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Managing Cows' Milk Allergy in Children

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Managing Cows' Milk Allergy in Children CLINICAL REVIEW Managing cows’ milk allergy in children Follow the link from the online version of this article to obtain certi ed continuing 1 2 3 1 4 medical education credits Sian Ludman, Neil Shah, Adam T Fox . 1Children’s Allergy Service, Guy’s Cows’ milk allergy mainly affects young children and SOURCES AND SELECTION CRITERIA and St Thomas’ NHS Foundation because it is often outgrown is less commonly seen in older Our search included PubMed, the Cochrane Collaboration Trust, London SE1 9RT, UK using the search terms “Cow’s milk allergy,” “milk allergy,” 2 children and adults. It is one of the most common child- Paediatric Gastroenterology “natural history,” “management,” and “treatment.” When Department, Great Ormond Street hood food allergies in the developed world, second to egg 1 2 possible, evidence from randomised controlled trials and Hospital, London, UK allergy, affecting 2-7.5% of children under 1 year of age. 3 systematic reviews were used, although case series and TARGID, KU Leuven University, The mainstay of treatment is to remove cows’ milk protein observational studies were also included. We referenced Belgium from the diet while ensuring the nutritional adequacy of 4Division of Asthma, Allergy and expert review articles and used expert clinical opinion. Lung Biology, MRC and Asthma UK any alternative. Centre in Allergic Mechanisms of Cows’ milk allergy can often be recognised and managed of sugar can cause bloating and diarrhoea), these are Asthma, King’s College London, UK in primary care. Patients warranting a referral to specialist extremely rare in very young children. Except after a gas- Correspondence to: A T Fox [email protected] care include those with severe reactions, faltering growth, trointestinal infection, infants with gastrointestinal symp- Cite this as: BMJ 2013;347:f5424 atopic comorbidities, multiple food allergies, complex toms on exposure to cows’ milk are more likely to have doi: 10.1136/bmj.f5424 symptoms, diagnostic uncertainty, and incomplete reso- cows’ milk allergy than lactose intolerance. This article lution after cows’ milk protein has been excluded. focuses on immune mediated reactions to cows’ milk in Although there are non-immune reactions to cows’ milk, children and reviews the evidence on how to diagnose and such as primary lactose intolerance (when malabsorption manage the condition. Table 1 | Symptoms and signs of IgE and non-IgE mediated cows’ milk allergy4 What is cows’ milk allergy? IgE mediated Non-IgE mediated Cows’ milk allergy is an immune mediated reaction to pro- 3 Skin teins within milk. Milk contains casein and whey fractions, Pruritus Pruritus each of which have five protein components. Patients can be Erythema Erythema sensitised to one or more components within either group. Acute urticaria—localised or generalised Atopic eczema Cows’ milk allergies are classified according to the Acute angioedema—most commonly lips, face, and around eyes underlying mechanism, which affects the presentation, Gastrointestinal system diagnosis, treatment, and prognosis. IgE mediated allergy Angioedema of the lips, tongue, and palate Gastro-oesophageal reflux disease is an immediate type (type 1) hypersensitivity reaction that Oral pruritus Loose or frequent stools occurs rapidly after exposure, usually within 20 minutes. Nausea Blood or mucus in stools One of the main causes of symptoms is histamine release, Colicky abdominal pain Abdominal pain and the symptoms are highlighted in table 1. Vomiting Infantile colic Non-IgE mediated allergy is a delayed type (type 4) hyper- Diarrhoea Food refusal or aversion sensitivity reaction that seems to be equally common but Constipation less well described than IgE mediated cows’ milk allergy. Perianal redness Non-IgE mediated milk allergy can occasionally cause a Pallor or tiredness severe form of allergic reaction with acute gastrointestinal Faltering growth in conjunction with at least one of above gastrointestinal symptoms (with or symptoms that can mimic sepsis (food protein induced without atopic eczema) enterocolitis syndrome). However, the T cell mediated Respiratory system (usually in combination with one or more of above symptoms and signs) reactions are usually more delayed and are often chronic Upper respiratory tract symptoms (nasal itching, sneezing, Lower respiratory tract symptoms (cough, chest because of continued milk exposure during infancy. Typical rhinorrhoea, stridor, or congestion ± conjunctivitis) tightness, wheezing, or shortness of breath) symptoms are largely gastrointestinal or cutaneous (table Lower respiratory tract symptoms (cough, chest tightness, 1).4 The high frequency of such symptoms in infants without wheezing, or