Milk allergy (Paediatric Guidelines)

• First reactions are often to cows' milk infant formula.
• Most common symptoms are mild. Eg, urticaria, lip &eyes angioedema / swelling, vomiting.
• Tongue & throat angioedema / swelling is considered severe.

Lactose intolerance

• This is not immune mediated. This is caused by a lack of the enzyme lactase in the gut.
• Primary lactose intolerance is very rare in children but secondary lactose intolerance can occur after a bout of gastroenteritis.

Non-IgE mediated cows' milk protein allergy management

Reassure parents that non-IgE mediated cows' milk allergy is NOT a life threatening allergy.

1. Trial elimination of suspected allergen for 3 to 4 weeks.
2. If the symptoms do not improve, then allergy is unlikely.
3. Re-introduce the suspected allergen.
   If the symptoms have improved during elimination periods and worsen on re-introduction, make the diagnosis of non-IgE mediated milk allergy and advise on avoidance.
4. Refer to Paediatric dietitian.

For a diagnosis and treatment plan specific to non-IgE mediated cows' milk allergy please refer to Highland Non-IgE Cows' Milk Protein Allergy Guideline.

IgE mediated cows' milk protein allergy management

• Advise avoidance of foods containing cow’s milk (dairy). Other animal milks, eg, goat should also be avoided. For further information see: Milk allergy - British Dietetic Association (BDA)  
• HOWEVER, if infant / child reacted to milk itself but could already tolerate baked milk, eg, biscuits / cakes, encourage ongoing feeding with these baked products 2 to 3 times per week.
• Advise parents to ALWAYS have an anti-histamine:
  • Over 1 year of age: cetirizine when required
    (unlicensed below 2 years but BNFC has dosing from one year).
  • Under 1 year of age: chlorphenamine.
• Anaphylaxis: Prescribe AND train carers on the use of adrenaline autoinjectors, if required due to anaphylaxis.
  • Supply 2 x autoinjectors for parents and x 2 for nursery / school.
  • See: Anaphylaxis (Formulary) Epipen /Jext /Emerade
• Provide parent with CYANS information leaflet: Guidance on avoiding egg
• Give family a BSACI action plan, with a copy to nursery and other care providers.

General weaning advice

• There is no reason to think the child will be allergic to any other foods, therefore other foods should NOT be avoided.
• Recent evidence suggests that to reduce the risk of allergy, foods like peanuts and other hyper-allergenic foods should be introduced when weaning starts from 6 months of age. Whole nuts and whole peanuts should NOT be given to children under five years old, as they can choke on them. Instead crushed, ground or smooth nut or peanut butters should be offered on a regular basis.

Milk Allergy and Eczema

• Milk allergy may worsen eczema.
• Treat eczema.
  • If eczema is moderate to severe and not controlled in primary care: Refer to Dermatology.
• If infant (less than 1 year of age) has severe (but optimally treated under Dermatology) eczema, and diet includes milk and dairy foods, then refer to Dietitians to consider trial of 3 to 4 weeks' milk exclusion.

When to refer to Paediatric dietetics

• Refer all children with cows' milk allergy to Paediatric Dietitians via SCI store.
• Dietetics will support milk reintroduction via the 'milk ladder'.

When to refer to General Paediatrics

Refer to General Paediatrics via SCI Store:

• Children with anaphylaxis symptoms involving airway / breathing (cough, wheeze or swelling of the throat, e.g. choking), or the circulation (faintness, floppiness or shock).
• Children with severe protracted vomiting or diarrhoea during reaction.
• Children who also receive regular asthma preventative treatment and / or have difficult to control asthma.
• Milk allergy with another major food allergy (egg, peanut, tree nuts, wheat, fish).
• Still allergic when approaching primary school age.

If advice only is required please use Clinical Dialogue.

• CYANS Diagnosis and Management of food allergy

• Children and Young People's Allergy Network Scotland (nhs.scot)