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innovative treatments in cow’s milk allergy

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Innovative treatments in cow’s milk allergy is the last in this 5-part blog series on Cow’s Milk Allergy in Infancy and is best read following positive outcomes for cows milk allergy.

Infants who develop Cows Milk Allergy (CMA) usually outgrow it before they start school. Until recently, dietary treatment was based on strict cow’s milk avoidance for long periods; typically 1-2 years. Introduction is now advised at an earlier age, especially for those with delayed reactions affecting the gut. Starting with tiny amounts of baked milk as early at 9 months, identifies those infants who are ready to start building tolerance. It is now believed that strict avoidance for long periods is unhelpful in promoting tolerance.¹ Infants with more severe (IgE) reactions do take longer to outgrow their allergy, and care needs to be taken to make introductions safely for those infants.

Active Allergy Management
Active Allergy Management is one of today’s most innovative treatments in cow’s milk allergy. It can be described as the deliberate, early introduction of tiny amounts of milk proteins in a controlled way. Effective and safe for the majority of infants with CMA, the timing of this introduction depends upon age and the type and severity of previous reactions. See my blog identifying symptoms of cow’s milk allergy for more information. Tolerance to baked milk is now used as a marker of readiness for the next steps of cows milk reintroduction.²  This step-wise approach is known as the Milk Ladder, the earliest introduction of which can begin for non-IgE CMA around 9 months. Actively exposing an infant and educating the immune system in this way, enables young children to eat a normal diet at any earlier age.

The Infant Microbiota
The infant microbiota describes the total number of microbes living in an infants gut. Recent research shows earlier tolerance to cow’s milk using CMA treatment formulas with the added probiotic microbe strains Lactobacillus rhamnosus or Bifidobacteria breve . Other treatment formulas with added prebiotic co-factors (specialised sugars called oligosaccharides) may also be helpful, by providing food for these beneficial microbes. Breast feeding is known to be protective for food allergy. Although the mechanisms are not entirely understood, the higher numbers of lactobacillus and bifidobacteria which dominate the microbiota of breast fed babies are likely to be involved. Intimately involved with educating the immune system, the infant microbiota has a key role to play in allergy development and management.  Specialised formulas are now available (on GP prescription) which mimic the breast milk provision of those beneficial microbe species alongside prebiotic co-factors that help colonise the infant microbiota, with earlier resolution for children with Cow’s Milk Allergy.

  1.  Dietary baked milk accelerates the resolution of cow’s milk allergy in children, Kim JS et al 2011
  2. Tolerance to baked and fermented cow’s milk in children with IgE mediated and non IgE mediated CMA in patients under 2 years, Uncuoglu A et al, 2017

Next An introduction to the Infant Microbiome

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positive outcomes for cow’s milk allergy

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Positive outcomes for cow’s milk allergy is the 4th in the 5-part blog series on Cow’s Milk Allergy in Infancy and is best read following treatment options for cow’s milk allergy.

Around 50% of infants with non-IgE Cow’s Milk Allergy tolerate milk by age 1. Positive outcomes for Cow’s Milk Allergy depend on a number of factors including the type and severity of symptoms; the length of time taken to confirm a diagnosis; and the infants ability to tolerate exposure to baked and fermented milk. Good ongoing dietary management and support, helps those positive outcomes for cow’s milk firstly by ensuring symptoms are settled and supported with a milk free diet whilst breastfeeding or with the most suitable formula. Mum and baby can then develop confidence with feeding; mum managing the learning curve of a cow’s milk free diet, and baby learning that feeding doesn’t hurt.

Active Allergy Management
Only once there are no residual symptoms for at least 3 months exposure maybe considered; firstly to small amounts of baked milk and then fermented milk or yoghurt.  Active Allergy Management involves the deliberate introduction of small amounts of milk proteins at the right time. This helps to educate the immune system and develop tolerance.  Acquiring tolerance in this way speeds up the return to a normal diet. Considerations then:

Type and severity of symptoms
Infants with severe or immediate reactions (IgE) take longer to out grow their allergy. Those infants should not consume cow’s milk products within the first year after diagnosis, although 75% can tolerate small amounts of yoghurt by age 2.   For delayed reactions (non-IgE) such as reflux – see identifying symptoms of cow’s milk allergy most infants (>50%) have outgrown their allergy by their first birthday.

Length of time taken to confirm a diagnosis
In a 2015 survey, the average length of time taken to confirm a diagnosis was 4-5 weeks and 10 GP visits.  I am now seeing infants at a much earlier stage, due mainly to increased awareness in GP’s and in families. Early intervention is the key to seeing those positive outcomes for cow’s milk allergy at an earlier stage. In general, the longer it takes to identify symptoms, and confirm a diagnosis the longer it will take to acquire tolerance.

Ability to tolerate exposure to baked and fermented cow’s milk
Exposure and tolerance to baked and fermented cow’s milk, with the use of the Milk Ladder has seen more positive outcomes for cow’s milk allergy at an earlier stage. The Milk Ladder provides evidence based stepwise reintroduction of milk products; which can usually begin around 9 months of age. The latest version is available to download from the Allergy UK website.