shortness of breath) cows’ milk allergy, combined with the lack of an immediate Other temporal relation with milk exposure or any clinical tests, Signs or symptoms of anaphylaxis or other systemic allergic reactions can make non-IgE mediated allergy difficult to diagnose. How does it present? SUMMARY POINTS IgE mediated allergy usually manifests within minutes but Cows’ milk allergy is common, occurring in up to 7% of children and usually presents in infancy no longer than two hours after ingestion of cows’ milk pro- Allergy may be IgE mediated with rapid onset of symptoms such as urticaria or angioedema tein. Symptoms include angio-oedema of the oropharynx, or non-IgE mediated, producing more delayed symptoms such as eczema, gastro- oral pruritus, urticaria, and rhinorrhoea. Although most oesophageal reflux, or diarrhoea reactions are mild, around 15% may be more severe with Management is by exclusion of cows’ milk protein from the diet (including from the diet of a features of anaphylaxis such as stridor or wheeze.5 breastfeeding mother) under dietetic supervision Non-IgE mediated allergy presents with more non-specific Most children with milk allergy outgrow it (average age 5 years for IgE mediated and majority by age 3 years for uncomplicated non-IgE mediated allergy) symptoms that are often chronic because of regular con- sumption. The most common presentations are treatment 28 BMJ | 21 SEPTEMBER 2013 | VOLUME 347 CLINICAL REVIEW bmj.com Oer age appropriate information that is relevant to type of allergy (IgE mediated, non-IgE mediated, or mixed) including: Previous articles in this Type of allergy suspected series Risk of severe allergic reaction Any impact on other healthcare issues such as vaccination Ж Personality disorder Diagnostic process, which may include: (BMJ 2013;347:f5276) Elimination diet followed by possible planned rechallenge or initial food reintroduction procedure Skin prick tests and speci­c IgE antibody testing and their safety and limitations Ж Dyspepsia Referral to secondary or specialist care (BMJ 2013;347:f5059) Support groups and how to contact them Ж Tourette’s syndrome (BMJ 2013;347:f4964) IgE mediated allergy is suspected Non-IgE mediated allergy is suspected Ж Developing role of HPV in cervical cancer Oer skin prick test and/or blood tests for speci­c IgE antibodies Try eliminating suspected allergen for - weeks, then reintroduce prevention to suspected foods and likely co-allergens. Base choice of test on: Consult dietitian with appropriate competencies about Clinical history and nutritional adequacies, timings, and follow-up (BMJ 2013;347:f4781) Suitability for, safety for, and acceptability to child (or their Taking into account socioeconomic, cultural, and religious issues, Ж Frontotemporal parent or carer) and oer information on: Available competencies of healthcare professional What foods and drinks to avoid dementia Test should only be undertaken by healthcare professionals with How to interpret food labels (BMJ 2013;347:f4827) appropriate competencies Alternative foods to eat to ensure balanced diet Only undertake skin prick tests where there are facilities to deal Duration, safety, and limitations of an elimination diet with an anaphylactic reaction Oral food challenge or reintroduce procedures, if appropriate, Interpret test results in context of clinical history and their safety and limitations Do not use atopy patch testing or oral food challenges to diagnose If allergy to cows’ milk protein is suspected, oer: IgE mediated allergy in primary care or community settings Food avoidance advice to breastfeeding mothers Information on appropriate hypoallergenic formula or milk substitute to mothers of formula fed babies Consult dietitian with appropriate competencies Consider referral to secondary or specialist care if: Symptoms do not respond to single allergen elimination diet Child or young person has con­rmed IgE mediated food allergy and concurrent asthma Tests are negative but there is strong clinical suspicion of IgE mediated food allergy Fig 1 | National Institute for Health and Care Excellence recommendations for diagnosis and management of cows’ milk allergy4 resistant gastro-oesophageal reflux, eczema, colic or persis- What are the symptoms? tent crying, diarrhoea (sometimes with mucous or blood), An allergy focused history is vital in establishing food aversion, and, less commonly, constipation. Gastroin- whether cows’ milk allergy is a potential diagnosis in testinal symptoms are thought to be due to gastrointestinal patients presenting with suggestive symptoms. The inflammation and associated dysmotility. investigations depend on whether the clinician suspects an IgE or non-IgE mediated allergy. The history should Who is affected? elicit the symptoms and how quickly they occur after Cows’ milk allergy affects all ages but
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