Dietary management of milk allergy,Rachel De Boer Paediatric Allergy Dietitian Guys and St Thomas Hospital London, UK,Learning objectives,Prevalence of food allergy worldwide (inc. Cows milk protein allergy),Dietary management in infancy: Hypoallergenic formula (inc. indications) Milk free weaning Allergen avoidance,Dietary management in the older child: Ensuring adequate growth Nutritional intake Tolerance acquisition,Prescott et al 2013,Increasing FA globally Australia highest at 10% but others including China = 7-8% (Prescott et al 2013) CMA higher in Australia and west than Asia Outgrowth majority by 2 years (but different studies show different results) - (IgE takes longer to outgrow),Global food allergy rates in young children,Hu Y, Li H Chin. J. Pediatr 2000,38:431(CHINA) Hill DJ et al. Env Tox Pharma 1997;4:101.(AUS) Eggesbo M et al J.Paed 2001,139:583 (NOR) Du Toit G et al. JACI 2008; 122: 984-91 (UK),Sampson H.A. JACI 2004;13:806. (USA) Rance F et al CEA 2005;35:167.(FRA) Du Toit G et al. JACI 2008; 122: 984-91 (ISR) Hu Y et al. Pediatrics International (2010) 52, 820824,Increasing food allergy in SE Asia?,Children aged 0-24months in Chongqing Questionnaire followed by SPT/OFC Significant increase Milk & egg most,n=304,n=382,2009,Hu Y et al. Comparison of food allergy prevalence among Chinese infants in Chongqing, 2009 versus 1999. Pediatrics International (2010) 52, 820824,Increasing food allergy in SE Asia?,Few robust studies (mainly questionnaires) 2014 - 3.7% of 16,749 children in Soeul Best studies show comparable rates to Europe/US 2012 6.2% in 2yrs in SW China Milk, egg and shellfish are most common allergens Appear to be increasing Non IgE mediated FA reported in numerous settings,Park M. Allergy Asthma Immunol Research 2014;6(2):131-6 Chen J et al. Prevalence of Food Allergy in Children under 2 years of age in 3 cities in China. Zhonghua Er Ke Za Zhi 2012 Lee JL et al. Food Allergy in Asia:how does it compare?Asia Pac Allergy 2013 Prescott S etal. A global survey of changing patterns of food allergy burden in children. WAO Journal 2013;6:21.,Focus on cows milk protein allergy: Dietary management,Dietary management,Nutritional assessment,Other allergens/co-morbidities,Reaction recognition and treatment,Elimination diet (allergen avoidance),Follow up/monitoring,Dietary management principles for milk allergy,CMPA: Dietary management in infancy,Dietary management: Milk allergy in infancy,Dietary elimination/allergen avoidance Appropriate cows milk alternative Allergen avoidance Label reading Suitable alternatives Level of restriction required,Dietary management: Milk allergy in infancy,Dietary elimination/allergen avoidance Appropriate cows milk alternative Allergen avoidance Label reading Suitable alternatives Level of restriction required,Breast is BEST!,Aim to follow WHO guidelines Continue breast feeding where possible ? maternal exclusion diet necessary Support mum to avoid CM Maternal calcium and vit D intake Sensitisation through breastmilk manifests primarily Exacerbation of atopic eczema and/or Allergic proctocolitis Identify infants where HAF may be indicated,Restani et al. Ann Allergy Asthma Immunol 1999;84:353360. Hill et al. Clinical and Experimental Allergy, 2007;37:808822 Host A, et al. A prospective study of cows milk allergy in exclusively breast-fed infants. Incidence, pathogenetic role of early inadvertent exposure to cows milk formula, and characterization of bovine milk protein in human milk. Acta Paediatr Scand 1988: 77:663 70. Kilshaw PJ, Cant AJ: The passage of maternal dietary proteins into human breast milk. Int Arch Allergy Appl Immunol 1984, 75(1):8-15.,Hypoallergenic formula,Definition of a “hypoallergenic feed”,Two definitions exist: The first such definition for labelling infant formulas with reduced allergenicity is arbitrarily based on a content of 1% immunoreactive protein of total nitrogen The second definition for products for treatment of cows milk protein allergy in infants should be tolerated by at least 90% (with 95% confidence) of groups of infants with documented cows milk protein allergy,Host et al. Arch Dis Child 1999;81:8084 AAP. Pediatrics 2000;106;346,Extensively Hydrolysed 95% 1.5KDa,Hydrolysed cows milk protein,Hypoallergenicity of infant formulas,Partially Hydrolysed 60% 1.5KDa,Amino acid based 100% amino acids,Hypoallergenic formulas used in treatment of CMPA,Extensively hydrolysed formulas,Siemensma et al. Trends of Food Science 7(1):62.,Hydrolysed casein or whey in which most of the nitrogen is in the form of free amino acids and peptides 3.5kDa in size Degree and extend of hydrolyses varies amongst the formulas,Amino acid formulas,Elemental Formula, which doesnt contain any peptide fragments Free amino acids that require little or no hydrolyses by intestinal peptidase Protein = vegetarian source,Guidelines,Venter et al Diagnosis and management of non-IgE-mediated cows milk alle