City Hospitals Sunderland Dietetics department and Sunderland CCG Medicines Optimisation Team

Guidelinefor theprescription of infant formulafor infantswithsuspectedcow’smilkprotein(CMPA)allergyor lactose intolerance

Initiated 03/2016

Review 03/2018

Introduction

Theseguidelinesare intendedtoassist GPs andHealthVisitors withinformation ontheuseofprescribableinfantformulafor thetreatmentof cow’s milk proteinallergy(CMPA)or lactoseintolerance.

Quantities of formulato prescribe

When anyinfant formula isprescribed theguide below should beused:For powdered formula:

NB somechildrenmayrequire moree.g.thosewith falteringgrowth. This tableprovidesguidanceonlyand recentcorrespondencefrom paediatricianor paediatricdietitianshouldbereviewed. Review quantity every 3 months.

Generalprinciples

Tryastraightswap tonewformulaas anybenefitstoexcluding theallergenwill not beseenuntilall theoldformula isexcluded. Iftherearedifficultiesintroducing thenewformula, mixthe newformulawith usualformulaandgraduallyincreasetheproportionofnewfeedto encourage thebabyto acceptthemilk.

Do notroutinelyswitch betweenpreparations.

Soyabasedformulaeplayno role inthemanagementoflactoseintoleranceor CPMA inchildren lessthan 6months

Babiesover theageof 12months shouldbeseenbyadietitianfor theneedtocontinueformulatobereviewed

Whilst theseguidelinesadvise onappropriateprescribing ofspecialistinfantformulae,breastmilk remains the optimalmilkfor infants.This shouldbepromotedandencouragedwhere it isclinicallysafe todo soandthemother is in agreement.

Contact details
Sunderland Dietetics Department / 0191 5699013
Sunderland CCG Medicines Optimisation department / 0191 5128276

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Disclaimer: These guidelines are for advice only. It is entirely the decision of the clinician which products to prescribe

Prescription of infant formula in infantswithsuspectedcow’smilk proteinallergy(CMPA)orlactoseintolerance

1

Disclaimer: These guidelines are for advice only. It is entirely the decision of the clinician which products to prescribe

MildtomoderatesymptomsofCMPA

Oneormoreofthefollowingsymptoms:

Gastrointestinal:

Frequentregurgitation,vomiting,diarrhoea,constipation

Persistentdistressorcolic(≥3hrsperday–wailing/irritable),foratleast3days/weekover>3weeks

Dermatological:

Atopicdermatitis,urticariaunrelatedtoacuteinfections,drugintakeorothercauses

Suitableformula/feedingCow’smilkfreefoodsifweaning*Step1:Breastfeeding

ConsiderCMPfreedietformother,**withcalciumsupplements(e.g,Adcal-D3),foraminimumtrialof4-6weeks

Step2:Extensivelyhydrolysedformulas(EHF)

Caseinbased:SimilacAlimentum or Nutramigen LGG (<6months)Nutramigen2 LGG(>6months)

Wheybased:AptamilPepti1(<6monthsold)AptamilPepti2(6-12monthsold)-NBAptamilPepti1&2containslactose

Step3:Aminoacidbasedformulas(AAF)

Ifsymptomsdonotimproveafter4weeks(orthechildpersistentlyrefusesEHF)then:NutramigenPuramino

NeocateLCP

Trialforaminimumof4weeks

Donotusesoyabasedformulas

*AnychildrespondingtoCMPfreeformuladietshouldbereferredtoapaediatricdietitianforongoingdieteticadviceincludingbreastfedbabies.

**thepaediatric dietitian will give milk-free dietary advise to breast feeding mothers

SeveresymptomsofCMPA

Oneormoreofthefollowingsymptoms–Referforspecialistfollowup

Gastrointestinal:

1.Faltering growth duetochronicdiarrhoeaand/orregurgitation/vomitingand/orrefusaltoeat

2.Rapidweightloss

3.Irondeficiencyanaemiaduetooccultormacroscopicbloodloss

4.Proteinlosingenteropathy(hypoalbuminaemia)

Dermatological:

Exudativeorseveratopicdermatitiswithhypoalbuminaemia, faltering growthorirondeficiencyanaemia.Swellingofthelipsoreyelids(angio-oedema)

Respiratory:

Acutelaryngoedemaorbronchialobstructionwithdifficultybreathing

Systemicreactions:Anaphylacticshock–needsimmediatereferraltohospitalformanagement

Suitableformula/feedingCow’smilkfreefoodsifweaning*Step1:Breastfeeding

ConsiderCMPfreedietformother**,withcalciumsupplements(e.g.,Adcal-D3),foraminimum trialof4-6weeksStep2:Aminoacidbasedformulas(AAF)

Foraminimumtrialof4weeksNutramigenPuramino

NeocateLCP

*AnychildrespondingtoCMPfreedietshouldbereferredtoapaediatricdietitianforongoingdieteticadviceincludingbreastfedbabies.

**ReferbreastfeedingmotherstoanadultdietitianforMilkFreeDietaryAdvice

SecondaryLactoseintolerance

Includes:

Profusewatery,yellow,explosivediarrhoea

Symptomsareusuallytransientand2otoGIinsulte.g.,rotavirusinfection

Diagnosis:

Clinicalhistory Rarelyseeninexclusivelybreastfedbabies

Treatment:

Breastfedbabies–rarelyseen

Formula:LactoseFreeformulasbasedonCMPe.g.:EnfamilO-Lac,SMALF

Mostchildrenshouldonlyrequirelactosefreeformulafor6-8weeksandcanthen

reverttostandardformula(thisshouldbeintroducedgraduallybytitratingwithstandardformula)

DoNOTputlactose-freeformulaonrepeatprescription

SoyabasedformulasarenotrecommendedWeanedchildrenshouldbereferredfordieteticadvice

Ifinitialsymptomsdonotimproveaftertwoweeksonlactosefreeformulaconsideralternativediagnosis

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Disclaimer: These guidelines are for advice only. It is entirely the decision of the clinician which products to prescribe

1

Disclaimer: These guidelines are for advice only. It is entirely the decision of the clinician which products to prescribe

References:

DavidsonGPetal.Incidenceanddurationoflactosemalabsorptioninchildrenhospitalisedwithacuteenteritis:Studyinawellnourishedurbanpopulation.TheJournalofPaediatrics.1994;19:170-174

‘Guideline for the prescription of infant formula for infants with suspected cow’s milk protein (CMPA) allergy or lactose intolerance’ North of Tyne APC, June 2013

‘Appropriate prescribing of specialist infant Formulae Bulletin 67’ Prescqipp, July 2014

Footnote:

Guidanceforconcernsaboutcolic:

1.Inmostcasesofcolic,nounderlyingcausecanbefound

2.Addressingparentalconcernsisoftenthebestwaytocopewithcolic.Reassureparentsthatcolicwillresolve

3.ParentsmaywishtopurchasecolicremediessuchasDentinox,InfacolorGripeMixture.Althoughthereisnogoodevidenceofeffectiveness,parentsmayperceivethistobebeneficial.

4.Consideratrialofacolicandconstipationformulae.g.SMAComfort,AptamilComfortorCowGateComfort.

5.Lactaseenzymes(e.g.Colief)should not be prescribed forcolicasthereislimitedevidenceofeffectivenessandtheirusecontradictsDHguidanceonthepreparationofinfantformula.

6.Forunresolvedseverecolic,considerCMPA.

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Disclaimer: These guidelines are for advice only. It is entirely the decision of the clinician which products to prescribe