LET US DISCUSS
KALPESH
DIXIT
7/7/10
EXPERIENCE 1
AB, 5 DAYS OLD
 BLEEDING PR
 BREAST FED BABY
 5-10 STOOLS PER DAY.
 UNSETTLED

EXAMINATION NORMAL
 HAS REGAINED BIRTH WEIGHT


??? CAUSE
EXPERIENCE 2
6 WEEKS OLD BABY
 CRYING OFTEN
 EXPLOSIVE DIARRHOEA
 HV CHANGES MILK- SMA C&G
 MUM DECIDES TO TRY WYSOY
 NO RESPONSE
 VISITS GP
 EXAMINATION NORMAL


??? WHAT TO DO?
APTAMIL
EXPERIENCE 3
3 MONTH OLD
 CRYING
 ARCHING AND VOMITING
 UNSETTLED FOR PROLONGED PERIODS
 CENTILES DROPPING
 POOR SLEEP FOR ALL
 EXAMINATION NORMAL


?? HOW WILL YOU PROCEED??
EXPERIENCE 4
6 MONTH OLD BABY
 SEVERE ECZEMA
 TRIED ALL POSSIBLE CREAMS, STEROIDS,
ANTIFUNGAL AND ANTIBACTERIAL
CREAMS
 REFERRAL TO DERMATOLOGY
 AWAITING 12-15 WEEK PERIOD FOR APPT.


WHAT TO DO IN THE INTERIM?
COWS’ MILK PROTEIN ALLERGY
– DEFINITION AND INCIDENCE
What is CMPA?

"...an adverse reaction to cows' milk resulting from an
immunologic hypersensitivity to one or more milk proteins“1
How many infants are affected?

Most common food allergy in infancy

Affects an estimated 2-7.5% of UK births1
– 5% would be 38,000 babies/year
(imagine filling the 02 arena twice over)

Generally resolves by 1-3 years of age2
1 Hill DJ et al. J Pediatr 1986; 109; 270-276.
2. Høst A. Ann Allergy Asthma Immunol 2002; 89 (6 Suppl 1): 33-37.
ALLERGY OR INTOLERANCE?
Hypersensitivity
Involving the
immune system
Food allergy
(allergic hypersensitivity)
Not involving the
immune system
Food intolerance
(non-allergic hypersensitivity)
IgE mediated allergy
Non-IgE mediated allergy
Adapted from Johansson SGO et al. 2004.
Go to symptoms
ALLERGIC SYMPTOMS
Body system affected
Symptoms
Oral tract
• Itching and redness
of mouth and lips
Respiratory tract
• Rhinitis
• Asthma
• Wheezing
Skin
• Urticaria
• Angiodema
• Atopic dermatitis
Gastrointestinal tract
• Vomiting
• Abdominal pain
• Diarrhoea
BREASTFEEDING
IS THE GOLD STANDARD
IN INFANT NUTRITION TO
Protection
against
Protection
chest
against
infections
diarrhoea and
and
upset
wheezing
stomach
Lower risk
of
Less
smelly diabetes
nappies
Protectio
n against
ear
infections
6 MONTHS
Breastmilk content per 100ml1
Better
mental
development
Less
eczema
1. Jensen RG (ed) Handbook of Milk Composition. New York: Academic Press, 1995. 2. Vandenplas Y et al.
Arch Dis Child. 2007; 92 (10): 902-908.
DIAGNOSIS AND MANAGEMENT OF CMPA IN FORMULA-FED INFANTS*
*Adapted from Vandenplas Y et al. Arch Dis Child. 2007; 92 (10): 902-908.
DIAGNOSIS AND MANAGEMENT OF CMPA IN FORMULA-FED INFANTS*
*Adapted
from Vandenplas Y et al. Arch Dis Child. 2007; 92 (10): 902-908.
MANAGEMENT IN BREAST FED INFANTS

