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50% of children with non-IgE-mediated CMPA have a concomitant soya allergy, which is in contrast to the significantly lower levels of soya allergy (7-14%) in IgE-mediated CMPA.17-20

In addition, higher

rates of adverse reactions to soya are reported in infants below 6 months of age in both IgE and non-IgE-mediated allergies.19 World Allergy Organisation17

The has therefore published guidelines

recommending that soya formulas should not be used below 6 months of age, and that EHF or AAF should be the preferred feed. The indications for using either EHF or AAF are highly debated.

Current guidance suggests the use of AAF in preference to an EHF in a child with a history of anaphylaxis/respiratory distress, severe atopic dermatitis, allergic eosinophilic disease, growth faltering and reactions to the traces of CM present in breast milk.11

THE CHALLENGES OF DIAGNOSING AND MANAGING CMPA A study by Sladkevicius et al. in 2010 highlighted that children with CMPA waited 3.6 months on average from the first visit to the general practitioner (GP) until the diagnosis of CMPA was confirmed.21


addition, there are limited allergy specialist centres in the UK to deal with the growing number of food allergy-related referrals.22


challenge therefore is not only to identify those children with CMPA, but to initiate treatment earlier at a primary care level.

THE ROLE OF PRIMARY CARE Due to the identified challenges related to the diagnosis and management of food allergy, NICE guidelines were published in 2011, guiding the diagnosis and assessment of food allergies in children in primary care.8

2. Host A. Frequency of cow’s milk allergy in childhood. Ann Allergy Asthma Immunol 2002;89(6 Suppl 1):33-7.

3. Kvenshagen B, Halvorsen R, Jacobsen M. Adverse reactions to milk in infants. Acta Paediatr 2008;97(2):196-200.

4. Wright T, Meyer R. Dietary Management: Milk and Eggs. In: Skypala I, Venter C, editors. Food Hypersensitivity. Oxford: Blackwell Publishing Ltd; 2009. p117-28.

5. Johansson SG, Bieber T, Dahl R, et al. Revised nomenclature for allergy for global use: Report of the Nomenclature Review Committee of the World Allergy Organization, October 2003. J Allergy Clin Immunol 2004;113(5):832-6.

6. Du Toit GL, Meyer R, Shah N, et al. Identifying and managing cow’s milk protein allergy. Arch Dis Child Educ Pract Ed 2010;95(5):134-44.

7. Sicherer SH, Sampson HA. 9: Food allergy. J Allergy Clin Immunol 2006;117(2 Suppl Mini-Primer):S470-S475.

8. National Institute for Health and Clinical Excellence. Diagnosis and assessment of food allergy in children and young people in primary care and community settings. London: NICE; 2011. Available at: http://

9. Sackeyfio A, Senthinathan A, Kandaswamy P, et al. Diagnosis and assessment of food allergy in children and young people: summary of NICE guidance. BMJ 2011;342:d747.

10. Boyce JA, Assa’ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID- sponsored expert panel. J Allergy Clin Immunol 2010;126(6 Suppl):S1-58.

11. Fiocchi A, Brozek J, Schunemann H, et al. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow’s Milk Allergy (DRACMA) Guidelines. Pediatr Allergy Immunol 2010;21 Suppl 21:1-125.

The aim of this document was to guide

healthcare professionals in primary care on the recognition of children with food allergies, but it does not discuss management. Soon after the publication of these NICE guidelines, the Royal College of Paediatrics published Care Pathways for children with food allergies in primary, secondary and tertiary care.23

12. Venter C, Vlieg-Boerstra BJ, Carling A. The Diagnosis of Food Hypersensitivity. In: Skypala I, Venter C, eds. Food Hypersensitivity: Diagnosing and Managing Food Allergies and Intolerances. Oxford: Blackwell; 2009. p85-106.

These have

been developed around the competences required to diagnose and optimally manage food allergy, and have not been assigned to specific health professionals or settings in order to encourage flexibility in service delivery. With the help of these guidelines, it is hoped that children with

CMPA will be identified and managed in primary care, in addition to identifying those children that require a referral to secondary or tertiary specialist centre.

CONCLUSION CMPA is very prevalent in infants and young children and presents with a range of symptoms that may be IgE or non IgE-mediated. The allergy-focused clinical history is key to identifying a child with CMPA, and deciding which diagnostic pathway should be followed. Management of CMPA involves guidance on appropriate

avoidance of CM and may involve advice to breastfeeding mothers, and selecting the most appropriate hypoallergenic formula in non-breastfed infants. Dietary management can be very challenging and the dietitian (as per the NICE guidelines) plays a crucial role in this process.

REFERENCES 1. Fiocchi A, Assa’ad A, Bahna S. Food allergy and the introduction of solid foods to infants: a consensus document. Adverse Reactions to Foods Committee, American College of Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol 2006 Jul;97(1):10-20.

13. Venter C, Meyer R. Session 1: Allergic disease: The challenges of managing food hypersensitivity. Proc Nutr Soc 2010;69(1):11-24.

14. Host A, Halken S. Hypoallergenic formulas - when, to whom and how long: after more than 15 years we know the right indication! Allergy 2004;59 Suppl 78:45-52.

15. Palmer DJ, Gold MS, Makrides M. Effect of cooked and raw egg consumption on ovalbumin content of human milk: a randomized, double-blind, cross-over trial. Clin Exp Allergy 2005;35(2):173-8.

16. Franke AA, Halm BM, Custer LJ, et al. Isoflavones in breastfed infants after mothers consume soy. Am J Clin Nutr 2006;84(2):406-13.

17. Fiocchi A, Brozek J, Schuneman H, et al. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow’s Milk Allergy (DRACMA) Guidelines. World Allergy Organisation Journal 2010;Apr:57-161.

18. Kemp AS, Hill DJ, Allen KJ, et al. Guidelines for the use of infant formulas to treat cows milk protein allergy: an Australian consensus panel opinion. Med J Aust 2008;21;188(2):109-12.

19. Agostoni C, Axelsson I, Goulet O, et al. Soy protein infant formulae and follow-on formulae: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2006;42(4):352-61.

20. Zeiger RS, Sampson HA, Bock SA, et al. Soy allergy in infants and children with IgE-associated cow’s milk allergy. J Pediatr 1999;134(5):614-22.

21. Sladkevicius E, Nagy E, Lack G, Guest JF. Resource implications and budget impact of managing cow milk allergy in the UK. J Med Econ 2010;13(1):119-28.

22. House of Lords. Science and Technology Committee: Allergy. Authority of the House of Lords; 2007 Sep 26. Volume 1: Report.

23. The Royal College of Paediatrics and Child Health. Care Pathways for Food Allergy. Available at:

54 Nursing in Practice March/April 2012

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