Cow’s Milk Protein A llergy (CMPA) - PowerPoint Presentation

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Cow’s Milk Protein Allergy (CMPA)

Children's DietitiansSouth Tees NHS Foundation Trust

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Cow’s Milk Protein

Allergy

Up to 7% of infants have a milk allergy

When a baby’s immune system over reacts to the protein found in cow’s milk

It can affect both breast and bottle fed babiesMost children will out grow cow’s milk allergy by the age of 3 years

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Types of Reaction

There are two different types of reaction to milk

Delayed

– symptoms occur 2-72 hours after consuming milk. Only diagnosed by removing milk and seeing if symptoms improve.

Immediate – mostly within minutes or up to 2 hours of exposure to milk. Diagnosed by blood test / skin prick test.

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Delayed Onset Reaction ( Non-

IgE )

Gastro

: irritability, colic type symptoms, vomiting reflux, loose / frequent stools, constipation, abdominal discomfort, blood and/or mucus in stools.

Feeding: food aversion or difficulty feeding Skin

: – a

rash that lingers

for

days, weeks

and months

and is diffuse and rough in feel is likely to be eczema and delayed allergy

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Non allergy skin rash – baby acne

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Immediate

Onset Reaction (

IgE

)

Skin

: Rash that develops quickly, within

minutes to 2 hours and

are

like hives /

nettle rash and also go away same day or next day is

suggestive of immediate

allergy. Eczema that flares when the baby has been exposed to milk may also suggest an immediate reaction.

Swelling of eyes or mouth / lips

Gastro

: vomiting, diarrhoea, abdominal pain/colic

Respiratory : acute rhinitis, conjunctivitis or wheeze

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Immediate Allergy related skin reactions

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Immediate allergy related skin reactions

Eczema that flares on exposure to milk

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Plan for babies with the delayed reaction

Continue on a milk free formula or breast feeding with mum following milk free diet for ~ 4 weeks.If it is safe to do so reintroduce milk to confirm that baby does have milk

allergy. This is explained in the – How to confirm that my baby has cows milk protein allergy presentation.

Continue on milk free formula / breast feeding with mum excluding milk from her diet and milk free weaning diet for 6 months

Challenge at home using the milk ladder to see if baby is starting to develop tolerance.

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Plan for babies with suspected immediate reaction to milk

Continue on a milk free formula or breast feeding with mum following milk free diet and follow the milk free weaning advice

Do

not try and reintroduce milk at home.

Ask your dietitian or GP to refer to the paediatrician. Do not reintroduce milk at home

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Breast Fed Babies

Mum needs to exclude all cow’s milk containing foods from her diet to ensure her breast milk does not contain cows milk protein.

If baby has atopic dermatitis or severe gut symptoms egg and soya exclusion may also be needed.

If the baby has immediate symptoms or atopic dermatitis baby will need referring for blood test for immediate allergy

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Breast Feeding Mums -

Mum

needs daily calcium intake of

1000mg.

Calcium Fortified Foods

Calcium mg

Calcium enriched milk alternatives e.g. oat/ soya/ coconut

120mg in 100mls

Calcium Fortified cereal

– Rice Kripsies, multigrain shapes , Cheerio's

140mg in 30g serving

Enriched

hot Oat cereal

200mg in serving

Calcium enriched bread – e.g. Hovis best of both,

Warburton's Crusty White Bread

190mg per slice

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Vitamin D for mum and baby

The recommendation is that all breastfeeding mothers who are dairy free take vitamin D

supplement -10

µg of vitamin

D, which can be found in healthy start women's vitamin tablets. In babies that are exclusively breastfed it is a precaution to give

vitamin D

due to the climate we live in

. Vitamin D drops for babies are available from a pharmacy.

If you think you may struggle

to get enough calcium through diet a supplement can be used e.g. Pregnacare lactation, Adcal

D3 (

prescription

) Tesco

breast feeding support . These contain vitamin D so you will not need

the healthy start women's vitamin tablets.

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Is my baby on the right formula?

If baby's symptoms have improved then baby will be on the correct formula.

If baby still has symptoms discuss with your baby’s

dietitan

or GP if a trial of a different formula may be helpful.

The main difference in the formulas is the amount that the milk protein is broken down.

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Normal formula Comfort milks

Nutramigen

Aptamil

Pepti

Althera

Neocate

LCP

Alfamino

Puramino

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What next ?

If you are think that your baby does have cow’s milk protein allergy, baby will need to follow a milk free weaning diet.

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Milk Free

Weaning

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Weaning

Start ideally around 6 months old

Baby is ready if they can stay in a sitting position and hold their head steady and co-ordinate eyes , hands and mouth.

Getting messy is an important part of baby's development

Eat together as baby will learn by watching youBabies have small stomachs and will know when they are fullHomemade is best as different textures

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Foods to watch out for

Salt and salty foods

–

like bacon, crisps, convenience foods are bad for babies and should be limited

Honey

–

occasionally contains bacteria so avoid

till over one year old

Nuts

– children under 5 should not be given whole nuts due to choking risk. Finely ground nuts can be given from around 6 months if no concerns around allergy.Sweet drinks- like squash , fizzy drinks, some fruit juices can have a lot of added sugar . Other drinks to avoid include tea, coffee and no added sugar drinks as babies can fill up on these and be less interested in foods. Offer sips of water from a cup at meal times

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Other Food Allergies ?

Soya

30 – 40% of babies with CMPA may also react to soya.

Most likely to react to soya dairy replacements such as soya milk and soya yoghurt. Many children can tolerate soya as an ingredient e.g. soya flour and soya lecithin.

Soya can be introduced from 6 months. Establish on weaning diet and then introduce foods that contain soya as an ingredient, then soya yoghurt and milk.

