Prescribing milk-free formula for cows' milk protein intolerance (CMPI) in children


The following symptoms may be indicative of CMPI in children:
  • Gastro-intestinal
    • failure to thrive with vomiting and/or diarrhoea
    • gastro-oesophageal reflux disease (GORD) unresponsive to thickened feeds and anti-acid treatment
    • blood or mucous in stools
    • excess flatus
  • Skin
    • moderate to severe eczema in a young baby, particularly in association with diarrhoea and poor weight gain
    • urticarial rash associated with change in feed/introduction of solids
  • Respiratory
    • asthma (wheeze or cough)
  • Behavioural change and feed refusal may also occur
Over 75% of children with cows' milk intolerance have more than one symptom.
 

Treatment

Complete avoidance of cows' milk and its products is necessary. If there is no improvement in symptoms after a four-week trial, return to normal diet.  If symptoms improve - continue with the diet until the child is 10 to 12 months old. Most children become tolerant to milk around this age. Children following a milk-free diet should be challenged at one year old.
 
For breastfed babies consider a two-week trial of milk exclusion in the mother. If helpful and continued the mother should be recommended to take a calcium supplement.
 

Milk challenge

Reintroduce milk containing solids first and if tolerated change back to a standard formula or cows' milk depending on age. Around 60% of children tolerate cows' milk by 1 year with 80% achieving tolerance by 2 years of age. For most children this is done at home. Only children with significant immediate type reactions, e.g. facial swelling or wheeze require challenge in hospital.
 

Milk-free formula

Hydrolysed formula are the recommended choice. See Table 1 for formula most often used in NHS Grampian.
 

Soya Milk

Hydrolysed formula should be the first choice as babies with CMPI may also be sensitive to soy protein, particularly below the age of 6 months. Some infants will refuse to take hydrolysed formulas, particulary if diagnosed at 6 months, due to palatability. In this situation a soya formula can be considered for babies from the age of 6 months, e.g. Infasoy, Wysoy, Farley's soya formula.
 

Lactose intolerance

SMA LF and Enfamil O-Lac are lactose-free formula but contain cows' milk protein and are therefore not suitable if CMPI is suspected. Lactose intolerance is caused by a temporary intolerance to the milk sugar, lactose. It is self-limiting and in an otherwise well baby may not require treatment. Where treatment is required, the child's normal infant formula should be re-introduced after 4 weeks.
 

Local guidance

Further details on milk-free diets and how to challenge are provided in the infant feeding guidelines http://intranet.grampian.scot.nhs.uk/foi/files/InfantFeedingguidelines2009.pdf
 

Milk-free formula prescribed in NHS Grampian

Nutramigen Lipil 1 and 2 are the first-choice products for the treatment of CMPI, including GORD where CMPI is suspected.
*For infants commenced on Nutramigen Lipil 1, this should be changed to Nutramigen Lipil 2 at 6 months. Nutramigen Lipil 2 has a higher calcium content in a smaller volume. Therefore most infants can meet their calcium requirements while consuming a reduced volume of feed.
 
Aptamil Pepti 1 and 2 are hydrolysed formula similar to the Nutramigen range. They are a suitable second-choice if Nutramigen is refused by the baby. This is commoner in babies over 6 months starting a milk-free diet, e.g. breastfed babies. They do contain lactose, however this should not be a problem if the baby has an allergy to cows' milk protein. §For infants commenced on Aptamil 1, this should be changed to Aptamil 2 at 6 months for the same reasons outlined above.
 
The Neocate range can be considered if hydrolysed formula is refused or on advice from a dietitian. The Neocate range is 2-3 times more expensive than the Nutramigen products and Apatamil Pepti.
 

Table 1: Milk-free formula

Feed Characteristics Indicators

*Nutramigen Lipil 1
(Mead Johnson)

Extensively hydrolysed casein formula, lactose-free For infants with cows' milk protein intolerance.
From birth until 6 months

*Nutramigen Lipil 2
(Mead Johnson)

Extensively hydrolysed casein formula, lactose-free (higher calcium)

For infants with cows' milk protein intolerance.
From 6 months onwards

§Aptamil Pepti 1
(Milupa)

Hydrolysed whey product, not lactose-free

For infants with cows' milk protein intolerance.
From birth until 6 months

§Aptamil Pepti 2
(Milupa)

Hydrolysed whey product, not lactose-free

For infants with cows' milk protein intolerance.
From 6 months onwards

Neocate LCP
(SHS Nutricia)

Amino acid based formula, lactose-free

For cows' milk protein intolerance or as an elemental infant feed.
From birth until 1year

Neocate Active
(SHS Nutricia)

Amino acid based formula, lactose-free
Unflavoured or blackcurrant

For cows' milk protein intolerance where solids are also taken.
From 1 year

Neocate Advance
(SHS Nutricia)

Amino acid based formula, lactose-free

Usually used as a tube feed for cows' milk protein intolerance.
From 1 year

Wysoy
(SMA)
Infasoy
(Cow and Gate)

Soya Infant formula
Lactose-free

Cows' milk protein intolerance.
Suitable from 6 months - see guidance above

Other products are available however these should not be prescribed unless directed by a dietitian.

Contact numbers
RACH - 01224 552630
Dr Gray's - 01343 567350
Community dietetic department- Aberdeen/Aberdeenshire - 01224 556305

August 2011