Dr Toni Hazell shares 10 top tips on the primary care diagnosis and management of cow’s milk protein allergy in children
Read this article to learn more about:
- presentation, diagnosis, and management of cow’s milk protein allergy
- the differences between immunoglobulin E (IgE)- and non-IgE-mediated allergy
- management in primary care and when referral to secondary care is indicated.
Read this article at: GinP.co.uk/455827.article
After reading this article, ‘Test and reflect’ on your updated knowledge with our multiple-choice questions. We estimate that this activity will take you 30 minutes—worth 0.5 CPD credits.
Cow’s milk protein allergy (CMPA) in children is defined by NICE as ‘… a reproducible immune-mediated allergic response to one or more proteins in cow’s milk’.1 It can be complex to diagnose in general practice because there is a wide range of presenting symptoms, which vary depending on whether or not the allergy is mediated by immunoglobulin E (IgE).
Cow’s milk protein allergy is more common in boys than girls and other risk factors include pre-existing personal or family history of atopic disease, such as asthma, eczema, or other food allergy.2
1. Remember immunology
It is important to understand the two different types of CMPA. IgE-mediated allergy is caused when an antigen, such as cow’s milk protein, binds to two IgE molecules on the surface of mast cells. This causes cross-linking and the mast cell degranulates, releasing mediators such as histamine and causing symptoms.3 Other atopic conditions such as asthma and hay fever are IgE-mediated.3 This process is well understood, in contrast to non-IgE-mediated allergy, about which we know less; it is thought to be T cell-mediated.4 The two key clinical differences between these types of allergy lie in how they present, and the ability to test for them in primary care.
2. Consider that not all allergy presents immediately
Children with IgE-mediated allergy present with symptoms that most doctors, and many of the public, would immediately recognise as being an allergy (see Table 1). Symptoms often occur within minutes of ingesting the substance, and never more than 2 hours later.5 They may include an urticarial rash, itch, angioedema, or flare of pre-existing eczema.5
In contrast, children with non-IgE-mediated disease present with symptoms at least 2 hours after ingestion of the allergen, and sometimes up to 72 hours afterwards (see Table 1).5 This causes a diagnostic challenge as the reaction is not immediately linked to the allergen. Children with non-IgE-mediated allergy can present with an itch, rash, or flare of pre-existing eczema, but also with symptoms not immediately linked to allergy, such as gastroesophageal reflux, loose stools containing blood or mucus, constipation, or redness in the perianal area.5 Some children will have even more vague symptoms, such as pallor, tiredness, or failure to thrive.5 It is important to have a low threshold for diagnosis of CMPA in children with gastrointestinal symptoms or failure to thrive, even if there are no symptoms that are ‘classic’ for allergy.
Speed of symptom onset
Respiratory (usually in combination with one or more of the above)
[A] Note: the list of clinical features is not exhaustive, and the absence of these symptoms and signs does not exclude a diagnosis of food allergy. Mixed IgE- and non-IgE-mediated responses may present with GORD, diarrhoea, constipation, and/or eczema.
IgE=immunoglobulin E, GORD=gastro-oesophageal reflux disease
© NICE 2019. Cow’s milk allergy in children: when should I suspect cows’ milk allergy? Available from: cks.nice.org.uk/topics/cows-milk-allergy-in-children/diagnosis/diagnosis All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.
3. Do not miss anaphylaxis
Many children with CMPA will have symptoms that can be managed in primary care, at least initially, but it is important to be alert for anaphylaxis and angioedema.
Anaphylaxis is defined by NICE as: ‘… a severe, life-threatening, generalized or systemic hypersensitivity reaction characterized by rapidly developing airway and/or breathing and/or circulation problems usually associated with skin and mucosal changes.’ 6 It causes around 20 deaths in the UK each year, although this may be an underestimate.7
Angioedema is defined by NICE as: ‘… swelling of deep dermis, subcutaneous, or submucosal tissue, often affecting the face (lips, tongue, and eyelids), genitalia, hands, or feet. Less commonly, submucosal swelling affects the bowel and airway.’6 Angioedema is a less severe reaction as the cardiorespiratory collapse seen in anaphylaxis does not occur in angioedema. The two reactions do, however, have the same mechanism and it may sometimes be appropriate to prescribe an adrenaline auto-injector (AAI) for patients with a history of angioedema but not anaphylaxis.8
4. Take a good history
Most of us will remember being taught at medical school that 80% of the diagnosis is in the history,9 an aphorism that comes from a small study done 46 years ago,10 which probably still holds true even now that we have so many more investigations at our fingertips.
