for complete article go to www.medscape.com/viewarticle/563463?sssdmh=dm1.305977&src=nldne

Recommendations for Management of Cow's Milk Protein Allergy in Infants  CME/CE 
News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD

September 27, 2007 — A review in the October issue of the Archives of Disease in Childhood offers recommendations to assist general pediatricians and primary care clinicians in diagnosing and managing cow's milk protein allergy (CMPA) in breast-fed and formula-fed infants...(snip)
Because CMPA can develop in exclusively and partially breast-fed infants, and when CMP is introduced into the feeding regimen, the guidelines provide separate algorithms detailing diagnosis and management of CMPA in breast-fed and formula-fed infants. The algorithms also differ based on the severity of symptoms...(snip)

Blood-stained stool in an infant is usually benign and self-limited, is observed primarily in exclusively breast-fed infants, and is sometimes associated with viral infection. Because cow's milk allergy in these infants is less frequent than was previously thought, cow's milk challenge is indicated for infants who become symptom-free during a CMP-free diet. Such challenge will decrease the number of false-positive diagnoses of CMPA....(snip)

When symptoms recur after dairy products are reintroduced into the mother's diet, the algorithm recommends extensively hydrolyzed formula if the mother wishes to begin weaning the infant and if the child is between 9 and 12 months of age..(snip)

For formula-fed infants, skin prick tests, patch tests, and specific IgE determination may assist diagnostic evaluation and guide management in some cases. However, in formula-fed infants as well as in breast-fed infants, elimination diets and challenges are the gold standards for diagnosis of CMP...(snip).

Breast-feeding is the preferred method for nourishing healthy infants...(snip)

Infants with mild to moderate symptoms should be fed extensively hydrolyzed formulas, or amino acid formula if extensively hydrolyzed formula is refused or if the cost-benefit ratio favors amino acid formula, for 2 to 4 weeks or longer..(snip)

Unmodified mammalian milk protein (cow, sheep, buffalo, horse, or goat) or unmodified soy or rice milk is not recommended for infants because they lack sufficient nutrition to be the sole source of food for infants, and they run the risk for possible allergenic cross-reactivity.(snip)

Study Highlights:

a.. Breast-feeding should be the sole means of milk-feeding for at least the first 4 months of life. Breast-feeding significantly reduces the risk of developing CMPA. If a breast-fed infant develops symptoms of CMPA, the mother should consider exclusion of cow's milk, peanuts, and hen's eggs from her diet. Such an exclusion diet should be continued for at least 2 weeks before judging its effectiveness or up to 4 weeks in cases of atopic dermatitis or allergic colitis. 
a.. If symptoms improve after implementation of an elimination diet, the nursing mother may reintroduce 1 food into her diet per week. If there is no improvement after an elimination diet, referral to a specialist with experience in pediatric allergy should be considered. 
a.. Among formula-fed children, suspected mild or moderate CMPA may be diagnosed by implementation of a formula based on extensively hydrolyzed proteins or other amino acids. Although amino acid formulas may be more expensive, IgE-mediated reactions have been documented with the use of extensively hydrolyzed formulas. During this elimination diet, the use of other supplementary foods should be limited as much as possible
a.. Formula-fed children with suspected severe CMPA should be referred to a pediatric specialist and should receive amino acid, not extensively hydrolyzed, formula. 
a.. The use of unmodified mammalian milk protein from any animal is not recommended during infancy because these milks do not provide adequate nutrition for a growing child. Soy protein formulas are not necessarily hypoallergenic, and extensively hydrolyzed formulas or amino acid formulas are preferred for the alimentation of children with CMPA. 

~vicki hayes rn ibclc in brunswick ga~

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