CMPA MANAGEMENT TOOLS AND INFORMATION

Dai is only two months old but she has been suffering from constipation and has been crying excessively for weeks. Her parents could not understand why she was always distressed. “We haven’t slept for nights and we cannot rest during the day because she cries constantly. We are really worried and don’t know what it could be”  said Dai’s parents.

When Dai was one month old, she was hospitalised but the symptoms were not linked to CMPA and her parents were advised to try a partially hydrolysed infant formula for her constipation.

Unfortunately, there was no symptom relief and an upper gastrointestinal examination was performed. This revealed a high count of eosinophils in the blood. In addition, total IgE and cow’s milk IgE were also high, which led to Dai’s diagnosis of CMPA. Dai’s parents were given Althéra, an extensively hydrolysed formula (eHF) to manage her CMPA and asked to return to see the doctor in two weeks.

Within just two days of taking Althéra, Dai’s constipation and crying had stopped!  “We couldn’t believe it! Dai has never been happier…and we were so relieved that she was no longer suffering. Now we can all get a good night’s sleep!”  said Dai’s mother. Dai’s parents were pleased to return to the doctor two weeks later to tell him the good news! 

Oliver was referred to a dietician at 11 weeks of age with a history of constipation, unsettledness and reflux without vomiting. Oliver initially presented with these symptoms at around two weeks old and was seen by a paediatrician as an outpatient.

Oliver was currently on a standard formula and had previously been prescribed lactulose to help with his constipation. His weight was on the 50th percentile however his height could not be measured due to his distress.

An allergy focused history was taken. With a certain incidence of asthma in the family and a suspicion of non-IgE-mediated symptoms, an elimination diet was considered, with the exclusion of cow’s milk protein for two to eight weeks. The theory being that if symptoms do not improve then Cow’s Milk Protein Allergy is unlikely.

Three sample tins of the lactose containing, extensively hydrolysed formula (eHF), Althéra were prescribed and Oliver’s parents were asked to contact the dietician if they felt that any improvement was seen so that a prescription could be arranged.

After six days, Oliver’s parents phoned to say that Oliver was straining less to pass stools and was noticeably more settled. At the next appointment at 15 weeks (four weeks later), Oliver’s weight was on the 75th – 91st percentile and his height on the 50th percentile.

Oliver’s parents were really happy with his improvement; stools were being passed with ease and he was much happier overall. “Things are getting a lot easier and we are all less tense. It’s so good to see him on form.”  Althéra was well tolerated by Oliver and his weight had increased, although his intake was just under the recommended amount.

Oliver remained on Althéra and his parents were given guidance on cow’s milk protein-free complementary feeding and suitable first foods. 

Joey was four months old when he had his first consultation. He was exclusively breastfed and he was suffering from severe atopic dermatitis which was especially prominent on his face. “We took Joey to see the doctor because he had a terrible rash on his face which he could not stop scratching. He was also not sleeping at night, which left us all sleep deprived”  said his mother Agnes. There was a family history of allergic atopy; Joey’s mother had atopic dermatitis as a child and still has an egg allergy. Joey’s father also suffers from allergic rhinoconjunctivitis.

“Joey’s doctor gave us a lot of information about atopic dermatitis which was very helpful.” Joey was given a basic skin treatment and a topical preparation containing cortisone. This led to an improvement of Joey’s skin condition and a slight stabilisation.

When Joey’s parents began complementary feeding his skin deteriorated significantly. Joey’s parents took him to see the doctor again and a food allergy test was performed, showing that Joey had a sensitisation to cow’s milk protein and walnut.  Joey’s skin prick test also confirmed a sensitisation to cow’s milk protein. Based on these results, Joey was prescribed Alfamino as a milk substitute and his mother Agnes, who was still partially breastfeeding began a cow’s milk protein-free diet. This resulted in a rapid healing of the skin.

After his 1st birthday, Joey was invited for a food challenge by his doctor. This resulted in an increase of the eczema, accompanied by acute urticaria. Alfamino was therefore prescribed again as a cow’s milk substitute, leaving Joey free of symptoms.  

When Joey was two years old he began to eat processed milk products without any allergic symptoms.  Joey’s parents were so happy that Joey no longer had allergic symptoms and even happier that they could all get a good night’s sleep.

Vivian was five months old when she was first given a cow’s milk-based formula.  “Vivian vomited more than four times two hours after feeding!  We were so worried that we took her to the hospital straight away”  said Vivian’s parents. When the doctor first saw Vivian he reported that she looked lethargic, dehydrated and pale. She also cried weakly. Vivian was admitted immediately and put on an intravenous drip overnight. The doctors also decided to start Vivian on a course of intravenous antibiotics to treat any possible infection.

Vivian was referred to an allergist to investigate her condition further. She was tested for Cow’s Milk Protein Allergy with a skin prick-test and a blood test but she tested negative for Cow’s Milk Protein Allergy with both tests. Vivian was then diagnosed with a non-IgE-mediated Cow’s Milk Protein Allergy called food protein-induced enterocolitis syndrome (FPIES). 

