Clinical Standars and Guidelines for Cows Milk Protein Intolerance/Allery

NUTRITION AND DIETETIC DEPARTMENT

PROFESSIONAL CONSENSUS STATEMENT

GUIDANCE FOR COW'S MILK PROTEIN INTOLERANCE/ALLERGY

TARGET GROUP

Children (0-18) who have been clinically and dietetically assessed and found to be, or for investigation of cow's milk protein intolerance/allergy.

AIM OF DIETETIC INTERVENTION

1. To enable parent/carer/child to exclude all dietary sources of cow's milk protein. 2. Maintain a nutritionally complete diet, which meets the child’s need, including an adequate calcium and vitamin D intake.

TEAM AIMS

1. To improve symptoms relating to cow's milk protein intolerance/allergy. 2. To achieve and maintain the appropriate centile for height and weight.

STANDARDS

Parent/carer/child is given information to enable:

1. Appropriate selection of milk substitutes. There are many types of milk available, choosing the appropriate formula will be dependent on the individual case, clinical presentation, age, palatability and nutritional status.

Breast Milk

Exclusive breast feeding is method of choice for six months. Cows milk protein B lactoglobulin can be detected in the milk of 95% lactating women but is tolerated by the majority of infants with cows milk protein allergy/intolerance. However if symptoms persist, (often in infants with severe atopic eczema or enterocolitis), a trial of cows milk protein free diet for mother may be needed. It is important to ensure an adequate calcium and vitamin D intake for the mother ( see appendix 1).

For infants where breast milk is not an option then a suitable infant formula should be used. Hypoallergenic formulas available in the UK

Type of Name of Formula Age Comments Formula restriction Extensively Ist line at HEFT <6 months Birth to 6 Contains higher level of pepties hydrolysed casein age months below 1.5Kd. Nutramigen lipil 1 (mead and Johnson) Well tolerated in children with IgE 6months to mediated allergy 1st line at HEFT >6months 2 years age Nutramigen lipil 2 Mead and Johnson) Extensively Pregestimil Birth to 2 Contains 54% MCT hydrolysed casein (Mead and Johnson) years Extensively Pepti 1 Birth to Contain 40% lactose hydrolysed whey (Aptamil) 6months Whey empties the stomach faster so may be of benefit to children with gastrointestinal symptoms

Pepti 2 6 months to Addition of lactose improves taste (Aptamil) 2 years Extensively Pepti-Junior Birth to 2 Contains 50% MCT hydrolysed whey (Cow and gate) years Can be used as first line if MCT is indicated Non milk bases Prejomin From birth Contain meat derivatives so not extensively (Milupa) suitable for certain cultures, hydrolysed religions or vegetarians. Poor taste formulas Peptide (SHS)

MCT Peptide (SHS) Soya Formulas SMA Wysoy From 6 Not recommended for children months to 2 under 6 months (see appendix 2) years Alternatively Alpro Junior 1+ can Cow & Gate Infasoy be used from the age of 1 year in place of formula

Beyond 2 years calcium rich soya milk can be used as an alternative source of milk Elemental amino Neocate LCP 1ST line at From birth Indicated when hydrolysed acid based HEFT if symptoms persist until infant formulas do not resolve symptoms formula with extensively has grown or when there is a evidence of hydrolysed formula out of severe/multiple allergy allergy

Nutramigen AA (Mead and Johnson) At HEFT we use Nutramigen 1 and 2 or Pepti Junior (if MCT indicated) as our first line infant formula. If symptoms persist then Neocate LCP is used. It is estimated that upto 10% infants will continue to react to extensively hydrolysed formula due to the residual cows milk protein peptides.

Infants over 6 months of age often reject the introduction of hypoallergenic formula due to the poor taste compared to breast milk / standard infant formula. To help this : a. Hypoallergenic formula should be introduced as soon as possible. If breast feeding continues then use incremental mixing of the two milks to aid transition. b. Offer the hypoallergenic formula as the only fluid source c. If over 6 months of age introduce the formula in a beaker d. Mask the smell with a few drops of vanilla essence e. As last resort mix hypoallergenic formula with commercial milkshake powders (as these are high in sugar and create a sweet preference). Once the formula is established gradually reduce the amount of milkshake powder added until formula is tolerated neat.

