NUTRITIONAL MANAGEMENT OF SUSPECTED COW’S MILK PROTEIN ALLERGY

DOCUMENT TYPE: GUIDELINE

Purpose

To create a guideline which includes a systematic way of managing suspected Cow’s Milk Protein Allergy (CMPA) for consistency of care across disciplines. The purpose of this document is to provide evidence-based and easy to understand information for health care providers so they can determine the feasibility and success of the diet. Individual clinical assessment should be applied throughout treatment.

Background

CMPA is a common food allergy in early childhood with an incidence of 2-3% in the first year of life. The immunological response to the food allergen can be classified as immunoglobulin (Ig) E- mediated, non-IgE-mediated or mixed. IgE-mediated reactions are typically immediate with onset occurring within 30 minutes of ingestion of cow’s milk and non-IgE-mediated reactions are typically delayed reactions often occurring hours or days after food ingestion. Non-IgE mediated CMPA commonly presents in infants as gastrointestinal manifestations. A small percentage of infants (0.05%) who are exclusively breastfed may also develop CMPA through transfer of cow’s milk protein from mother’s diet into maternal breastmilk. The treatment for CMPA is the elimination of cow’s milk protein in the infant’s diet or in the mother’s diet of an infant receiving maternal breastmilk. For infants with suspected CMPA who are receiving exclusive maternal breastmilk it is recommended that the mother follow a cow’s milk free diet. The recommendation for formula fed infants with CMPA is to feed a semi-elemental formula (SEF). For those infants who do not respond to the use of SEF, a trial of an elemental formula (EF) is recommended.

Infants Receiving Maternal Breast Milk

Mothers of infants who are suspected to have CMPA will be asked to eliminate cow’s milk and cow’s milk protein containing products from their diet. Guidelines for a dairy-free (DF) diet will be provided for mothers and successful initiation of the diet should be confirmed by the team (see appendix for parent handout). Mothers will label their expressed breastmilk (EBM) “Dairy Free” once successfully on the diet. Pasteurized donor EBM is not suitable for infants with suspected CMPA. During the mother’s initiation of a DF diet, the infant may continue to receive breastmilk if symptoms are mild (see appendix for classification examples).

If symptoms are moderate to severe (see appendix) they may need to go directly onto SEF while mom establishes a DF diet prior to re-introduction of DF maternal breastmilk. Infants may require SEF for a period of several days to a maximum of 2 weeks for symptoms to resolve. Timing for the reintroduction of DF breastmilk in these cases will be based on the severity of symptoms.

Due to cross-reactivity between CMPA and soy allergy, a soy free diet may be considered in combination with the DF diet if the baby continues to have reactions to maternal breastmilk. This should be determined on an individual basis due to the very restrictive nature of a soy and DF diet. Consideration of a SEF should be made for infants who continue to have symptoms even with successful maternal elimination of dairy and soy, or where soy free diet is not feasible (see appendix for suggested timeline).

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DOCUMENT TYPE: GUIDELINE

Infants Receiving Human Milk Fortifier

The use of powder human milk fortifier (HMF) is contraindicated for preterm infants suspected to have CMPA as it is a cow’s milk-based additive. When the preterm infant tolerates DF EBM, the addition of other hypoallergenic products and suitable vitamins / mineral supplements will be necessary to meet the infant’s nutritional needs. For example, SEF powder may be added to DF EBM to concentrate the calories. The determination of additives, modules and vitamins and minerals will be individualized based on the infant’s gestational age, weight, and intake. Consult a Dietitian for review of nutritional adequacy of the preterm infant’s intake.

Infants Receiving Formula Feeds

Term infants who are suspected to have CMPA while feeding milk-based formula will be switched to an SEF such as Nutramigen A+. SEF are hypoallergenic with its protein source coming from hydrolyzed casein; it is unlike Goodstart Formula which is only partially hydrolyzed and not appropriate for CMPA. If the infant continues to show symptoms once established on SEF, then a change to an EF, such as PurAmino A+, is recommended.

For preterm infants who are formula fed and are suspected to have CMPA, the recommendation is to change to a SEF. However SEF is a term formula, therefore will not be nutritionally adequate for preterm infants. Preterm infants may need to be advanced to 81 kcal/100mL and/or have added protein, vitamins and minerals to better meet their nutritional needs. Consult a Dietitian for review of nutritional adequacy of the infant’s intake.