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Other Food Allergies ?

Egg

The first time egg is given, give a food that contains egg as an ingredient e.g. milk free cake /

Yorkshire pudding.

Then if tolerated include well cooked egg in baby’s diet.

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Lactose-free products still contain milk protein

Lactose

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From 6 months- first foods

Start with mashed or soft cooked fruits and vegetables – parsnip, potato, sweet potato, carrot, apple or pear.

Some babies like to start with mashed foods , others manage better with puree food on a spoon

.

Introduce soft finger foods when you think baby is ready

(the

size of your finger is a good

guide)

such as soft ripe banana, melon, soft cooked

carrots, soft peach

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Next foods

Soft cooked meat such as chicken, pasta, pieces of chapatti, lentils, rice

Cereals such as porridge,

W

eetabix with breast / alternative milk.Introduce a cup from around 6 months, choose an open cup or a lidded free flow cup without a valve.

From 8 – 9 months

Gradually

move towards 3 meals a day and snacks

Mixture of soft finger foods and mashed and chopped foods

.

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Snack Time

Soft ripe fruit – your finger size e.g. banana, melon, peach

Lightly cooked vegetable sticks e.g. carrot sticks

Bread sticks dipped in hummus/ mashed avocado

Toast with dairy free spreadUnsalted rice cakes, bagels – check milk free

Milk free baby crisps

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Example milk free meal plan from ~ 9 months

Meal

Foods

Breakfast

Cereal – / milk free cereal , porridge/ Weetabix made with milk alternative

Toast with dairy free spread and thin spread

of jam

Fruits – soft banana

Snack meal

Sandwiches with dairy free spread and cooked

meats, egg, dairy free cheese

Pasta with cooked meats, vegetables or tuna

Baked beans / tinned pasta shapes on toast

Middle of a baked potato with beans or tuna

Fruit

Dairy free yoghurt

Main

meal

Minced or finely chopped meat / flaked fish / lentils with

Potato/

rice / pasta and vegetables

Adapt the texture based on your baby

Try and use family foods when possible

Dessert

Soft ripe fruit, dairy

free yoghurt e.g. coconut yoghurt, custard made with the milk substitute, or oat / soya based custard.

Jelly made with milk substitute

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What can I give

instead of milk ?

There is a large range of alternative milks available in the supermarket such as oat milk, soya milk, almond, hazelnut and coconut

Choose varieties that are enriched with calcium

Do not use rice milk as not suitable for children under 5 years

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What can I give

i

nstead of butter, yoghurt, cheese and chocolate?

Use dairy free spreads instead of butter e.g.

V

italite

/ Flora dairy free / Pure

Home baking - replace butter with

Trex

or full fat milk free spread

Replace yoghurts with soya yoghurt if tolerated, coconut yoghurts e.g. KOKO

Replace custard with oat or soya custard. Make Bird’s custard powder in the tin with replacement milk.

Replace cream / cream fraiche with oat / soya based product

Avoid

chocolate / yoghurt

coated fruit and choose plain fruit instead

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Breads, cereals and pasta

Avoid breads that are made with butter such as croissants and brioche and use normal breads and wraps - check supermarket’s sliced loaves

Use homemade pastry made with

Trex

instead of shop-bought pastryUse fresh or dried pasta or tinned spaghetti instead of stuffed pasta such as ravioliMake homemade pizzas using dairy free cheeseReplace chocolate based cereals with W

eetabix,

Shreddies

, Cornflakes or Rice

K

rispies

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Are all meats and fish milk free?

Replace processed foods in batter / breadcrumbs and pastry with plain meat and fish

Check supermarket own brands of products such as chicken nuggets and fish fingers as usually milk free.

Check processed meats and sausages as some contain milk

Make omelettes and scrambled egg with a milk substitute

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Milk free or milk containing ?

Breaded hamOven chipsFromage frais

Bourbon cream and rich tea biscuits

Cheese puff crisps

Baby egg custard jarCHECK THE LABELS OF ALL PROCESSED FOODS

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Food labels

Hidden sources – if you see the word Casein, whey or lacto joined onto another word it will contain milk.

Milk should be listed in bold

Some baby food companies allow you to search for milk free foods on their website.

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Food Maestro

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Vitamins For Babies on Milk Free Formula

Babies who drink more than 500mls

( ~ 16

oz

) of formula a day do not need additional vitaminsWhen baby takes less than this start Healthy Start Children's vitamin drops.

If any concerns re nut allergy discuss with

dietitian

.

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Is my baby getting enough calcium?

Infants under 1 year = 525mg/d

Children 1-3 years = 350mg/d

Children 4-6 years = 450 mg/d

100mls calcium enriched oat / soya/ nut milk = 120mg

1 x slice

H

ovis Best

O

f

Both bread = 190mg1 x pot soya dessert = 150mg

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What happens next?

If you think your baby has the delayed reaction to cows milk protein watch the next presentation :The Milk Ladder, this will explain how and when to reintroduce cow’s milk into babies diet to see if they are starting to develop tolerance.

If you think your baby may have had an Immediate reaction to cow’s milk protein, follow the milk free weaning advice and do not try and reintroduce cow’s milk in any form at home. Your baby will need to be assessed by a paediatrician, discuss this with your babies

dietitian

or GP.

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If your baby has been referred to the children's dietitians you will receive a telephone consultation to answer any questions you may have about the information in the presentation.

If your child has not been referred to the children's dietitians but you feel that you need further support such as a change of formula or referral to paediatrician, or you are concerned about your babies weight gain, please ask your GP or health visitor to refer to the children's

dietitians

at James Cook University Hospital

or the Friarage Hospital Northallerton