CPDIN
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encouraged to speak to a healthcare professional about a lactose free diet. Babies who are bottle fed are usually recommended to move to a lactose free milk for 6-8 weeks. After this time the damage to the baby’s gut has usually resolved and they can move back to their usual milk.
Milks for colic and >
CMPA can induce both acute IgE immunoglobulin-mediated reactions (within 2 hours) e.g. rash or urticaria, wheeze, vomiting, and also non IgE-mediated reactions which are more delayed, e.g. mild-moderate eczema, reflux.
Management of the allergy necessitates the complete removal of CMP from a baby’s diet. For the breastfed infant, this means that the mother must follow a strict milk-free diet, and because of this, she also needs to take supplements containing 1000mg calcium and 10 micrograms of vitamin D daily. Bottle-fed infants need a formula which contains no cow’s milk, and there are two main options available to achieve this3
: Extensively Hydrolysed
Formula (eHF) In these milks the protein causing the allergy is broken up into smaller fragments (peptides) that are less likely to illicit an immune response. Aptamil Pepti and SMA Althera are whey-based eHF milks and Nutramigen and Similac Alimentum are casein-based ones. 90% of babies with CMPA can tolerate these formulae. If a baby is still showing symptoms after 2-6 weeks on an eHF formula, they may be switched onto an amino acid formula.
Amino Acid formula (AAF) These are for the remaining 10% of babies whose symptoms do not resolve on an eHF, and who require the peptides to be broken up further, into amino acids. AAFs are quite expensive and are more likely to be needed for babies who have multiple allergies or a family history
24 - PHARMACY IN FOCUS
of CMP. Examples include Neocate LCP, Nutramigen Puramino and SMA Alfamino.
CMPA usually resolves over time, and in most cases has completely resolved by 3-5 years. Guidance on how to gradually introduce food with increasing amounts of CMP in a controlled manner is laid out in the Milk Ladder4, and this process is managed by a paediatric dietician. Parents should introduce cow’s milk back into their child’s diet under medical advice.
Lactose intolerance This is usually transient and often follows an episode of gastroenteritis, during which there is a reduction in lactase activity for a period lasting from a few days up to a few weeks. True lactase deficiency is extremely rare. Unlike CMPA, symptoms are usually limited to the gastrointestinal tract, e.g. diarrhoea, abdominal pain, flatulence and bloating.
The 3 main types of lactose intolerance are: Congenital – an extremely rare condition where babies are born with a genetic defect resulting in the absence of the lactose enzyme.
Primary – a genetically inherited condition uncommon before 2-3 years of age, normally becoming apparent after 5 years of age. Secondary – a temporary, more common, condition caused by damage to the gut (where lactase is produced) e.g. following gastroenteritis. Usually resolves after a few weeks once the gut heals. If a baby has been diagnosed with temporary lactose intolerance breastfeeding mothers should be
constipation Types of milk are commonly known as comfort milks and are a specialised formula for the dietary management of colic and constipation. They should only be used under medical supervision. They are nutritionally complete from birth to 6 months and can be used as part of a weaning diet from 6 months.
Anti-reflux (AR) formulae It’s perfectly normal for a healthy baby to bring up a small amount of milk during or shortly after a feed. This is known as regurgitation or posseting. Reflux is more frequent and can occur with symptoms such as persistent crying, irritability, back arching and sleep.
Latest guidelines recommend:5 1. Reviewing the feeding history
2. Avoid overfeeding 3. Thicken feeds
4. Breastfeeding mums should be encouraged to continue.
5. If there has been no improvement, consider 2-4 weeks of a protein hydrolysate or amino
6. acid based formula or, in breastfed infants, elimination of cow’s milk in maternal diet.
7. If there is no improvement the patient should be referred to a paediatric GI.
There are thickened milks available that are suitable for the dietary management of reflux such as Cow and Gate and Aptamil AR and SMA staydown and Enfamil AR.
Cow and Gate instant carobel is a thickener that can be used in expressed breastmilk, standard formula or used as a paste before during and after breastfeeding.
The NI Infant Feeding Guidelines has further information on all of the above and can be accessed via the nutrition section of the NI Formulary website.
MODULE 4 TAKE THE 5
MINUTE TEST To receive your CPD logsheet and certificate;
Visit
www.pharmacyinfocus.co.uk/ education
Register your details for the relevant module; Infant feeding, Module 4
Having studied the module and without referring to it again complete the 5 minute test. If you need to refer to the text to answer the questions then you may need to study the module again.
ASSESSMENT: Upon completion of the test your answers will be scored and if you are successful you will be issued with your CPD certificate.
*Downloadable PDF of this module is available online the Pharmacy in Focus Website for your records
Vitamin D Finally, a note on the sunshine vitamin. Current advice is that all babies under 1 year receive 8.5- 10micrograms of vitamin D daily. Those who are receiving 500ml or more of formula will already be receiving this, but those who are getting less, or who are partially or exclusively breastfed will require a supplement, available over the counter as drops.
Once a baby is six months old, and up until they are five years, daily vitamin A, C and D supplements are recommended (unless they’re having 500ml or more of formula each day).
1. Breastfeeding on the Island of Ireland:
https://www.publichealth.ie/document/iph- report/breastfeeding-island-ireland 2. Incidence of cow’s milk protein allergy, BMJ 2016:
https://bjgp.org/content/66/651/512.2 3. CKS: Cows' milk protein allergy in children:
https://cks.nice.org.uk/cows-milk-protein- allergy-in-children#!scenario:1 4. The Map Guideline Milk Ladder:
http://ifan.ie/wp- content/uploads/2014/02/Milk-Ladder-2013-M AP.pdf 5. Paediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Paediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (2018), Journal of Paediatric Gastroenterology and Nutrition, 66; 3, 516-554.
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