How pharmacists can help diagnose and manage cow’s milk allergy

Awareness is growing about childhood allergies, especially peanut allergy. But according to the Australasian Society of Clinical Immunology and Allergy (ASCIA), the symptoms of one of the most common food allergies seen in infants in Australia¹ – cow’s milk allergy (CMA) – are often missed.

This is because the symptoms can vary between children and can be nonspecific. Children may develop eczema and rashes, gastrointestinal symptoms including mucus and blood in the stool, vomiting and diarrhoea as well as rhinorrhoea. Not all symptoms are always present. The reaction can be immediate or delayed by 2 or more hours.

The lack of a good diagnostic test for CMA, together with the often nonspecific nature of the symptoms, has seen many parents face delays in diagnosis for their baby. In one UK-based study², it took an average of 10 weeks for parents to receive a diagnosis after presenting to their GP. This causes distress and distrust in healthcare professionals.

Pharmacists are often the first port of call for distressed parents looking to manage their baby’s symptoms. They are in a unique position to be mindful of the possibility of CMA and, if suspected, suggest a review by the GP. Meanwhile, they can assist parents to make good choices for their allergic babies. Fully breastfed babies should continue to breastfeed. Some paediatricians insist mum must totally eliminate cow’s milk protein from her own diet³. However, ASCIA says this is unnecessary⁴.

Pharmacists can also assist parents in choosing an appropriate formula in formula-fed babies.

The ASCIA guidelines state emphatically that for children with CMA, not only should unmodified cow’s milk derived milk and formula never be given, but ‘lactose free’ milk and formula, goat’s milk and goat’s milk formula, sheep’s milk and sheep’s milk formula as well as other alternatives like camel’s milk, HA formula and A2 milk may cause severe allergic reactions including anaphylaxis and must be completely avoided.

So, what can these little ones have? If they are over 6 months of age, soy-based formulas are an option, although some babies with CMA are also soy allergic. Under 6 months, or in babies and children with a known or suspected soy allergy, with CMA but no history of anaphylaxis to CMA, a cow’s milk based extensively hydrolysed formula (EHF) is recommended first line by ASCIA⁴. An EHF has been treated with enzymes to metabolise the actual proteins.

One in 10 babies will still react to an EHF⁵.These babies will likely need an amino acid based formula on prescription from an allergy specialist, clinical immunologist or paediatric gastroenterologist⁶.

Pharmacists have the knowledge, patience and empathy to help shorten the time to diagnosis of CMA and help parents through the difficult time of getting their baby’s problems recognised and treated.

This content is for pharmacists or healthcare professionals only.

Breastmilk is best for babies; professional advice should be followed before using infant formula. Introducing partial bottle feeding could negatively affect breastfeeding. Good maternal nutrition is important for breastfeeding and reversing a decision not to breastfeed may be difficult. Infant formula should be used as directed. Proper use of infant formula is important to the health of the infant. Social and financial implications should be considered when selecting a method of feeding.

References

1. Australasian Society of Clinical Immunology and Allergy. Food allergy. 2019. At: www.allergy.org.au/patients/food-allergy/food-allergy
2. Lozinsky A, Meyer R, Anagnostou K, et al. Cow’s milk protein allergy from diagnosis to management: A very different journey for general practitioners and parents. Children 2015;2(3):317–329.
3. Brill, H. Approach to milk protein allergy in infants. Can Fam Physician 2008;54(9):1258–1264.
4. Australasian Society of Clinical Immunology and Allergy. Cow’s milk (dairy) allergy. 2019. At: www.allergy.org.au/patients/food-allergy/cows-milk-dairy-allergy
5. Giampietro PG, Kjellman NI, Oldaeus G, et al. Hypoallergenicity of an extensively hydrolyzed whey formula. Pediatr Allergy Immunology 2001;12(2):83–6.