reinstate or confiscate? case studies on cows' milk...

'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)


Immediate IgE mediated minutes to 2 hours

Delayed after 2 hours


What causes food allergy?


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?


What food(s) in infancy?

Milk

Egg : ⅕ children with egg allergy are more likely to have allergy to

Peanut


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?


Milk Allergens


Infant Formula

Birth – 12 months

Protein class

Whole protein

Cows milk

Goat milk Soy

“Broken” protein = hydrolysed

Partially Extensively

no whole protein =Amino acid


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


What about other “milk” ?


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?



•measures sensitivity

•sensitivity ≠ allergy

“Judicious” Testing

If, when and why allergy test?


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?


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.


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)


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?


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


Weaning


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?


Delayed CMPA red flags!


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


Challenging non IgE mediated delayed


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?


If all else fails….


Eliminating CMP

Bone health

Protein & growth

Behavioural food aversion


• Website

• Guidelines for management of childhood food allergy in Primary and Secondary care

• Guidelines for common food allergies (Milk, egg, nuts)

www.ifan.ie


Contact Ruth Charles

www.nutrikids.ie

[email protected]

www.fsai.ie


http://www.nutrikids.ie

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