NICE Clinical Guideline 116 on Food allergy in under 19s: assessment and diagnosis sets out the components of the ‘allergy-focused clinical history’ (see Box 1).11 It reminds practitioners to set the allergic reaction in a broader context and that the questions will change depending on the child’s age. For infants, it is important to know if the mother is breastfeeding and, if so, whether her diet contains any suspected allergens. Allergic reactions will happen in all settings: does the child have a similar reaction at home, at nursery/school, when they visit grandparents, or anywhere else? Knowing the speed of the reaction will help to determine if it is likely to be IgE-mediated or non-IgE-mediated, which is vital when deciding how to investigate.
It is also very important to find out what has been done already. If a child’s diet has been significantly restricted before the consultation then there may be concerns about nutrition, making dietetic involvement at an early stage an important step.
Box 1: Components of an allergy-focused clinical history11
If food allergy is suspected (by a healthcare professional or the parent, carer, child or young person), a healthcare professional with the appropriate competencies (either a GP or other healthcare professional) should take an allergy-focused clinical history tailored to the presenting symptoms and age of the child or young person. This should include:
- any personal history of atopic disease (asthma, eczema, or allergic rhinitis)
- any individual and family history of atopic disease (such as asthma, eczema or allergic rhinitis) or food allergy in parents or siblings
- details of any foods that are avoided and the reasons why
- an assessment of presenting symptoms and other symptoms that may be associated with food allergy (see recommendation 1.1.1 in NICE Clinical Guideline 116), including questions about:
- the age of the child or young person when symptoms first started
- speed of onset of symptoms following food contact
- duration of symptoms
- severity of reaction
- frequency of occurrence
- setting of reaction (for example, at school or home)
- reproducibility of symptoms on repeated exposure
- what food and how much exposure to it causes a reaction
- cultural and religious factors that affect the foods they eat
- who has raised the concern and suspects the food allergy
- what the suspected allergen is
- the child or young person’s feeding history, whether they were breastfed or formula-fed and the age of weaning
- the mother’s diet, if the child is currently being breastfed
- details of any previous treatment, including medication, for the presenting symptoms and the response to this
- any response to the elimination and reintroduction of foods.
© NICE 2011. Food allergy in under 19s: assessment and diagnosis. Available from: www.nice.org.uk/guidance/cg116 All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.
5. Use blood tests wisely
My GP trainer once told me ‘never do a test if the result won’t affect your management’, and that principle applies to allergy as much as to any other area of medicine. Adult patients and parents of young children often come to the GP with an opening gambit of ‘I need allergy tests, doctor’. Take a step back and think about the interpretation of such tests before requesting them.
There are two ways to diagnose CMPA: skin prick testing (SPT) and blood tests for specific IgE (sIgE).1 SPT is generally carried out in secondary care or in clinics with a GP with a special interest/extended role, but sIgE tests are available in primary care. Crucially, no tests can diagnose non-IgE-mediated CMPA and it is important to be upfront about this with patients.1 Requesting an sIgE test in a child with symptoms of non-IgE-mediated CMPA is not a benign decision: the parents will be confused when the test is negative and the child will have undergone a blood test for no reason.
If you suspect IgE-mediated CMPA, or indeed any other food allergy, target the tests at the likely allergen(s). Testing for total IgE is not generally useful: all it will tell you is that the patient is, or is not, atopic and you will already know that from the history. Similarly, do not be tempted to take a ‘scattergun’ approach, testing for a wide range of common allergens; tests should be requested and interpreted in the context of the history.11 It is possible for someone to have a positive sIgE to a food that they eat regularly with no clinical reactions. This is sensitisation, not allergy,12,13 and diagnosing as an allergy by tests that were not clinically indicated runs the risk of their diet being unnecessarily restricted.
