New CPS guidance on cow’s milk protein allergy in children

Cow’s milk protein allergy in children and infants is complex, and the Canadian Paediatric Society has released a new position statement to help healthcare providers navigate it.The guidance focuses on non-IgE-mediated cow’s milk protein allergy (CMPA). Its recommendations include making the difference between CMPA and lactose intolerance clear to families. Lactose intolerance usually develops during late childhood or beyond and has only GI symptoms. CMPA, on the other hand, happens in early childhood—it’s the leading cause of allergy in children under three years old. Its symptoms go beyond the GI tract to the skin and respiratory system, and it can be severe and even life-threatening. It usually resolves in childhood, somewhere between ages one and six. Non-IgE/cell-mediated CMPA falls into three categories: IgE-mediated, which is immediate and includes multiple systems.Mixed IgE + non-IgE/cell-mediated, which includes two subtypes, eosinophilic esophagitis and eosinophilic gastrointestinal diseases.Non-IgE/cell-mediated reactions fall into three subtypes: food protein-induced allergic proctocolitis, food protein-induced enteropathy and food protein-induced enterocolitis syndrome. Read: First vaccine to prevent RSV in infants by immunizing pregnant individuals now available in CanadaThe guidance covers the symptoms associated with each, how to diagnose them, and specific foods to remove and how to resolve them. Food protein-induced allergic proctocolitis (FPIAP) is the most common subtype in infants. Symptoms include blood in the stool and localized inflammation of the distal colon in otherwise healthy infants that appear well. Usually, FPIAP resolves within a few days of changing the maternal diet or switching to hypoallergenic formula. There are no specific tests for non-IgE-mediated CMPA, except for food protein-induced enteropathy, which can be confirmed with a small bowel biopsy. Read: The dos and don’ts of managing bronchiolitis in infants in primary care settingsIt also says clinicians need to “exercise prudence” to avoid over-diagnosis, which can lead to the unnecessary use of expensive hydrolyzed formulas. They should not use unproven diagnostic tests, such as IgG tests, which can lead to over-diagnosis of food intolerances. Healthcare providers can refer infants to a pediatric gastroenterologist if they’re unsure of a diagnosis. The treatment is “strict avoidance” of cow’s milk protein, the statement says. Most infants and children will tolerate an extensively hydrolyzed formula, and less than than 10% will need amino acid formula. In the case of breastfed infants with food protein-induced allergic proctocolitis (FPIAP), dairy and soy should be eliminated from the maternal diet, and breastfeeding should be encouraged. A dietitian is strongly recommended to make sure that the mother isn’t consuming any hidden allergen sources and that her nutritional needs are being met. If that doesn’t work, healthcare providers should consider extensively hydrolyzed formula. Read: Cellphone and data plans should be cheaper and more reliable—for the good of infant healthThey should also consider extensively hydrolyzed formula for formula-fed infants with CMPA. For infants with severe food protein-induced enterocolitis syndrome and failure to thrive, an amino acid formula is recommended. Most children outgrow CMPA, with 50% tolerating cow’s milk protein by age one, more than 75% by age three, and more than 90% by age six. As a result, CPS recommends that healthcare providers consider families re-challenging for infants with FPIAP and food protein-induced enteropathy after they turn one. That can be done with fresh, pasteurized cow’s milk at home. Infants with food protein-induced enterocolitis syndrome should do an oral food challenge between a year and a year-and-a-half old under close physician supervision. Providers should avoid prolonged dietary eliminations, which can be costly for families and pose nutritional risks that can impact growth and lower quality of life. Read: New CPS statement on managing febrile infants disrupts usual management strategy

New CPS guidance on cow’s milk protein allergy in children

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