Cows Milk Protein Allergy CMPA Childrens Dietitians South

Cow’s Milk Protein Allergy (CMPA) Children's Dietitians South Tees NHS Foundation Trust

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 babies • Most children will out grow cow’s milk allergy by the age of 3 years

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.

Delayed Onset Reaction ( Non-Ig. E ) • 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

Non allergy skin rash – baby acne

Immediate Onset Reaction (Ig. E ) 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

Immediate Allergy related skin reactions

Immediate allergy related skin reactions Eczema that flares on exposure to milk

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.

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

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

Breast Feeding Mums • Mum needs daily calcium intake of 1000 mg. Calcium Fortified Foods Calcium mg Calcium enriched milk alternatives e. g. oat/ soya/ coconut 120 mg in 100 mls Calcium Fortified cereal – Rice Kripsies, multigrain shapes , Cheerio's 140 mg in 30 g serving Enriched hot Oat cereal 200 mg in serving Calcium enriched bread – e. g. Hovis 190 mg per slice best of both, Warburton's Crusty White Bread

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 D 3 ( prescription ) Tesco breast feeding support. These contain vitamin D so you will not need the healthy start women's vitamin tablets.

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.

Normal formula Comfort milks Nutramigen Aptamil Pepti Althera Neocate LCP Alfamino Puramino

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.

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 you • Babies have small stomachs and will know when they are full • Homemade is best as different textures

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

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.

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.

Lactose • Lactose-free products still contain milk protein

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

Next foods • Soft cooked meat such as chicken, pasta, pieces of chapatti, lentils, rice • Cereals such as porridge, Weetabix 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.

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 spread • Unsalted rice cakes, bagels – check milk free • Milk free baby crisps

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

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

What can I give instead of butter, yoghurt, cheese and chocolate? • Use dairy free spreads instead of butter e. g. Vitalite / 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

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 shopbought pastry • Use fresh or dried pasta or tinned spaghetti instead of stuffed pasta such as ravioli • Make homemade pizzas using dairy free cheese • Replace chocolate based cereals with Weetabix, Shreddies, Cornflakes or Rice Krispies

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

Milk free or milk containing ? • Breaded ham • Oven chips • Fromage frais • Bourbon cream and rich tea biscuits • Cheese puff crisps • Baby egg custard jar • CHECK THE LABELS OF ALL PROCESSED FOODS

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.

Food Maestro

Vitamins For Babies on Milk Free Formula • Babies who drink more than 500 mls ( ~ 16 oz ) of formula a day do not need additional vitamins • When baby takes less than this start Healthy Start Children's vitamin drops. If any concerns re nut allergy discuss with dietitian.

Is my baby getting enough calcium? • Infants under 1 year = 525 mg/d • Children 1 -3 years = 350 mg/d • Children 4 -6 years = 450 mg/d 100 mls calcium enriched oat / soya/ nut milk = 120 mg 1 x slice Hovis Best Of Both bread = 190 mg 1 x pot soya dessert = 150 mg

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.

• 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