Next Innovative Treatments in Cow’s Milk Allergy

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treatment options for cow’s milk allergy

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Treatment options for cow’s milk allergy is the 3rd in this 5-part blog series on non-IgE Cow’s Milk Allergy in Infancy and is best read following confirming a diagnosis of cow’s milk allergy.

 

Treatment options for cow’s milk allergy in infancy depend on the severity of symptoms and whether breast, formula or combination feeding is the preferred choice for parents.  An allergy focused clinical history taken by a GP or Paediatric Dietitian, will have the key information on which the best treatment options for cow’s milk allergy can be considered for both mum and baby.

Considerations

  • Breast feeding the cow’s milk allergic infant
  • Supplementary calcium, iodine and Vitamin D for mum
  • Advantages of continuing breast feeding for mum and baby
  • Alternative formulas for the cow’s milk allergic infant
  • First line prescription formulas
  • Symptoms requiring a more specialised formula

Breast feeding the cow’s milk allergic infant
Breast feeding can safely continue in the knowledge that it is protective for the allergic infant, with many advantages.  But it’s not without it’s challenges! Strict avoidance of all cow’s milk and it products, including the small amounts hidden in foods, will resolve the symptoms.  Mum needs to follow a well-balanced but strictly cow’s milk free diet at a time when her needs for nutrition are especially high. The widely available range of milks such as soya, oat, rice and nut milks are low in nutritional value and make a poor contribution to mums’ nutritional needs.  Mum needs to be committed and knowledgeable about her own needs.  For mums whose weight is low or who struggle to eat enough, or for mums who are having difficulty coping should seek further advice if they wish to continue breast feeding.  For babies with severe atopic eczema and poor weight gain, a formula milk should be considered.

Nutrition for mum and baby
Cow’s milk (and it’s products) are the principal source of calcium and iodine in UK diets, with needs increased during pregnancy and lactation by around 50-66%. Calcium is of central importance for women’s bone health and iodine for foetal and infant brain development and function.  Vitamin D is limited in foods but essential to ensure calcium is absorbed into bone and together with calcium and iodine should be taken in supplement form.

Breastfeeding Pros for baby Pros for mum
  • Improved immune development
  • Reduced incidence of ear, gut and respiratory infections
  • Enhanced tolerance to new foods
  • Enhanced taste development, facilitating broader weaning foods
  • Development of varied Microbiome, enhancing immune development
  • Bonding with baby
  • Helpful in return to pre-pregnancy weight
  • Reduction in breast cancer risk
  • Convenience and low cost
  • Bonding with baby

Alternative formulas for the cow’s milk allergic infant
Soya or goats milk formula are not recommended as treatment options for cow’s milk allergy in infants: 50 – 66% of infants will have immune reactions similar to those in cow’s milk allergy. Broadly, two types of formula are available as treatment options for cow’s milk allergy in infancy – peptide (EHF) or amino acid (AA).   The first treatment option is an extensively hydrolysed formula (EHF), in which the proteins are hydrolysed, “digested” or  broken down into short chains called peptides. The immune system does not recognise these peptides as cow’s milk protein in 90-95% of infants with non-IgE CMA, and the EHF is well tolerated.  There are a variety of EHF types and brands available on prescription, subtely suited to different needs, and is one area of a Paediatric Dietitian’s expertise.  Current EHF formulas are available with or without lactose (the milk sugar); casein (curds) or whey based protein; first or second (follow-on) milks with added iron and calcium.  Lactose has the advantage of making the formula taste better, but may not be well tolerated in infants with delayed diagnosis. Whey based formulas tend to empty from a baby’s tummy more quickly and may help improve symptoms of reflux. Second or follow-on milks are only suited for babies over 6 months.

Symptoms requiring a more specialised formula
For infants who develop symptoms of cow’s milk allergy during exclusive breast feeding, have severe symptoms or who are symptomatic following a 2-4 week trial on an EHF, an amino acid formula (AA) is indicated.  Proteins in this type of formula are further broken down from peptide chains into individual units called amino acids and are well tolerated by almost all infants.  As an expensive option (£30 per tin) careful consideration is given to its prescription.

Next Positive Outcomes for Cow’s Milk Allergy

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confirming a diagnosis of cow’s milk allergy

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Confirming a diagnosis of Cow’s Milk Allergy is the 2nd in this 5-part blog series about Cow’s Milk Allergy in Infancy and is best read following identifying the symptoms of cow’s milk allergy.

Common symptoms of CMA eg. loose stools, pain/colic and reflux frequently occur in babies without CMA.  This makes the diagnosis a bit tricky.  CMA is more likely when there are at least two significant problems present which impact the baby’s wellbeing, growth or feeding.  In the absence of reliable tests, the following diagnostic pathway is used by GP’s, Paediatricians and Paediatric Dietitians in order to confirm (or exclude) a diagnosis of cow’s milk allergy.

