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LET US DISCUSS

LET US DISCUSS. KALPESH DIXIT 7/7/10. EXPERIENCE 1. AB, 5 DAYS OLD BLEEDING PR BREAST FED BABY 5-10 STOOLS PER DAY. UNSETTLED EXAMINATION NORMAL HAS REGAINED BIRTH WEIGHT ??? CAUSE. EXPERIENCE 2. 6 WEEKS OLD BABY CRYING OFTEN

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LET US DISCUSS

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  1. LET US DISCUSS KALPESH DIXIT 7/7/10

  2. EXPERIENCE 1 • AB, 5 DAYS OLD • BLEEDING PR • BREAST FED BABY • 5-10 STOOLS PER DAY. • UNSETTLED • EXAMINATION NORMAL • HAS REGAINED BIRTH WEIGHT • ??? CAUSE

  3. EXPERIENCE 2 • 6 WEEKS OLD BABY • CRYING OFTEN • EXPLOSIVE DIARRHOEA • HV CHANGES MILK- SMA C&G APTAMIL • MUM DECIDES TO TRY WYSOY • NO RESPONSE • VISITS GP • EXAMINATION NORMAL • ??? WHAT TO DO?

  4. EXPERIENCE 3 • 3 MONTH OLD • CRYING • ARCHING AND VOMITING • UNSETTLED FOR PROLONGED PERIODS • CENTILES DROPPING • POOR SLEEP FOR ALL • EXAMINATION NORMAL • ?? HOW WILL YOU PROCEED??

  5. EXPERIENCE 4 • 6 MONTH OLD BABY • SEVERE ECZEMA • TRIED ALL POSSIBLE CREAMS, STEROIDS, ANTIFUNGAL AND ANTIBACTERIAL CREAMS • REFERRAL TO DERMATOLOGY • AWAITING 12-15 WEEK PERIOD FOR APPT. • WHAT TO DO IN THE INTERIM?

  6. Cows’ milk protein allergy – definition and incidence What is CMPA? • "...an adverse reaction to cows' milk resulting from an immunologic hypersensitivity to one or more milk proteins“1 How many infants are affected? • Most common food allergy in infancy • Affects an estimated 2-7.5% of UK births1 – 5% would be 38,000 babies/year(imagine filling the 02arena twice over) • Generally resolves by 1-3 years of age2 1 Hill DJ et al. J Pediatr 1986; 109; 270-276. 2. Høst A. Ann Allergy Asthma Immunol 2002; 89 (6 Suppl 1): 33-37.

  7. Allergy or intolerance? Hypersensitivity Involving the immune system Not involving the immune system Food allergy (allergic hypersensitivity) Food intolerance (non-allergic hypersensitivity) IgE mediated allergy Non-IgE mediated allergy Go to symptoms Adapted from Johansson SGO et al. 2004.

  8. Allergic symptoms

  9. Breastfeeding is the gold standard in infant nutrition to 6 months Protection against chest infections and wheezing Breastmilk content per 100ml1 Protection against ear infections Protection against diarrhoea and upset stomach Vits & mins 0.173g Carbohydrates6.7g Fat 3.4g Prebiotic OS 1.0g Better mental development Protein1.2g Lower risk of diabetes Other 0.2g Less smelly nappies Less eczema 1. Jensen RG (ed) Handbook of Milk Composition. New York: Academic Press, 1995. 2. Vandenplas Y et al. Arch Dis Child. 2007; 92 (10): 902-908.

  10. Diagnosis and management of CMPA in formula-fed infants* *Adapted from Vandenplas Y et al. Arch Dis Child. 2007; 92 (10): 902-908.

  11. Diagnosis and management of CMPA in formula-fed Infants* *Adapted from Vandenplas Y et al. Arch Dis Child. 2007; 92 (10): 902-908.