The allergist offered Vivian’s parents an extensively hydrolysed specialty formula, Alfaré to help manage CMPA. Vivian tolerated Alfaré well, was successfully weaned over to Alfaré and also started with cow's milk protein-free complementary feeding. Her parents were advised to adhere to strict avoidance of cow’s milk protein. They were also advised to read food labels carefully to ensure complete avoidance of dairy products until a formal food challenge could be conducted.  “At first we were really nervous to start giving Vivian complementary solid foods because we were told that there was a small risk of FPIES to grains, meats, fruits and vegetables, but the dietician gave us lots of helpful advice so we had no problems introducing Vivian to lots of different baby foods”  said Vivian’s father Rahul.

When Vivian was seven months old, she was accidently given some yoghurt melts to eat at a birthday party. About two hours later, Vivian began vomiting, but this time it was less severe than before.

At 24 months old, Vivian was given a formal cow’s milk challenge as an inpatient at hospital. Senali, Vivian’s mother couldn’t stop smiling “We were so happy that she didn’t react to the cow’s milk and even happier that her FPIES had resolved!”

Harry was five months old when his paediatrician first referred him to a dietician for nutritional treatment of his persistent gastrointestinal problems. Harry had been suffering with what his paediatrician thought was gastro-oesophageal reflux (GOR) for some time and had undergone multiple treatments for this problem with no success.  He was firstly treated with infant Gaviscon (alginate) but there was no improvement. He was prescribed Ranitidine (a H2 antagonist) and a pre-thickened formula, but these also failed.

When Harry first saw the dietician, an allergy focused clinical history was conducted in order to distinguish between IgE and non-IgE symptoms. He had colic type symptoms (unsettled, back arching and persistent crying) as well as both immediate and delayed GI symptoms (loose watery stools, wind, vomiting after each feed). Based on the mix of non-IgE and IgE-mediated symptoms, a serum specific IgE test was requested. Finally, a diagnosis of Cow’s Milk Protein Allergy was made and Harry was started on an extensively hydrolysed infant specialty formula.  Although there was some marginal improvement, Harry was still unsettled; his symptoms did not fully resolve and he continued to suffer from loose stools and frequent vomiting. After four weeks, Harry was prescribed an amino acid-based specialty infant formula, Alfamino.

One week later, a telephone follow up was conducted with Harry’s mother. She reported that Harry was doing much better on Alfamino. “His stools are now soft and formed and his vomiting has significantly reduced. Overall he is much more settled.”  A follow up in the clinic one month later revealed that all of Harry’s symptoms had completely resolved thanks to Alfamino and he was now fully weaned onto a cow’s milk protein-free diet.

A few weeks later, Harry had an accidental exposure to baked cow’s milk from a breadstick. This led to explosive diarrhoea within 30 minutes to 1 hour after consumption. The date and the location of a future food challenge is currently being discussed. Oral food challenges can be performed either at home or in a hospital. It can be safer to challenge those with immediate type reactions (usually IgE-mediated) in a hospital, depending on the severity of their initial symptoms. The results of the initial and repeated measurement of serum specific IgE will help doctors to make this decision. 

Emily was seven months old when she presented at a scheduled  paediatric dietician appointment with resistant atopic dermatitis (eczema) and concomitant gastric-oesophageal reflux, for which she was on anti-reflux medication.  Emily’s weight was 6.3 kg and she was on the 9th percentile. A family history of atopic allergy was identified, as well as a zinc deficiency and skin infections for which zinc supplements and antibiotics had been prescribed. Emily was being breast fed by her mother, Abigail, who had tried eliminating wheat and dairy from her diet, as Emily’s older sibling had a wheat allergy.

Abigal was advised  to adhere to a strict cow’s milk protein-free diet and asked to take calcium and vitamin D supplements. Emily’s anti reflux medications were increased and she was given zinc supplements. Abigail carried on breast feeding and was advised to continue cow’s milk protein elimination throughout the complementary feeding period.

Three months later, Emily re-presented with severe discoid eczema and food associated enterocolitis. At which point she was diagnosed with severe non-IgE-mediated food allergy. Her weight had not increased significantly and she was now faltering in growth with both zinc and vitamin D deficiency; Abigail was still breast feeding Emily and avoiding wheat, dairy, nuts and eggs but Emily was having episodes of loose stools. Emily was also not sleeping well due to itchiness and was admitted to the ward directly. It was upsetting for Abigail too “I’ve tried everything I can to help Emily but her symptoms seem to be getting worse – I feel like a terrible mother. ”

Emily‘s symptoms were so severe that she was started on an amino acid-based formula, Alfamino, via a nasogastric tube and after 24 hours bottle feeding was started. Within three days Emily was sleeping better and the eczema on her face and body was beginning to settle. She was discharged from hospital with zinc and vitamin D supplements and Alfamino.

Emily’s condition was reviewed after one month; she had gained 1.2 kg in weight and the eczema continued to improve considerably with less itchiness, redness and inflammation. Abigail noticed she was also sleeping better and the reflux had resolved, however she still had bouts of diarrhoea. “ I am so happy that she is getting better – each day there is an improvement; the whole family can see it.”

Emily continued on Alfamino and with complementary feeding in progress, Abigail was starting to introduce low atopic risk food.