6. Know how to diagnose non-IgE-mediated allergy
Non-IgE-mediated allergy can only be diagnosed by a trial of dietary change; in the case of CMPA this involves eliminating all cow’s milk from the diet for 2–4 weeks.1 For infants this can be done by the provision of prescribed hypoallergenic formula, or by the elimination of dairy from the mother’s diet if the child is breastfed. Depending on local resources and the urgency and severity of the child’s symptoms, you may be happy to supervise this in primary care or you may feel that referral to a paediatric dietitian is more appropriate.1 The diagnosis of CMPA can only be made when the symptoms resolve during this elimination period and, crucially, recur when cow’s milk is reintroduced.14 Reintroduction of cow’s milk is important to avoid a false diagnosis of CMPA leading to unnecessary restriction, but parents can be understandably reluctant to restart giving their child the cow’s milk when it has previously caused them unpleasant symptoms. For this reason, it is important to make it clear at the start of the trial that if symptoms resolve, a reintroduction will be necessary to confirm the diagnosis. With only around 2% of children having a true diagnosis of CMPA, the use of an elimination diet without a reintroduction test is one of the most likely causes of overdiagnosis.15
7. Start hypoallergenic formula feeds and refer at the same time
Hypoallergenic formula feeds are expensive and so many CCGs16 have prescribing guidelines limiting their use to those who have been diagnosed with CMPA by a paediatrician. However, there is usually an exemption stating that such formula feeds can be started in primary care while the child is waiting to be seen in secondary care.
Two types of formula feed are available: extensively hydrolysed formula (eHF) and amino acid formula (AAF). eHF, in which the cow’s milk protein has been broken down into smaller peptides, should always be used first-line and will be tolerated by most children. eHF is cheaper than AAF and, anecdotally, it tastes better. A minority of children will not tolerate eHF and a trial of AAF, in which there are no peptides, may be indicated. An infant who is fully formula fed will usually need 2–3 tins of formula per week,17 with the amounts reducing as the child gets older. Guidelines on the specific brands to prescribe may be available from your local CCG, and the British Dietetic Association provides fact sheets on milk allergy and suitable milks for children with CMPA.18,19
Parents should not use soya milk as an initial substitute for formula feed during the diagnostic process as some patients with CMPA will also react to soya.17 It also has a weak oestrogenic action, although the clinical significance of this is unclear. NICE advises against the use of soya milk in infants under the age of 6 months.17 Similarly, the poor nutritional value of other milks such as almond, oat, and coconut means that they should not be used in children under the age of 1 year. Milk from sheep or goats should not be used because of the risk of cross-reactivity in those with CMPA.17
8. Remember that most children with allergy do not need an AAI
Adrenaline auto-injectors have been in the news over the past few years for different reasons, including concerns about the length of the needle20 and drug shortages,21 which led to official advice to use some devices beyond their expiry date.22 GPs could be forgiven for being confused about what to prescribe and when.
All patients with a history of anaphylaxis should be prescribed an AAI. NICE recommends seeking specialist advice about prescribing an AAI for people at high risk of anaphylaxis while they are awaiting specialist review.8 The high-risk group includes those who have had angioedema and also have asthma, chronic obstructive pulmonary disease, or heart disease, as well as people who have had angioedema with trace amounts of an allergen, and those who cannot easily avoid an allergen.8 If specialist advice is not available rapidly, pragmatically it may be necessary to give this group an AAI pending specialist review, making it clear in your referral that you have done this as a temporising measure and would like advice from the specialist if it needs to be continued. Three brands of AAI are available in the UK (Emerade®, Jext®, and EpiPen®) and the dose varies depending on the weight of the child.23
9. Prepare for parents to ask if their child will grow out of CMPA
Broadly speaking, children with non-IgE-mediated allergy are more likely to grow out of it than those with IgE-mediated allergy.1 One large prospective study identified CMPA in 55 of 12,000 children.24 At 1 year after diagnosis, 32 of these children were re-evaluated with a double-blind, placebo-controlled food challenge and it was found that 22 (69%) could tolerate cow’s milk. The allergy had resolved in all the children with non-IgE-mediated allergy and in 57% of those with IgE-mediated allergy.24
A retrospective review carried out in 2007 also found high levels of resolution, with 79% of the cohort of 807 children having grown out of their allergy by the age of 16 years.25 Factors associated with non-resolution include:25
- coexisting asthma or allergic rhinitis (or a family history of atopy)
- severe symptoms
- strongly positive tests (larger reaction on SPT or higher sIgE values)
- a history of multiple food allergies.