  12. MANAGEMENT IN BREAST FED INFANTS • MILD TO MODERATE: • CONTINUE BREAST FEEDING BUT ELIMINATION DIET IN MOTHER 2-4 WEEKS WITH CA SUPPLEMENT AND NO EGG • IF IMPROVEMENT REINTRODUCE CMP AND CHECK SYMPTOMS –IF YES THEN eHF AFTER BF, SOLIDS WITHOUT CMP UNTIL 9-12 MONTHS AND ATLEAST FOR 6/12. EGG TO BE ADDED IF NO SYMPTOMS. SEVERE CMPA: • REFER PAEDIATRICS AND IN MEANTIME ELIMINATION DIET IN MOTHER PLUS CA SUPPLEMENT VANDENPLAS: ADC OCT 2007,92, P 902-08

  13. Management of cows’ milk allergy in the UK Sladkevicius & Guest, 2008 1,000 infants with CMPA analysed for treatment patterns and outcomes over first 12 months following initial presentation to a GP Mean age to be put on a diet after initially seeing a GP was 2.2 months Mean time to diagnosis = 3.6 months Time to symptom resolution = 2.9 months Average 18.2 GP visits over 12 months 42% of patients referred to a specialist physician Waiting time for referral = approx 3.7 months Mean 7.6 GP visits before referral Conclusion Consensus guidelines are required for the management of CMPA in order to shorten the time to treatment, diagnosis and symptom resolution and to decrease the consumption of healthcare resources Effective management of CMPA within the NHS could lead to quicker improvement in symptoms and reduce the burden on NHS resources Sladkevicius E & Guest J. Abstract presented at WCPGHAN, Brazil, August 2008: WCP-307.

  14. Effective management of CMPA within the NHS could lead to quicker improvement in symptoms and reduce the burden on NHS resources Budget impact of managing cows’ milk allergy in the UK Sladkevicius & Guest, 2008 Each infant with CMPA costs an estimated £1,289 to the NHS over the first 12 months after initial diagnosis For managing 18,350 infants in the UK this equate to an estimated annual cost of £23.6 million Conclusion Any strategy that can improve healthcare delivery and thereby shorten the time to diagnosis, treatment and symptom resolution should potentially decrease the burden CMPA imposes on the UK’s NHS Guest J & Sladkevicius E. Abstract presented at WCPGHAN, Brazil, August 2008: WCP-309.

  15. Soya-based formulas Historically used for the management of food hypersensitivity (e.g. lactose intolerance and CMPA) Approximately 2% of formula-fed infants are fed a soya-based formula by 10-14 weeks¹ Sales of soya based infant formula accounted for 260,000kg in 2008, 0.9% of total infant formula sales¹ However, studies have shown that some 30-50% of infants given a soya-based formula for the management of CMPA present with concomitant soya protein allergy² 1. AC Nielsen/IMS. 2. ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2006; 42: 352-361.

  16. Soya-based formulas Chief Medical Officer’s Statement on soya-based formulas¹ (Jan 2004) Soya-based formulas should not be first choice for the management of infants with proven cows’ milk sensitivity due to the potential risk from their high phytoestrogen levels Soya-based formulas should only be used in exceptional circumstances to ensure adequate nutrition, e.g. for vegans or infants who find alternatives unacceptable ESPGHAN are also in agreement and state that "Soya protein formula should not be used in infants with allergy during the first 6 months of life”. They also raise concerns over their use post 6 months and suggest that soya tolerance "should first be established by clinical challenge”2 1. Department of Health. CMO's Update 37 - January 2004. London: Department of Health, 2004. 2. ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2006; 42: 352-361.

  17. Prescribable indications

  18. CONCLUSION • CONSIDER CMPA EARLY- REMEMBER GOR IS AS COMMON AND DOES NOT NEED ELIMINATION DIET • TREAT EARLY • AVOID SOY BASED FORMULAE UNTIL ATLEAST 6 MONTHS. AVOID GOAT’S MILK, RICE MILK (ARSENIC) AS NOT APPROPRIATE CALORIES AND NUTRITION • IF IN DOUBT DISCUSS WITH COLLEAGUES

  19. THE LEARNING CURVE • ALLERGY WORKSHOPS: DIAGNOSING AND MANAGING CMPA IN COMMUNITY AND WEANING THE ALLERGIC CHILD • THURSDAY 16TH SEPTEMBER • REGISTRATION 1730-1800(INC BUFFET) • HAYDOCK THISTLE HOTEL, PENNY LANE HAYDOCK WA11 9SG • COST £ 10- NUTRICIA LTD • PHONE 0800 781 7195 • E MAIL: INFO@LEARNINGCURVE.UK.NET

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