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children under two years).12


These tests and cut-off points,


however, do have their limitations, and food challenges (ie, introducing CM supervised in hospital/outpatient setting) are recommended if the history is vague or if the child has never previously consumed CM. If the history suggests delayed type non IgE mediated CMPA: there is no role for skin prick test or specific IgE test in the diagnosis of delayed onset CMPA. If this is suspected from the history, an elimination period of 4-6 weeks is recommended, followed by introduction of CM at home. A diagnosis is only confirmed when symptoms reappear on the re-exposure of CM.


MANAGEMENT The mainstay of treatment for CMPA is the avoidance of all CMP, which includes CM-derived infant formulas and other dairy products (see Table 2). Breast milk remains the “gold standard” source of nutrition for


the young child with CMPA. Although cow’s milk β-lactoglobulin can be detected in 95% of breast milk from lactating women, the


amount is insignificant to many of the infants with food induced gastrointestinal allergies, and maternal elimination is not always necessary.14-16


However, if symptoms persist in the breastfed infant,


a strict maternal exclusion diet may be required. With such a dietary intervention, it is important to consider the adequacy of the lactating mother’s dietary intake, specifically calcium, vitamin D and protein requirements. Most children with CMPA who are not breastfed will require a


hypoallergenic formula. Hypoallergenic formulae should be tolerated by 90% of cow’s milk allergic infants and are divided according to the degree of protein hydrolysis. Extensively hydrolysed formulae (EHF) contain peptides, with most of the peptide lengths below 1500 Da, whereas amino acid formula (AAF) provides protein in the form of amino acids.14,17


Both AHF and AAF


are suitable for treating CMPA and should be used as first-line treatment in infants that are not breastfed. The role of soya formula in the treatment of CMPA has received


significant attention over the last few years due to the concomitant soya allergy seen in children with CMPA. It is thought that about


TABLE 1. IGE AND NON IGE-MEDIATED REACTIONS AS DESCRIBED IN THE NICE GUIDELINES9 IgE mediated symptoms


Skin Pruritis.


Acute angioedema (lips, face, around the eyes). Acute urticarial. Erythema.


Gastrointestinal tract


Acute angioedema (lips, tongue and palate). Oral pruritis.


Acute vomiting/diarrhoea. Colicky abdominal pain. Nausea.


Respiratory Tract (combination with one of the above symptoms) Upper respiratory tract symptoms (nasal itching, sneezing, rhinorrhoea, or congestion (with or without conjunctivitis). Lower respiratory tract symptoms (cough, chest tightness, wheezing, or shortness of breath).


Systemic Signs and symptoms of anaphylaxis and other systemic reactions.


TABLE 2. THE SOURCE, LABELLING TERMS, NUTRIENTS INVOLVED AND ALTERNATIVES. Sources


Butter/most fat spreads. Cheese.


Cow/sheep/goat milk. Evaporated/condensed milk. Cream. Ghee. Yoghurt. Ice cream. Custard.


Dairy desserts. Manufactured foods using milk or butter in their ingredients.


Adapted from Venter C & Meyer R13


Other terms Casein.


Caseinates. Curd.


Lactoglobulin. Lactose. Milk solids. Whey.


Buttermilk. Milk sugar. Whey sugar. Whey syrup. Sweetener.


Nutrients involved


Vitamin A. Vitamin D. Riboflavin.


Pantothenic acid. Cyanocobalamin. Calcium. Magnesium. Phosphate.


Alternatives


Under six months: EHF. AA.


Above six months - up to two years: EHF. AAF.


Soy formula.


Over two years: Rice milk. Soya milk. Oat milk. Potato milk. Almond milk. Coconut milk. Pea milk.


Other foods: Milk-free versions of spreading fats Cheese Yoghurts Ice cream Cream


Non-IgE mediated symptoms Skin


Pruritis. Erythema.


Atopic eczema.


Gastrointestinal tract Constipation. Gastro-oesophageal reflux disease. Loose frequent stools. Blood and/or mucus in stools. Abdominal pain. Infantile colic. Food refusal/aversion. Perianal redness. Pallor and tiredness. Faltering growth and one or more of above gastrointestinal symptoms (with/without serious atopic dermatitis).


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