement with maternal elimination diet (for breastfed infants).

Continue to manage these infants in primary care with periodic reintroduction trials of CMP and regular monitoring.

Consider other diagnoses if symptoms persist without improvement on EHF, AAF, or maternal elimination diet.

Once diagnosis is confirmed by challenge, formula milk can then be put on the child’s repeat prescription. Children under 6 months of age will require approximately 8 x 400g tins every 4 weeks. Once the child is over 6 months and weaning has commenced, this quantity should decrease on a monthly basis and the prescription should stop at the age of 12 months. Prescriptions should only be continued for children over the age of 12 months if requested by a Dietitian.

If the child is still unable to tolerate cow’s milk by the age of 12 months, they should transition onto a supermarket calcium fortified, plant based milk of the parent’s choice. Rice milk should be avoided in children less than 4.5 years old, due to the arsenic content.