Older Children ( over 12 months of age)

Continue with breast milk or suitable formula. If on Neocate LCP, Neocate Active (1-10yrs) or Neocate Advance (1-10yrs) can be used . Neocate Active contains more calcium and iron. If child is having a soya formula, Alpro 1+ could be introduced if diet adequate.

Other mammalian milks (sheep, goat, horse,water buffalo) have similar milk proteins to cows milk and thus harbour an allergic potential and are not suitable alternatives to cows milk.

Replacement milks ( rice, oat, soya, pea,coconut) have a poor nutrient content compared to cows milk. There are lower in calories, protein, fat soluble vitamins and minerals. If used the calcium enriched varieties should be advised.

Due to concerns regarding arsenic levels in rice milk the food standard agency advises it should not be given in children under 4 1/2 years of age ( see appendix 3).

2. Successfully follow a strict cow's milk free diet. 3. Achieve a nutritionally adequate diet that meets estimated requirements. When necessary, appropriate dietary supplements e.g. Calcium and Vitamin D are recommended. 4. To achieve/maintain the child’s expected weight for height. 5. To obtain prescription if required for milk substitute on FP10 form from the child’s GP. (See appendix 4 for prescribing guidelines)

MEASURE OF SUCCESS

Parent/carer/child is able to:

1. Use and incorporate cow's milk substitute as advised by the Dietitian. 2. Avoid cow’s milk and its derivatives from the child’s diet. 3. Provide a diet which is balanced and meeting child’s nutritional requirements. 4. Achieve/maintain the child’s weight within the normal limits. 5. Contact the Dietitian if needed. 6. Obtain milk substitute on a prescription from the GP if appropriate. RESOURCES

. Child Health Foundation Four in One Growth Chart (boys and girls)1996.

. Child Health Foundation 0-4yrs old growth chart (boys and girls) 2009

. Dietary Reference Values for Food Energy and Nutrients for the UK 1997.

. Nutritional Requirements for Children in Health & Disease (GOS) 2000.

. Srndi Milk free zone diet sheet

. Srndi Milk free weaning diet sheet

. Composition of milk alternatives ‘H drive- specialist Team Folders-Paediatrics’

. Calcium Intake on a Cows Milk Free Diet (HEFT diet sheet) . Milk free product information Pepti Junior Recipe & Information Booklet.  Aptamil Pepti recipe and information booklet  Nutramigen recipe cards

PROCESS

Parent/carer/child are seen in accordance to general standards for dietetic consultation: interview and documentation.

1. Introduce yourself and explain the purpose of the consultation. 2. Explain reasons for cow's milk protein exclusion. 3. Measure weight and height, plot centile. 4. Take a dietary history of present intake. 5. Note clinical symptoms reported. 6. Clearly outline sources of cow’s milk protein and derivatives. 7. Identify sources included in current dietary intake. 8. Explain food labelling. 9. Recommend a suitable milk substitute and advise regarding use and incorporation into cow’s milk free diet. 10. Advise on dietary practices as appropriate to child’s requirements and assess calcium intake. 11. Provide parent/carer with written information to support advice. 12. Dietitian’s name and contact number is given. 13. Contact child’s GP if required to prescribe milk substitute where appropriate.

FOLLOW-UP

. Follow-up arranged as written in general standards for dietetic consultation : interview and documentation.

. Follow-up within one month of initial consultation and then at the discretion of Dietitian.

. Arrange cow’s milk protein dietary challenge at the discretion of Dietitian/Clinician.

