reinstate or confiscate? case studies on cows' milk...
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'Reinstate or Confiscate? Case Studies on Cows' Milk Allergy'
Ruth Charles
Paediatric Dietitian, MINDI.
Ruth Charles May 7, 2014
Food Allergy is…..
An immune mediated adverse reaction to food which is either:
Immediate (IgE mediated)
Or
Delayed (Non IgE/Cell mediated)
Ruth Charles May 7, 2014
Immediate IgE mediated minutes to 2 hours
Delayed after 2 hours
Ruth Charles May 7, 2014
What causes food allergy?
Ruth Charles May 7, 2014
Ruth Charles May 7, 2014
Ruth Charles May 7, 2014
Ruth Charles May 7, 2014
David
6 months old and has been exclusively breast fed since birth. He has mild eczema since birth which has improved recently. His dad gave him some baby rice today made up with formula milk. Following this he vomited and developed a raised red rash on his face and body. The rash resolved whilst waiting to be seen in A&E.
Q what caused the reaction: Rice or formula?
Ruth Charles May 7, 2014
What food(s) in infancy?
Milk
Egg : ⅕ children with egg allergy are more likely to have allergy to
Peanut
Ruth Charles May 7, 2014
David
6 months old and has been exclusively breast fed since birth.
He has mild eczema since birth which has improved recently.
His dad gave him some baby rice today made up with formula milk.
Following this he vomited and developed a raised red rash on his face and body. The rash resolved whilst waiting to be seen in A&E.
Q What “milk” will you now recommend now to make up solids?
Ruth Charles May 7, 2014
Milk Allergens
Ruth Charles May 7, 2014
Infant Formula
Birth – 12 months
Protein class
Whole protein
Cows milk
Goat milk Soy
“Broken” protein = hydrolysed
Partially Extensively
no whole protein =Amino acid
Ruth Charles May 7, 2014
Infant Formula
Birth – 12 months
Protein class
Whole protein
Cows mlik
Goat milk Soy
“Broken” protein = hydrolysed
Partially Extensively
Amino acid = no whole protein
Managing CMPA
Ruth Charles May 7, 2014
What about other “milk” ?
Ruth Charles May 7, 2014
David
6 months old and has been exclusively breast fed since birth. He has mild eczema since birth which has improved recently. His dad gave him some baby rice today made up with formula milk. Following this he vomited and developed a raised red rash on his face and body. The rash resolved whilst waiting to be seen in A&E.
Q Is there anything else you might do?
Ruth Charles May 7, 2014
Ruth Charles May 7, 2014
•measures sensitivity
•sensitivity ≠ allergy
“Judicious” Testing
If, when and why allergy test?
Ruth Charles May 7, 2014
Kate 4 months old. Breast milk only (did get one top up of formula at birth) Mum gave 2 oz of CMF today. Within minutes Kate vomited, developed facial rash with swelling. She quickly developed noisy breathing and a hoarse cry which prompted his parents to bring him to hospital.
Q What history features are important?
Ruth Charles May 7, 2014
Kate
4 months old.
Breast milk only (did get one top up of CMF at birth)
Mum gave 2 oz of CMF today.
Within minutes Kate vomited, developed facial rash with swelling.
She quickly developed noisy breathing and a hoarse cry which prompted his parents to bring her to hospital.
Ruth Charles May 7, 2014
Ruth Charles May 7, 2014
Clinical Criteria for Diagnosing Anaphylaxis
Criterion 1 Acute onset of an illness (minutes to Several hours) with involvement of the skin and/or mucosal tissue and at least 1 of the following: a. Respiratory compromise
b. Reduced blood pressure or associated symptoms of end-organ dysfunction PEDIATRICS Volume 119, Number 3, March 2007
Criterion 2 Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours): a. Involvement of the skin/mucosal tissue
b. Respiratory compromise c. Reduced blood pressure or associated symptoms d. Persistent gastrointestinal symptoms Criterion 3 Reduced blood pressure after exposure to Known allergen for that patient (minutes to several hours)
Ruth Charles May 7, 2014
Kate 4 months old. Breast milk only (did get one top up of formula at birth) Mum gave 2 oz of CMF today. Within minutes Kate vomited, developed facial rash with swelling. She quickly developed noisy breathing and a hoarse cry which prompted his parents to bring him to hospital.
Q What would you do?
Ruth Charles May 7, 2014
Know your formula for CMA Presentation
1st
choice
2nd
choice
Anaphylaxis1,5,6
AAF eHF
Allergic eosinophilic oesophagitis1,5,6
AAF
Enteropathy + faltering growth & hypoprotenemia5 AAF
Food protein-induced enterocolitis (FPIES) 1,5
AAF
Growth faltering2,3,4,5,6
AAF eHF
Breast fed unresponsive to maternal milk avoidance2,3,4,5
AAF eHF
Multiple food allergies2,3,4
AAF eHF
Severe eczema***2,3,4,5,6
AAF eHF
Maternal milk avoidance requiring top up4,6
AAF
Severe Gastrointestinal symptoms***6 AAF
Heiner’s syndrome 1,6
AAF eHF
Acute urticaria or angioedema1 eHF AAF
Atopic dermatitis***1 eHF AAF
Immediate gastrointestinal allergy1 eHF AAF
Gastroesophageal reflux disease (GERD) ***1
eHF AAF
Cow’s milk protein-induced enteropathy1,4,
eHF AAF
CM protein-induced gastroenteritis and proctocolitis1 eHF AAF
Severe irritability (colic)*** 1 eHF AAF
C Constipation/Diarrhoea***1 eHF AAF
1. DRACMA guidelines 2009 2. de Boissieu et al. 1997 3. Vandenplas et al. 2007 4. Hill et al. 2007 5. ESPGHAN guidelines 2012 6. MAP guidelines 2013
no improvement within 2 weeks on eHFAAF
Ruth Charles May 7, 2014
Weaning
Ruth Charles May 7, 2014
When Can How to reintroduce cows milk? No reaction evident continue to give
Paul 14 months old. Thriving and growing along centiles. Happy and content except around food & eating! Severe colic as an infant. Treated for GOR. Chronic constipation and altered bowels since 6 months, on treatment.
Q What would/could you do?
Ruth Charles May 7, 2014
Delayed CMPA red flags!
Ruth Charles May 7, 2014
No tests currently available Trial of exclusion for 3-6 weeks with reintroduction The “big four” - Milk, Egg, Wheat, Soya
Access to qualified Dietitians
• Primary Care
– Community Nutrition Service Manager:
• Food intolerances and Allergy (following definitive diagnosis) · IgE mediated reaction to 1 or more foods · Intolerances such as lactose intolerance · Dietary assessments to assist in the diagnosis of food intolerance.
• Private Sector
Ruth Charles May 7, 2014
Challenging non IgE mediated delayed
Ruth Charles May 7, 2014
Nicola
Nicola is 3 yrs old. She has constipation but after straining always passes a soft stool. This is very distressing for her. Her parent complains that her abdomen is always distended. She has mild eczema.
Q They ask about York testing............
What would you do?
Ruth Charles May 7, 2014
If all else fails….
Ruth Charles May 7, 2014
Eliminating CMP
Bone health
Protein & growth
Behavioural food aversion
Ruth Charles May 7, 2014
• Website
• Guidelines for management of childhood food allergy in Primary and Secondary care
• Guidelines for common food allergies (Milk, egg, nuts)
www.ifan.ie
Ruth Charles May 7, 2014
Contact Ruth Charles
www.nutrikids.ie
info@nutrikids.ie
www.fsai.ie
Ruth Charles May 7, 2014
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