Refer to Paediatrician PAN-DORSET COW’S MILK ALLERGY PATHWAY Suspicion of Non IgE mediated CMPA Slower onset over 2 hours or longer One or more of the following: • Skin symptoms • Gastro symptoms • Respiratory symptoms If exclusive breast feeding Check feeding technique Strict maternal milk free diet for 2-4 weeks Allergy focused history If formula feeding Extensively hydrolysed formula (EHF) for 2-4 weeks Poole Hospital NHS Foundation Trust 01202 665511 Bleep 0155 If mixed breast and formula Strict maternal milk free diet Plus Extensively hydrolysed formula (EHF) for 2-4 weeks Milk free weaning from 6 months Improvement If exclusive breast feeding Re-introduce cow’s milk into maternal diet If symptoms return this confirms CMPA diagnosis Restart maternal milk free diet Appendix C Milk free weaning from 6 months For Urgent advice or Rapid Access Clinic Telephone – Suspicion of IgE mediated CMPA Rapid onset within minutes to 2 hours One or more of the following: • Urticaria • Wheeze • Anaphylaxis If formula feeding or mixed feeding Re-introduce cow’s milk formula If symptoms return this confirms CMPA diagnosis Continue with EHF and/or restart maternal milk free diet Milk free weaning from 6 months *Refer to full policy at: http://www.dorsetccg.nhs.uk/aboutus/medicines-management-policies.htm for more detailed guidance about milk free diets and weaning and reintroduction of cow’s milk. February 2014. Taken from the full Medicines Code chapter on Cow’s Milk Protein Allergy. No improvement Dorset County Hospital NHS Foundation Trust 01305 251150 Bleep 353 Eliminate soya as well for 2-4 weeks Partial improvement Still no improvement Telephone advice from Paediatrician (see above) or Children's Dietitian West Dorset 01305 255535 Poole 01202 442840 CMPA less likely Gradual return to normal diet Refer to Paediatrician if symptoms persist GUIDELINES FOR INDICATIONS FOR USING SPECIALISED INFANT FORMULA FOR INFANTS AGED 0-6 MONTHS Extensively hydrolysed formula Feed Manufacturer Type of formula Clinical Indication for use Nutramigen Lipil 1 400g First Line Choice Mead Johnson Extensively hydrolysed formula (EHF) lactose free Cow’s milk protein allergy Galactosaemia Alimentum 400g Abbott Extensively hydrolysed formula (EHF) Clinically lactose free Extensively hydrolysed formula (EHF) with 50% MCT fat, lactose free Extensively hydrolysed formula (EHF) Residual lactose Cow’s milk allergy and conditions requiring an EHF Pepti Junior 450g Cow & Gate Aptamil Pepti 1 400g or 900g Milupa Additional ACBS Indications Lactose and / or whole protein intolerance where additional MCT not needed Cow’s milk protein allergy. Malabsorption conditions including fat and disaccharide intolerance Lactose / whole protein intolerance or where amino acid peptides are indicated in conjunction with MCT Cow’s milk protein allergy Established cow’s milk protein intolerance Amino acid based formula Feed Neocate LCP 400g On advice of Dietitian or Hospital Specialist Nutramigen AA 400g Please check name carefully as similar named products Manufacturer SHS Type of formula Amino acid based Mead Johnson Amino acid based Colour Code Guide Clinical Indication for use Cow’s milk protein allergy Severe malabsorption If EHF not tolerated Cow’s milk protein allergy Severe malabsorption Additional ACBS Indications Cow’s milk protein allergy Multiple food protein intolerance Conditions requiring an elemental diet Cow’s milk protein allergy Multiple food protein intolerance Conditions requiring an elemental diet Green products = can be prescribed by Amber Products = Started by Dietitian or hospital specialist and continued by Red products = hospital doctor, GP or other person with Primary Care with request from a Paediatrician or Dietitian for GP to prescribe. Acute Trusts only extended prescribing NB Please remember to write ACBS on prescription. This product list is not exhaustive – see BNF for further information. February 2014. Taken from the full Medicines Code