. Cow’s milk protein intolerance children > 5 years old: review annually to assess quality of diet. References

Food Hypersensitivity. Diagnosing and Managing Food Allergies and Intolerance. Isabel Skypala and Carina Venter . Wiley-Blackwell (2009) Appendix 1

Daily Calcium requirements

AGE Calcium required (mg) 0 – 12 months 525 mg

1 – 3 years 350 mg

4 – 6 years 450 mg

7 – 10 years 550 mg

Males 11 – 18 years 1000 mg

Males 19 + years 700 mg

Females 11 – 18 years 800 mg

Females 19 + years 700 mg

Breast Feeding Female requirements + 550 mg Appendix 2

Paediatric Group of the BDA position statement Use of infant formulas based on soy protein for infants (Oct 2010)

PaediatricGroupGuidelineSoyInfantFormulas[1].pdf Appendix 3 Arsenic in rice research published Thursday 21 May 2009

The Agency has today published results from two studies: arsenic levels in rice drinks and one on cooking methods to reduce arsenic levels in rice. As a result of the rice drink study, the Agency recommends that toddlers and young children should not have rice drinks, often known as rice milk, as a replacement for cows’ milk, breast milk or infant formula.

The rice drink study followed concerns about results from a study published last year that measured arsenic levels in these types of drinks. The research published today examined 60 samples of rice drinks and found low levels of arsenic in all of them (see The science behind the story section below).

The level of total arsenic ranged from 0.010 - 0.034 milligram/kilogram and the levels of inorganic – the more harmful – form of arsenic ranged from 0.005 - 0.020 milligram/kilogram. The proportion of inorganic arsenic in the rice drink samples ranged from 48 - 63%. None of the results were over the current legal limit (but see the Current regulations section below).

In the second study, researchers looked at the effect of cooking methods on arsenic content of rice. The Agency is not advising anyone to change the way they cook rice as a result of this study as the impact on the overall dietary intake of arsenic from different cooking methods is minimal.

What the Agency advises As a precaution, toddlers and young children between 1 and 4.5 years old should not have rice drinks as a replacement for cows’ milk, breast milk, or infant formula. This is because they will then drink a relatively large amount of it, and their intake of arsenic will be greater than that of older children and adults relative to their bodyweight. This is both on nutritional grounds and because such substitution can increase their intake of inorganic arsenic, which should be kept as low as possible. A daily half pint or 280 millilitres of rice drink could double the amount of the more harmful form of arsenic they consume each day.

There is no immediate risk to children who have been consuming rice drinks and it is unlikely that there would have been any long-term harmful effects but to reduce further exposure to arsenic parents should stop giving these drinks to toddlers and young children.

If your child is allergic to cows’ milk, you are strongly advised to seek advice from your health professional or dietitian on suitable replacements.

Other groups of people do not need to change their diet because their exposure to inorganic arsenic from rice drinks is lower relative to their bodyweight.

Children under a year old should drink breast milk or infant formula milk. Cows’ milk or alternatives are not suitable as a drink until an infant is 12 months old.

The research published today does not affect the Agency’s advice on any other weaning foods. Advice from a survey in 2007, which included baby rice and other rice products, concluded that these foods did not have levels of inorganic arsenic that caused concern.

Further information: For further information on this survey, please contact: [email protected]

The science behind the story Arsenic is widely distributed in the environment. It occurs in soil, water – both sea and fresh – and in almost all plants and animal tissues. As a result, arsenic occurs naturally at very low levels in many foods and it is not possible to avoid it completely. How harmful the arsenic is depends on the chemical form in which it is present. The organic form is less harmful than the inorganic form which can cause cancer by harming our genetic material (DNA). Rice and rice products have higher levels of the inorganic form of arsenic compared with other food. The Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT) (an independent scientific committee that provides advice to the Food Standards Agency) has concluded that people should consume as little of this form of arsenic as reasonably practicable. Appendix 4

Guidelines for Prescribing Specialist Infant Formula in Primary Care September 2012. Full Document can be found on the ‘H’ Drive- Specialist Team Folders- Paediatric Team- Prescribing

Hdrive: Paed folder18.Stan.cows milk intol (April 2014) (Review April 2016)