Prescribing milk-free formula for cows' milk protein allergy (CMPA) in children

Cows' Milk Protein Allergy (CMPA) is an allergy to the protein in cows' milk.  It is not an allergy to lactose (milk sugar). It affects 2-4% of all infants in the UK.

The following symptoms may be indicative of CMPA 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
  • Behavioural change and feed refusal may also occur

Over 75% of children with cows' milk intolerance have more than one symptom.

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Treatment involves complete exclusion of cows' milk protein from the child's diet. If the child is breast-fed, the mother should exclude cows' milk for 2 weeks. For non-breast-fed children, a cows' milk-free formula should be trialled for 4 weeks. See table below for suitable formula to prescribe. If the child has not improved on a cows' milk-free diet after the appropriate trial, cows' milk should be gradually introduced into the diet again (either via breast milk with mother back on cows' milk or a suitable formula for non-breast-fed children). The NHS Grampian guidance (link below) provides detailed information on how to re-introduce milk.
If symptoms improve on a milk-free diet, continue milk-free diet until 12 months of age or a least 6 months continued improvement on a milk-free diet. For those babies being breast-fed the mother should be recommended to take a calcium and vitamin D supplement.

Children following a milk-free diet should be challenged at one year old.

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. The NHS Grampian guidance (link below) provides detailed information on how to challenge with milk.

Prescribing milk-free formula

Cows' milk-free formulae are those products specifically designed to treat CMPA. They can be extensively hydrolysed formula (EHF) or amino acid formula (AAF). AAF are three times as expensive as EHF, 90% of children will respond to an EHF, therefore these are the first product of choice. If symptoms do not improve, or improve then relapse, an AAF should be trialled. 
AAF should only be used once EHF have been tried, or on the recommendations of a paediatric consultant or dietitian.

Please refer to the flowchart in the guidance document (link below)

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Products to be prescribed

Choice of formula Recommended product Prescribing notes

First-choice EHF

First-choice for the treatment of GORD where CMPI is suspected.

Nutramigen Lipil 1 for babies under 6 months

Nutramigen Lipil 2 for babies 6 months and over

Babies prescribed Nutramigen Lipil 1 should be changed to Nutramigen Lipil 2 at the age of 6 months if a cows' milk-free diet is still required.

Note: Nutramigen AA is often prescribed in error. This is an amino acid formula and three times as expensive as the EHF formula.

Second-choice EHF

Aptamil pepti 1 for babies under 6 months

Aptamil Pepti 2 for babies over 6 months

 If Nutramigen Lipil is refused in breast or non-breast-fed babies
If symptoms don't resolve
or resolve then relapse try Amino Acid Formula
Neocate LCP, suitable from birth to 1 year AAF should only be use once EHF have been tried, or on the recommendation of a paediatric consultant or dietitian.

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

Lactose free formulae, such as SMA LF, should NOT be used to treat suspected CMPA

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Local guidance

Further details on milk-free diets and how to challenge are provided in the NHS Grampian guidance on prescribing cows' milk-free formulae to treat cows' milk protein allergy in children

Contact numbers
RACH - 01224 552630
Dr Gray's - 01343 567350
Community dietetic department- Aberdeen/Aberdeenshire - 01224 655577 or

Carole Noble 
January 2015

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