Standard Vitamin And Mineral Supplements

1) Term Infants on DF EBM or breastfeeding: Vitamin D 400 International Units daily 2) Term infants on SEF or EF: Vitamin D 400 International Units daily (if intake less than 1000mL per day) 3) Preterm infants on DF EBM + SEF or EF fortification: Requires individual assessment 4) Preterm infants on SEF or EF: Requires individual assessment

Preparing For Discharge Home

For formula fed infants who meet the criteria for Home Enteral Nutrition Program (HEN) or At Home Program (AHP), an application for funding can be submitted prior to discharge home. Of note, this process may take 7-10 days before approval is granted and is not guaranteed. If an infant does not meet the criteria for these funding agencies, information on purchasing the formula outside of the hospital can be given to the family by a Dietitian.

Maternal diet restrictions should continue until the infant is no longer receiving breastmilk or until the cow’s milk protein allergy is challenged, usually around 1 year of age (1 year corrected for preterm infants). If stable, an earlier trial of cow’s milk may be assessed individually by the pediatrician. A cow’s milk free diet can sometimes be indicated in infants up to 2 years of age and will need to be monitored on an individualized basis.

NN.07.25 Published Date: 06-Nov-2018 Page 2 of 4 Review Date: 06-Nov-2021 This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current. NUTRITIONAL MANAGEMENT OF SUSPECTED COW’S MILK PROTEIN ALLERGY

DOCUMENT TYPE: GUIDELINE

Appendix

Examples of Common Gastrointestinal Symptoms: Mild Moderate/Severe Occasional blood in stools otherwise Frequent blood in stools which have/may lead to anemia, growth generally well, with adequate growth failure, hypoalbuminemia *Atypical symptoms which may be considered include chronic vomiting, diarrhea or constipation.

Suggested Timeline for CMPA Management: *Individual considerations must be accounted for, as well as clinical judgement by the team if symptoms worsen. Timeframe What Tasks Day 0 Suspect CMPA  NEC, fissure etc. ruled out Day 0-1 CMPA Management  Follow “CMPA - Clinical Algorithm” for nutrition management of suspected CMPA Day 1-2 Confirm successful initiation of dairy-  Provide “CMPA – Parent Handout” free diet by the mother  Review diet; confirm if dairy-free diet acceptable and realistic for the mother  Start to label EBM as “dairy-free” Day 2-14 If infant had been placed on semi-  Monitor symptoms elemental formula: reintroduce DF EBM as able Day 28 If symptoms continue on DF EBM:  Discuss soy-free in combination with DF diet with recommend soy-free maternal diet the mother, provide Soy Allergy Health Canada handout  Determine if this very restrictive diet will be possible for the mother Day 42 If symptoms continue:  If infant must stay on a SEF/EF, consider 1) On DF and soy-free diet, or soy- applying for funding to cover the additional free not feasible  change to SEF expense of a therapeutic formula 2) On SEF  change to EF

References

Vandenplas, Y, DeGreef, E, Devreker, T. (2014) Treatment of Cow’s Milk Protein Allergy. Pediatric Gastroenterology, Hepatology and Nutrition.

Koletzko, S, Niggemann B, Arato A, et al. (2012) Diagnostic Approach and Management of Cow’s-Milk Protein Allergy in Infants and Children: ESPGHAN GI Committee Practical Guidelines. Journal for Pediatric Gastroenterology and Nutrition.

Caffarelli, C, Baldi,F, Bendandi, B et al. (2010) Cow’s milk protein allergy in children:a practical guide. Italian Journal of Pediatrics.

Host, A and Halken,S. (2014) Cow’s Milk Allergy: Where have we come from and where are we going? Endocrine, Metabolic and Immune Disorders.

Brill, H. (2008) Approach to milk protein allergy in infants. Canadian Family Physician.

NN.07.25 Published Date: 06-Nov-2018 Page 3 of 4 Review Date: 06-Nov-2021 This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current. NUTRITIONAL MANAGEMENT OF SUSPECTED COW’S MILK PROTEIN ALLERGY

DOCUMENT TYPE: GUIDELINE

Version History DATE DOCUMENT NUMBER and TITLE ACTION TAKEN 01-July-2018 NN.07.25 Nutritional Management Of Suspected Cow’s Approved at: Neonatal Leadership Milk Protein Allergy Committee

DISCLAIMER This document is intended for use within BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document. This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.

NN.07.25 Published Date: 06-Nov-2018 Page 4 of 4 Review Date: 06-Nov-2021 This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.