  1. An allergy focused clinical history including questions about family and individual atopy (eczema, asthma, hayfever), infants feeding and growth history, signs and symptoms focused on the gut, skin and respiratory systems, details of previous management.
  2. If the history is suggestive of Cow’s Milk Allergy, determination of whether symptoms are likely to be IgE (immediate) or non-IgE (delayed) and referral for allergy tests if IgE suspected.  The severity and timing of reactions being important. A 2-4 week trial of a strict cow’s milk exclusion diet with suitable formula, or maternal avoidance if breast feeding, with advice on supplementation of 1000mg Calcium + 10ug Vitamin D.
  3. Resolution of symptoms during the exclusion followed by obvious and confirmed relapse on re-introduction (formula or maternal consumption if breast-feeding) confirms the diagnosis.
  4. A diagnosis can only be made following a planned reintroduction of cow’s milk, which has resulted in the relapse of symptoms, mostly commonly in in 4 out of 5 infants following this diagnostic pathway.

Confirming a diagnosis of cow’s milk allergy in a timely manners and ensuring the most appropriate treatment and support is important for a variety of reasons.  For non-IgE CMA (delayed reactions) – gut symptoms resolve, pooh habits improve, tummy’s are more comfortable, eczema improves, feed volumes increase, infants are happier feeding, positive associations with feeding are made.  All of which support growth & feeding development, which in turn makes the next steps in feeding ie. weaning to solids, run much more smoothly.  Sleep is improved for all and parents anxiety is reduced – mostly!  So, just a few things then! Timely treatment also reduces risks to the baby of developing other food allergies, which are related to the presence of atopic conditions such as infant eczema.

Non-IgE Cow’s Milk Allergy is the first and most common food allergy to develop, affecting around 5% of infants in the UK, both in exclusively breast-fed and bottle-fed babies, and usually treated by the GP.  A diagnosis can be made anytime during the first year, and will depend on the severity of symptoms, other co-exisiting conditions eg. eczema and feeding or growth related difficulties.

Next Treatment options for Cow’s Milk Allergy

 

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identifying the symptoms of cow’s milk allergy

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Identifying the symptoms of Cow’s Milk Allergy is the 1st part in this 5-part blog series about Cow’s Milk Allergy in Infancy.

Cow’s Milk Allergy (CMA) is an immune reaction to the proteins found in cow’s milk affecting 1 in 20 infants in the UK.  There are two distinct types of cow’s milk allergy: IgE reactions with immediate onset of symptoms and non IgE reactions with delayed onset.  In both types, symptoms range from mild-moderate to severe and persisting with potentially life-threatening reactions such as anaphylaxis. The following table will help you in identifying the symptoms of Cow’s Milk Allergy.

Delayed Onset Symptoms

Non-IgE Cow’s Milk Allergy

2 – 72 hours after milk intake

 Immediate Onset Reactions

IgE Cow’s Milk Allergy

Minutes after milk intake
Affecting formula-fed, exclusively breast fed infants or at the onset of mixed feeding/solids Affecting formula-fed infants or at the onset of mixed feeding
Gastrointestinal symptoms may be mild-moderate or severe and persisting
colic, reflux, loose, frequent stools, soft stool constipation, painful wind,  blood or mucous in nappy, food refusal, feeding aversion, poor growth vomiting, diarrhoea, colic
Skin symptoms can be mild-moderate or severe and persisting
itchy, raised red rash, atopic eczema intense itching, erythema (raised red rash), urticaria (flushing, spreading rash), flare up of atopic eczema, angioedema (facial swelling)
Respiratory symptoms are confined to IgE reactions
acute rhinitis (hayfever), conjunctivitis (swelling in and around the eyes) ANAPHYLAXIS

This blog series will focus on non-IgE CMA with delayed onset, which although less severe can be more complex and difficult to diagnose.  This is due to a number of issues: the similarity to other common conditions during infancy such as colic, reflux or loose stools and also the symptoms being mistakenly treated as lactose intolerance. Again this is due to the similarity in gut symptoms such as colic, bloating, discomfort and diarrhoea.  Unlike IgE CMA, there is no diagnostic allergy test for non IgE CMA and because reactions are delayed up to 72 hours after intake, cause and effect is not quite so clear. Lactose intolerance does not involve immune reactions, but results from lack of the digestive enzyme lactase, with malabsorption of the “milk sugar” lactose  causing discomfort and diarrhoea. A lactose free formula (which normally contains cow’ s milk protein) will resolve lactose intolerance but not Cow’s Milk Allergy,

Non IgE Cow’s Milk Allergy in infancy responds extremely well to prompt dietary treatment, with the majority of infants outgrowing their allergy within 6-12 months.  Delays in diagnosis and treatment lead to symptoms becoming severe and persistent, with feeding difficulties and growth faltering more evident.  Identifying the symptoms of Cow’s Milk Allergy early and discussing an allergy focused history with a trained GP or Paediatric Dietitian will assist making a diagnosis and accessing prompt appropriate treatment.

Next Confirming a diagnosis of Cow’s Milk Allergy.

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cow’s milk allergy in infancy

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Cow’s Milk Allergy in Infancy affects 1 in 20 babies in the UK.  Sign up to my Blog series for this 5-part, evidence based overview of the condition: from identifying symptoms to acquiring tolerance.

cow's milk allergy in infancy

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