Overview

Cow’s Milk Protein Allergy

• Typically presents in first 3 months of life in formula-fed infants (rarely in breastfed infants).
• May be immediate (IgE mediated) or delayed (non-IgE mediated) reactions.
• Sx → regurgitation, vomiting, diarrhoea, urticaria, atopic eczema, irritabiltiy, crying, wheezing, chronic cough. Rarely may cause angioedema and anaphylaxis. (Symptoms after switching to formula).
• Ix → skin prick/patch testing. Total IgE and specific IgE (RAST) for cow’s milk protein. Regularly monitor growth.
• Mx →
  • Severe Symptoms (eg. failure to thrive) → refer to paediatrician.
  • Formula-Fed → extensive hydrolysed (hypoallergenic) formula milk.
  • Breastfed → continue breastfeeding, eliminate cow’s milk protein from maternal diet.
    • Consider co-prescribing calcium and vitamin D supplements for mother as she is removing milk from diet.
  • Regularly monitor growth, nutritional counselling with paediatric dietician.
  • Re-evaluate tolerance to cow’s milk protein every 6-12 months. Re-introduce with milk ladder.
• The majority of cases resolve before the age of 5 years (will be milk tolerant by this point).

Anaphylaxis

• IM Adrenaline 1:1000 → <6 = 150mcg, 6-12 = 300mcg, >12 = 500mcg.
• All patients should be monitored in hospital for up to 6 hours following initial reaction.
• Mx → IM Adrenaline (assess response after 5 mins and repeat if needed), High-Flow Oxygen, IV Fluids (paeds bolus = 10ml/kg), IV Chloramphenamine, IV Hydrocortisone, Salbutamol (if wheeze).
  • Dealing with immediate emergency → IM Adrenaline, Oxygen, IV Fluid Bolus.
  • Once resolution of immediate emergency → chloramphenamine and hydrocortisone.
  • SALBUTAMOL IF WHEEZE.
• Hereditary Angioedema (C1 Esterase Deficiency) → recurrent facial swelling + abdominal pain.

Making Diagnosis

Clinical Features

Investigations