chapter on Cow’s Milk Protein Allergy. GUIDELINES FOR INDICATIONS FOR USING SPECIALISED INFANT FORMULA FOR INFANTS OVER 6 MONTHS OF AGE Soya formula (available to buy over the counter). It is suitable for new presentations of cow’s milk allergy in infants over 6 months Feed Manufacturer Type of formula Clinical Indication for use Additional ACBS Indications Infasoy 900g Cow & Gate Wysoy 430g or 860g Wyeth Soya based (whole protein) lactose free Soya based (whole protein) Lactose free Simple cow’s milk protein allergy. Galactosaemia Simple cow’s milk protein allergy. Galactosaemia Clinical Indication for use Cow’s milk protein allergy, with or without secondary lactose intolerance Galactosaemia Cow’s milk allergy and conditions requiring an EHF Additional ACBS Indications Established lactose and / or whole protein intolerance (where MCT not indicated) Cow’s milk protein allergy Established cow’s milk protein intolerance Lactose / whole protein intolerance or where amino acid peptides are indicated in conjunction with MCT Extensively hydrolysed formula Feed Nutramigen Lipil 2 400g First line choice Manufacturer Mead Johnson Type of formula Extensively hydrolysed protein Lactose free Alimentum 400g Abbott Aptamil Pepti 2, 900g Cow & Gate Pepti Junior, 450g Cow & Gate Extensively hydrolysed formula (EHF) Clinically lactose free Extensively hydrolysed Residual lactose Extensively hydrolysed protein, with 50% MCT fat Lactose free Cow’s milk protein allergy. Malabsorption conditions including fat and disaccharide intolerance Amino acid based formula Feed Manufacturer Type of formula Clinical Indication for use Neocate LCP 400g On advice of Dietitian or Hospital Specialist SHS Amino acid based Cow’s milk protein allergy Severe malabsorption If EHF not tolerated February 2014. Taken from the full Medicines Code chapter on Cow’s Milk Protein Allergy. Additional ACBS Indications Cow’s milk protein allergy Multiple food protein intolerance Conditions requiring an elemental diet Feed Nutramigen AA 400g Please check name carefully as similar named products Manufacturer Type of formula Clinical Indication for use Mead Johnson Amino acid based Cow’s milk protein allergy Severe malabsorption Colour Code Guide Additional ACBS Indications Cow’s milk protein allergy Multiple food protein intolerance Conditions requiring an elemental diet Green products = can be prescribed by Amber Products = Started by Dietitian or hospital specialist and continued by Red products = hospital doctor, GP or other person with Primary Care with request from a Paediatrician or Dietitian for GP to prescribe. Acute Trusts only extended prescribing NB Please remember to write ACBS on prescription. This product list is not exhaustive – see BNF for further information. February 2014. Taken from the full Medicines Code chapter on Cow’s Milk Protein Allergy. REINTRODUCING COWS MILK How to Reintroduce Cow’s Milk NB Seek specialist advice first if initial presenting symptoms were severe/acute onset At around 12 months of age or 6 months after diagnosis Attempt a planned reintroduction of Cows milk If breastfeeding Reintroduce cow’s milk in to maternal diet* Improvement Return to normal diet If mixed feeding Reintroduce milk in to the infants diet* No improvement Return to milk free diet and repeat reintroduction of Cows milk in a further 6 months time Seek specialist advice from Paediatrician Poole Hospital NHS Foundation Trust 01202 665511 Bleep 0155 Dorset County Hospital NHS Foundation Trust 01305 251150 Bleep 353 Children's Dietitian West Dorset 01305 255535 If symptoms of eczema persist, seek advice from Dermatology service or Paediatrician *Refer to full policy at: http://www.dorsetccg.nhs.uk/aboutus/medicines-management-policies.htm for more detailed guidance about milk free diets and reintroduction of cow’s milk. February 2014. Taken from the full Medicines Code chapter on Cow’s Milk Protein Allergy.
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