10. Remember that most children can reintroduce cow’s milk at home
If we know that many children will grow out of their CMPA, it follows that it is important to reintroduce cow’s milk protein regularly, in a safe and controlled way, so that children can eat a less restricted diet. Introduction should follow the principles of the milk ladder26 produced by the international Milk Allergy in Primary Care guideline team. The ladder is based on the principle that cow’s milk protein is less allergenic the more it has been cooked. The six-step ladder starts with a biscuit and builds up to milk or infant formula. It is usually supervised by a dietitian, with the amount of time spent on each step varying from child to child. Clearly, it is important to use caution for children who have had an anaphylactic reaction to cow’s milk and they will generally be managed in the hospital setting.
It is important to work out whether CMPA is IgE-mediated or non-IgE-mediated; the latter may present up to 72 hours after ingestion of the allergen. There are no tests for non-IgE-mediated allergy, which is diagnosed by making dietary changes and seeing if the symptoms resolve. Hypoallergenic formula can be started in primary care while the child is waiting to see a paediatrician. Most children with CMPA will not need an AAI. Many children will grow out of their CMPA—milk challenges can be done at home if there is no history of anaphylaxis.
Dr Toni Hazell
Part-time GP, Greater London
Implementation actions for clinical pharmacists in general practice
written by Anjna Sharma, Director of Pharmacist Services, Soar Beyond
The following implementation actions are designed to support clinical pharmacists in general practice with implementing the guidance at a practice level.
- lead process improvement to address efficiency as well as quality of prescribing and adherence to local formulary
- proactively review parents and carers, for whom frequent trips to the surgery with an infant is distressing
- frequent visits also increase workload by creating multiple appointments with the clinician until a diagnosis is confirmed or treatment initiated
- proactive reviews provide the opportunity to raise awareness, take the lead, and drive change in how CMPA is managed in your practice.
- be aware, if running minor illness clinics, of the signs and symptoms of possible CMPA and the guidelines of how to diagnose, refer, and manage—depending on scope of competence
Clinical pharmacists are well-placed to support the management of CMPA and can do so in the following ways:
- determine who currently manages or leads on CMPA in your practice and the current process; if there is no lead, ascertain who you refer to and how long the process takes
- build relationships with health visitors or your local dietitian to help support improving personal and practice confidence and competence with respect to CMPA and collaborate with them to help support them and understand what changes the practice could make to address their challenges
- complete an audit to share the results; example outcomes you may want to review before and after changes include:
- detection and coding of IgE-mediated and non-IgE-mediated CMPA (Table 1 in this article is a helpful guide)
- time, and number of appointments, from initial discussion to diagnosis
- was a full history taken?
- has there been any dietary input?
- what is prescribed, and is it in line with local formulary guidelines?
- is an exit strategy in place?
- parent/carer experience.
- present your findings to the practice with suggested changes to how to manage CMPA going forward, and your role in supporting improvement and re-review in the future
If you have clinical pharmacists in your practice or organisation, contact Soar Beyond to see how we can support with their clinical delivery, training and development soarbeyond.co.uk
After reading this article, ‘Test and reflect’ on your updated knowledge with our multiple-choice questions. We estimate that this activity will take you 30 minutes—worth 0.5 CPD credits.
- NICE. Cow’s milk allergy in children: summary. NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/cows-milk-allergy-in-children (accessed 8 January 2021).
- NICE. Cow’s milk allergy in children: what are the risk factors? NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/cows-milk-allergy-in-children/background-information/risk-factors (accessed 8 January 2021).
- British Society for Immunology. Allergy. www.immunology.org/policy-and-public-affairs/briefings-and-position-statements/allergy (accessed 3 February 2021).
- NICE. Cow’s milk allergy in children: what causes it? NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/cows-milk-allergy-in-children/background-information/causes (accessed 8 January 2021).
- NICE. Cow’s milk allergy in children: when should I suspect cows’ milk allergy? NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/cows-milk-allergy-in-children/diagnosis/diagnosis (accessed 8 January 2021).
