Cow’s Milk Protein Allergy (CMPA)

Information

These are guidelines for the diagnosis and management of suspected cow’s milk protein allergy (CMPA) in primary care.

Please note there are no allergy tests for non-IgE mediated CMPA. Diagnosis is based on resolution of symptoms on a cows milk protein free diet AND reoccurrence on re-introduction of milk. Re-challenge is essential for diagnosis of non-IgE mediated CMPA. Do not re-challenge for suspected IgE mediated CMPA.

Introduction

The prevalence of cow’s milk allergy is up to 3% of infants during the first year of life.
Cow’s milk protein allergy is frequently over diagnosed with allergy formula milks being over-prescribed.
Cow’s milk allergy commonly presents in infancy, with most affected infants presenting with symptoms by 6 months of age.
Cow’s milk allergy can be classified into IgE mediated reactions (immediate onset) and non- IgE mediated (delayed onset).
Cow’s milk allergy will resolve in the majority of children during early childhood.

Who can refer:

GPs, Health Visitors, Paediatric Physicians, Family Nurse

Who to refer:

Infants with suspected non-IgE CMPA who meet the criteria for specialist dietician management as per the above flow chart e.g:

< 12 months old
Faltering growth
Multiple allergies suspected including CMPA
Blood in stools
Feeding aversion
Multiple maternal dietary exclusions
Under family nurse practitioner

Infants with suspected non-IgE CMPA who meet criteria for initial primary care management but who develop further symptoms following a subsequent milk challenge.

Who not to refer:

Infants with suspected IgE CMPA – Please refer these infants to RHCYP Dietetics and please add link to this refhelp page Heather. Do not re-challenge for suspected IgE mediated CMPA.
Infants with suspected non-IgE CMPA who can be assessed safely in primary care and who do not develop symptoms following a subsequent milk challenge following a period off dairy. See Primary Care Management tab.

How to refer:

A Sci-Gateway referral pathway is currently under development for this service. In the meantime please email loth.cypdieteticsinfantfeeding@nhs.scot with allergy assessment form attached.

After Referral:

Please see below detailing what families should expect from the Dietetic CMPA pathway:

Family will be called at 5 months of age and booked into cow’s milk free weaning group (in person or online). To continue dietary measures for breast fed infants or allergy formula for formula fed infants.
Family will be called at 12 months of age and booked into cow’s milk reintroduction group (online)
Discharged from dietetics unless ongoing dietetic review required. Prescription of allergy formula discontinued.
Our service offers one to one appointments with patients outside of the group where appropriate.

We have close working relationships with RHCYP Medical Paediatrics and Allergy teams and can forward referrals as appropriate

The following patients can be safely assessed and have initial management carried out in primary care:

<12 months old
No growth concerns
Suspected single non-IgE allergy to milk
No blood in stools
No feeding aversion

Step 1: To confirm/refute non-IgE CMPA diagnosis, complete 4 week dairy exclusion and subsequent milk challenge following guidance in the information sheets.

See parent information sheet for breast fed babies

See link 2 for a parent information sheet for combination fed babies and formula fed babies. + pdf doc Please prescribe appropriate allergy formula following guidance in appendix 1 (link). If baby was previously tolerating dairy through maternal diet and became symptomatic on introduction of formula milk please advise Mum to continue to keep dairy in her own diet.

PLEASE NOTE:

If no improvement after 2 weeks minimum on extensively hydrolysed formula, consider trial of amino acid formula for a further 2 weeks minimum, or alternative diagnosis eg. gastro-oesophageal reflux.

See parent information sheet for babies on solids + pdf doc

Step 2: If confirmed, please refer to specialist dietitian service – SCI-gateway link/IFD mailbox –loth.cypdieteticsinfantfeeding@.nhs.scot

Please continue allergy formula milk

Please see “after referral” in the Referral Guidelines tab to inform family of what to expect from dietetics

If no return of symptoms on milk challenge, resume normal diet and consider alternate diagnosis if required.

Infant Allergy Assessment Form

Milk challenge information sheets