Cow's milk protein intolerance (CMPI) or Allergy (CMPA) is a common cause of distress and may manifest even in breastfed babies, as they are exposed to milk peptides through breast milk. This may not be apparent until after several weeks of life. It can be difficult to differentiate from significant GO reflux, but symptoms may include more severe irritability and colic, wind and loose stools, sometimes even with blood (CMP colitis). GORD and CMP related disease may actually co-exist. Maternal strict milk free diet with soya as a substitute is used first line. Calcium and vitamin D supplementation for the mother will be required. Dietetic advice is required to ensure mother's health and breast milk quality are not compromised.
Remember, lactose intolerance in this young age group, in the absence of a family history and a preceding infective episode, is very unlikely and babies who are reacting to ingested milk are far more likely to have CMPI / CMPA.
For babies who require formula feeding, soya feeds are NOT recommended for use under the age of 6 months.
If CMPI / CMPA is suspected, in bottle fed babies, formula feeding initially with a specialised 'hypoallergenic' hydrolysed (peptide) formula (Nutramigen I ®), or an amino acid formula may be indicated (Neocate ®, Nutramigen AA ®).
Skin or specific IgE testing is generally not helpful for most GI related 'allergy' (as this is often delayed (Type IV) rather than IgE (Type I)) mediated and we tend not to use these tests in these patients when seen in the GI service unless they demonstrate other atopic tendencies. Some, particularly atopic babies, may have Type I or even both forms of reaction causing symptoms. An empirical trial of appropriate feed is indicated along with a referral to the paediatric dietetic service for specialist advice. In some, early improvement is seen, but it may be several weeks before this feed change results in improvement. If there is no improvement, a switch to amino acid formula should be considered, but discussion with a dietitian is mandatory to ensure that the diet is as strict as possible. Dietitians are expert in management of this condition. In children who are not weaned, the change of formula is the mainstay of therapy. When babies are weaned they should be completely milk (and usually soya) free and therefore need the help of a dietitian to give advice. Most babies with CMPI / CMPA seem to tolerate soya and then cow's milk protein at 12 months of age and are managed by gradual re-introduction as tolerated, but some continue to be problematic and would be challenged every 6 months or so if still intolerant, guided and monitored by the dietitian. Babies that have settled down and are progressing well may not need to be seen by a General paediatrician or GI specialist, but better by the Dietetic department for specific advice, but we appreciate that medical advice may be requested. We are more than happy to provide specialist advice. We are currently working on a specific guideline for GI allergy with the Dietetic department.
Last Updated on Sunday, 13 March 2011 14:22