- NICE. Angio-oedema and anaphylaxis: summary. NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/angio-oedema-anaphylaxis (accessed 8 January 2021).
- NICE. Angio-oedema and anaphylaxis: what are the complications? NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/angio-oedema-anaphylaxis/background-information/complications/ (accessed 9 January 2021).
- NICE. Angio-oedema and anaphylaxis: scenario: angio-oedema without anaphylaxis. NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/angio-oedema-anaphylaxis/management/angio-oedema-without-anaphylaxis (accessed 9 January 2021).
- Cooke G. A is for aphorism – is it true that ‘a careful history will lead to the diagnosis 80% of the time’?. Aust Fam Physician 2012; 41 (7): 534.
- Hampton J, Harrison M, Mitchell J et al. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. Br Med J 1975; 2 (5969): 486–489.
- NICE. Food allergy in under 19s: assessment and diagnosis. Clinical Guideline 116. NICE, 2011. Available at: www.nice.org.uk/cg116
- NICE. Cow’s milk allergy in children: what is it? NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/cows-milk-allergy-in-children/background-information/definition (accessed 8 January 2021).
- Bodtger U, Assing K, Poulsen L. A prospective, clinical study on asymptomatic sensitisation and development of allergic rhinitis: high negative predictive value of allergological testing. Int Arch Allergy Immunol 2011; 155 (3): 289–296.
- NICE. Quality statement 3: Diagnosing non-IgE-mediated food allergy. NICE Quality Standard 118. www.nice.org.uk/guidance/qs118/chapter/quality-statement-3-diagnosing-nonigemediated-food-allergy (accessed 8 January 2021).
- Fox A, Brown T, Walsh J et al. An update to the Milk Allergy in Primary Care guideline. Clin Transl Allergy 2019; 9: 40.
- NHS Wirral Clinical Commissioning Group. Prescribing guidelines for specialist infant formula feeds in cow’s milk protein allergy and lactose intolerance. Birkenhead: NHS Wirral CCG, 2016. Available at: mm.wirral.nhs.uk/document_uploads/guidelines/WirralCMAguidelines-16-V3.0.pdf
- NICE. Cow’s milk allergy in children: scenario: suspected cow’s milk allergy. NICE Clinical Knowledge Summary. cks.nice.org.uk/topics/cows-milk-allergy-in-children/management/suspected-cows-milk-allergy (accessed 8 January 2021).
- British Dietetic Association. Suitable milks for children with cow’s milk allergy: food fact sheet. www.bda.uk.com/resource/children-with-cows-milk-allergy.html (accessed 8 January 2021).
- British Dietetic Association. Milk allergy: food fact sheet. www.bda.uk.com/resource/milk-allergy.html (accessed 8 January 2021).
- The Pharmaceutical Journal. Coroner calls on MHRA to take action over ‘inherently unsafe’ EpiPen. www.pharmaceutical-journal.com/news-and-analysis/news-in-brief/coroner-calls-on-mhra-to-take-action-over-inherently-unsafe-epipen/20205588.article (accessed 8 January 2021).
- BBC News. EpiPen shortage ‘worrying’ for people with allergies. www.bbc.co.uk/news/health-45627015 (accessed 8 January 2021).
- Medicines and Healthcare products Regulatory Agency. Adrenaline auto-injectors: recent action taken to support safety. www.gov.uk/drug-safety-update/adrenaline-auto-injectors-recent-action-taken-to-support-safety (accessed 8 January 2021).
- British National Formulary for Children. Adrenaline/epinephrine. Available at: bnfc.nice.org.uk/drug/adrenalineepinephrine.html (accessed 9 January 2021).
- Schoemaker A, Sprikkelman A, Grimshaw K et al. Incidence and natural history of challenge-proven cow’s milk allergy in European children—EuroPrevall birth cohort. Allergy 2015; 70 (8): 963–972.
- Skripak J, Matsui E, Mudd K, Wood R. The natural history of IgE-mediated cow’s milk allergy. J Allergy Clin Immunol 2007; 120 (5): 1172–1177.
- International Milk Allergy in Primary Care team. The iMAP milk ladder. Available at: www.allergyuk.org/assets/000/001/297/iMAP_Final_Ladder-May_2017_original.pdf?1502804928