MILD TO MODERATE:
1.
CONTINUE BREAST FEEDING BUT ELIMINATION DIET IN
MOTHER 2-4 WEEKS WITH CA SUPPLEMENT AND NO EGG
2.
IF IMPROVEMENT REINTRODUCE CMP AND CHECK
SYMPTOMS –IF YES THEN eHF AFTER BF, SOLIDS
WITHOUT CMP UNTIL 9-12 MONTHS AND ATLEAST FOR
6/12. EGG TO BE ADDED IF NO SYMPTOMS.
SEVERE CMPA:
1.
REFER PAEDIATRICS AND IN MEANTIME ELIMINATION
DIET IN MOTHER PLUS CA SUPPLEMENT
VANDENPLAS: ADC OCT 2007,92, P 902-08
EFFECTIVE MANAGEMENT OF CMPA WITHIN THE NHS COULD
LEAD TO QUICKER IMPROVEMENT IN SYMPTOMS AND REDUCE THE
BURDEN ON NHS RESOURCES
Management of cows’ milk allergy in the UK
Sladkevicius & Guest, 2008
 1,000
infants with CMPA analysed for treatment patterns and outcomes over
first 12 months following initial presentation to a GP
 Mean age to be put on a diet after initially seeing a GP was 2.2 months
 Mean time to diagnosis = 3.6 months
 Time to symptom resolution = 2.9 months
 Average 18.2 GP visits over 12 months
 42% of patients referred to a specialist physician
 Waiting time for referral = approx 3.7 months
 Mean 7.6 GP visits before referral
Conclusion
 Consensus
guidelines are required for the management of CMPA in order to
shorten the time to treatment, diagnosis and symptom resolution and to decrease
the consumption of healthcare resources
Sladkevicius E & Guest J. Abstract presented at WCPGHAN, Brazil, August 2008: WCP-307.
EFFECTIVE MANAGEMENT OF CMPA WITHIN THE NHS COULD
LEAD TO QUICKER IMPROVEMENT IN SYMPTOMS AND REDUCE THE
BURDEN ON NHS RESOURCES
Budget impact of managing cows’ milk allergy in
the UK
Sladkevicius & Guest, 2008
 Each
infant with CMPA costs an estimated £1,289 to the NHS over the first
12 months after initial diagnosis
 For managing 18,350 infants in the UK this equate to an estimated annual cost
of £23.6 million
Conclusion
 Any
strategy that can improve healthcare delivery and thereby shorten the time
to diagnosis, treatment and symptom resolution should potentially decrease the
burden CMPA imposes on the UK’s NHS
Guest J & Sladkevicius E. Abstract presented at WCPGHAN, Brazil, August 2008: WCP-309.
SOYA-BASED FORMULAS
 Historically
used for the management of food hypersensitivity
(e.g. lactose intolerance and CMPA)
 Approximately
2% of formula-fed infants are fed a soya-based
formula by 10-14 weeks¹
 Sales
of soya based infant formula accounted for 260,000kg in
2008,
0.9% of total infant formula sales¹
 However,
studies have shown that some 30-50% of infants given
a soya-based formula for the management of CMPA present with
concomitant soya protein allergy²
1. AC Nielsen/IMS.
2. ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2006; 42: 352-361.
SOYA-BASED FORMULAS
Chief Medical Officer’s
Statement on soya-based
formulas¹ (Jan 2004)
• Soya-based formulas should not be first
choice for the management of infants with
proven cows’ milk sensitivity due to the
potential risk from their high phytoestrogen
levels
• Soya-based formulas should only be used in
exceptional circumstances to ensure
adequate nutrition, e.g. for vegans or
infants who find alternatives unacceptable
• ESPGHAN are also in agreement and state
that "Soya protein formula should not be
used in infants with allergy during the first
6 months of life”. They also raise concerns
over their use
post 6 months and suggest that soya
tolerance "should first be established by
clinical challenge”2
1. Department of Health. CMO's Update 37 - January 2004. London: Department of
Health, 2004.
2. ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2006; 42: 352-
PRESCRIBABLE INDICATIONS
Product
Indications
Uses
Cows’ milk protein intolerance
± secondary lactose intolerance
Cows’ milk protein
allergy/intolerance
Disaccharide ± whole protein
intolerance, or where amino acids
and peptides are indicated
for use with MCT
Complex multiple food
intolerances and malabsorption
Disaccharide ± whole protein
intolerance
Cows’ milk protein allergy
Cows' milk allergy, multiple food
protein intolerance and other
conditions where
an elemental diet is indicated
Severe cows’ milk allergy
and multiple food intolerances
CONCLUSION
CONSIDER CMPA EARLY- REMEMBER GOR
IS AS COMMON AND DOES NOT NEED
ELIMINATION DIET
 TREAT EARLY
 AVOID SOY BASED FORMULAE UNTIL
ATLEAST 6 MONTHS. AVOID GOAT’S MILK,
RICE MILK (ARSENIC) AS NOT
APPROPRIATE CALORIES AND NUTRITION
 IF IN DOUBT DISCUSS WITH COLLEAGUES

THE LEARNING CURVE

ALLERGY WORKSHOPS: DIAGNOSING AND
MANAGING CMPA IN COMMUNITY AND
WEANING THE ALLERGIC CHILD
THURSDAY 16TH SEPTEMBER
 REGISTRATION 1730-1800(INC BUFFET)

HAYDOCK THISTLE HOTEL, PENNY LANE
HAYDOCK WA11 9SG
 COST £ 10- NUTRICIA LTD
 PHONE 0800 781 7195
 E MAIL: INFO@LEARNINGCURVE.UK.NET
