Cow’s Milk Protein Allergy
Affects at least 2 - 3% of UK infants
Important to distinguish whether reaction IgE or non-IgE mediated (see Food Allergy)
IgE Mediated CMPA:
Children with IgE mediated reactions should be referred to the Allergy Clinic
- Advise total milk avoidance. If breastfeeding mother she should avoid milk products, but breastfeeding continuation should be advocated.
- Please give family a BSACI action plan, available from https://www.bsaci.org/professional-resources/resources/paediatric-allergy-action-plans
- Antihistamine advised- Cetirizine PRN if over 1 year of age, Chlorphenamine if under 1 year of age (see BNFc for doses)
- Adrenaline autoinjectors x2 if required due to anaphylaxis or known diagnosis of asthma requiring daily preventative steroid inhalers
- Advise continuation of baked milk 3x/week if already tolerated
- Please do not use Milk Ladder for IgE mediated Milk Allergy
Non-IgE mediated CMPA:
Non-IgE mediated CMPA can be manged in Primary Care
- Please use the iMAP guideline on the Allergy UK website- https://gpifn.org.uk/imap where there are additional resources such as information sheets for professionals and families.
- Note that there is no test for suspected non-IgE mediated CMP allergy apart from elimination and re-introduction, and most do not need Paediatric Allergy referral.
- Dietetic referral is often more appropriate in the first instance.
Refer to Dietitians if:
· Mild-moderate confirmed non-IgE CMP allergy (Routine)
· Faltering growth associated with proven milk allergy (Urgent)
NB – Refer cases of blood in an infant’s stool (even if thought to be to CMP allergy) as same-day referral to Paediatric observation unit due to differential diagnosis.
Overall Prognosis of Milk Allergy:
IgE mediated - some 80% of children grow out of this in childhood, although if severe tends to take longer so more important to monitor in allergy clinic using skin prick tests/specific IgE as child grows up.
Non IgE mediated – mean age of resolution sooner but can persist in some.
Appropriate Milks – Summary for different ages
Please refer to KCCG Formulary and information sheet for milk choices:
*Always the added calcium versions and ideally unsweetened.
*Vitamin drops A, C and D are recommended once talking under 17oz/500mls formula or if consuming calcium fortified plant based milk substitute for children under 5 years
*Advise to look for around 2-3g protein/100mls and at least 40-50 calories/100mls from plant based milk substitute (NOTE: almond milk is low in calories and has a very low protein content).
Paediatric Dietetics Guidelines available here
Lactose Intolerance:
- Congenital Lactose intolerance with symptoms from birth is extremely rare and presents with copious diarrhoea (patients are usually in hosptial as a result)
- Primary lactose intolerance usually presents in teens, not toddlers or younger children under the age of 6. It is more common in younger children in some ethnic groups.
- Secondary lactose intolerance is common after a gastroenteritis but usually resolves within a few weeks without need for lactose – free milk
Parents often think that lactose intolerance is milk allergy and vice-versa
There is no need to refer possible lactose intolerance to the Allergy, Dietetic or General Paediatric Service.
Lactose – free milks are not on the KCCG prescribing formulary and should not be used in milk allergy
A very good information sheet can be found at http://www.patient.co.uk/health/Lactose-Intolerance.htm
Date January 2022
Review Date January 2023
Authors: Simon Bedwani, Consultant Paediatrician, RCHT
Dr S Burns RMS GP