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Paediatric Dietetics: Non-IgE mediated/Delayed Cow’s milk protein allergy (CMPA)

This webpage has been created to help support those parent/guardians of infants who suspect they have or have been diagnosed with a non-IgE mediated/delayed cow’s milk protein allergy (CMPA).

This webpage does not include detailed information on IgE mediated milk allergy or other food allergies, please seek further advice from your Health visitor, GP or Paediatrician who will refer to Paediatric Dietetic services as appropriate.

Non-IgE CMPA is the most common food allergy observed in infants on the Isle of Man and can cause a number of symptoms, which are outlined in the resource titled, ‘Does my child have a cow’s milk protein allergy’ which is linked to the right of this page.Symptoms can range from mild to severe and not all symptoms are seen in every infant. This makes it difficult to diagnose at times. Unfortunately, there are NO blood tests or stool sample tests that can confirm this type of allergy. Emphasis is placed on the clinical history and an exclusion and re-introduction of dairy as appropriate.

The difference between IgE-mediated and Non-IgE mediated CMPA is explained briefly if you click either of the links to the following resources on the right hand side:

Cow’s milk protein allergy initial information

Does my child have a cow’s milk protein allergy?

Advice for parents/guardians who suspect Non-IgE CMPA is affecting their baby

On the Isle of Man, we have our own local care pathway which is based on evidence based guidelines, this is reviewed regularly to ensure it is both up to date and relevant to services available to Island residents.

If you suspect your baby is indeed suffering with CMPA, modifications to the diet may be required. It could be helpful to talk your concerns over with your Health Visitor or GP prior to making changes, so referrals to Dietetics (and Paediatricians) for support can be arranged if required.

If you wish to continue breast-feeding, it is advised you eliminate cow’s milk and all milk/dairy containing foods from your diet for a minimum of 2 weeks initially before re-introducing milk again to confirm suspicions of CMPA. Advice on following a dairy free diet is available following the appropriate link on the right hand side of this webpage. Please also see advice on calcium requirements in breastfeeding.

If your baby uses any formula, or is 100% formula fed, you will require a suitable alternative to any cow’s milk based infant formula. A specialist infant formula prescribed by your GP will be necessary if your child is less than 6 months old. On Island, we recommend GPs trial a formula called ‘Alimentum’ as first line and refer to Paediatric Dietetics simultaneously for further assessment and support on confirmation of diagnosis and milk free weaning as/when appropriate.

Soya formulae is available over the counter and can be trialled after 6 months old. It is possible your child may also be sensitive to soya, so please bare this in mind.

Please also be aware that Lactose Free formulae includes cow’s milk proteins and is not a suitable alternative. Goat’s milk based formulae are also not recommended for management of cow’s milk protein allergy since the protein structure is similar and may also elicit a reaction.

It may take a minimum of two weeks for your baby and you to feel and see the full benefits of changing to a dairy free diet and or formula.

After approx. 2-4 weeks, you can follow advice on ‘Confirmation of diagnosis via re-introduction’ linked on the right hand side. Alternatively, you can wait and discuss this in more detail at your appointment with the Dietitian.

Future management of Non-IgE mediated CMPA

For Non-IgE mediated CMPA, it is expected your child will begin to tolerate dairy in small amounts initially between the ages of 1-3. The majority of children outgrow a non-IgE mediated CMPA altogether. Other useful resources on this webpage includes copies of the ‘Milk Ladder’ and accompanying recipes, which should be discussed during dietetic consultation and/or milk free weaning group sessions.

Other Food Allergies

It is possible your child may be or become sensitive to other things including foods.

It is a myth that breast fed babies do not suffer from food allergies, so some food allergies may be evident since proteins from your diet transfer into milk produced. This does not mean you need to stop breastfeeding though. Please seek advice around this so you can be supported to restrict as few things from your own diet as possible and continue breast-feeding if you wish to. A dietitian will ensure your intake remains nutritionally adequate and you are getting everything you need to support your baby and your own short and long term health.

Other allergies may only become evident during weaning especially for those infants who are formula fed until weaned. Depending on the severity of the reaction, please seek urgent advice if instinct advises this. You may also need to request an onward referral to a Paediatrician.

There is recent evidence to suggest that for children who already suffer with an allergy (such as milk), that early introduction of other high risk allergenic foods such as egg and peanut and reduce the chances of developing allergy to these foods significantly. Further information on this is also linked to the right.

When to seek further advice

If you or your health visitor are concerned about any of the following, please do not hesitate to seek further advice and request onward referral to a paediatrician (and a dietitian) if you are not already under their care.

  • Ongoing feeding difficulties associated with poor growth i.e. falling 2 or more centiles on the growth chart
  • Reactions that happen very quickly after having a food, to include any of the following symptoms: projectile/forceful vomiting, loose stools with mucus or blood, facial swelling, difficulty breathing, general apathy and listlessness
  • Widespread atopic eczema
  • Ongoing parental suspicion of food allergy
  • Strong clinical suspicion of IgE mediated food allergy but any allergy tests are negative.
  • Possible multiple food allergies

Do not hesitate to seek urgent medical input if you are concerned about severe allergic reactions or possible dehydration by observation of dry nappies. This may include calling 999 or attending emergency department.

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