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CMPA Management



KEY MILESTONES



Successful management of cow’s milk protein allergy (CMPA) starts with an early diagnosis and requires ongoing support to ensure that infants and young children receive an appropriate elimination diet in order to reach their full potential. Nestlé Health Science is committed to helping you and your patients throughout the diagnosis and management journey.


1 - Starting the elimination diet
and food challenge­

2 - Advise caregivers for
complementary feeding

3 - Monitor long-term growth
and development

4 - Periodically test for
tolerance


BREAST MILK IS THE GOLD STANDARD
FOR INFANTS WITH CMPA



Mothers of infants with CMPA should be supported to continue breastfeeding. Breast milk contains all the essential nutrients infants need in their first 6 months of life and should thereafter be complemented with a cow’s milk protein-free diet. In rare cases where infants react to cow’s milk transmitted through breast milk, mothers might have to eliminate cow’s milk proteins from their diet.


A clear improvement of CMPA symptoms is usually noticeable after the exclusion of cow’s milk protein in 2 to 4 weeks, and sometimes even earlier. It may be necessary for the mother to take daily calcium and vitamin D supplements while on a cow’s milk protein-free diet.1-3


To confirm or exclude the diagnosis, a controlled oral food challenge under medical supervision may be required.2 Learn more about food challenge here.



BREAST MILK NURTURE INFANTS' IMMUNE SYSTEMS



Infants with CMPA are at an increased risk of infections and future allergies.4-6 As breastfeeding has been shown to reduce the incidence of infections and future allergies, this provides yet another important reason to support mothers to breastfeed.7-11


These outcomes are attributed to diverse bioactive components present in breast milk, including human milk oligosaccharides (HMO).12 HMO are the third most abundant solid component of breast milk, and play an important immune-nurturing role.12


While there are over 200 of these structurally complex carbohydrates,12 two of them, 2’ Fucosyllactose (2’FL) and Lacto-N-(neo)tetraose (LNnT), account for more than 30% of HMO in breast milk.13


Several clinical studies reported the protective effect of breastfeeding
for infants, including a reduced incidence of:


Gastroenteritis and diarrhea 8,11

Respiratory tract infections 8,11

Atopic manifestations 7,9,10

SPECIALTY FORMULAS FOR CMPA



When exclusive breastfeeding is not feasible, specialty formulas clinically proven to be hypoallergenic for infants with CMPA are recommended.1-3,14 These formulas contain all the necessary nutrients to support growth and development.


These specialty formulas can be:


Extensively hydrolysed formulas (eHFs): prepared from cow’s milk protein which have been hydrolysed (amongst other processes) to break them down into peptides, so that they are hypoallergenic and are less likely to cause an allergic reaction. eHFs, like Althéra® HMO and Alfaré® HMO, are recommended for first-line management of infants with CMPA.1-3,14


Amino acid-based formulas (AAFs): prepared from free amino acids. AAFs, such as Alfamino® HMO, are recommended in infants with severe symptoms of CMPA and/or multiple food allergies.1-3,14




Once an infant has eliminated cow’s milk protein from their diet with a specialty formula, CMPA symptoms typically resolve between 1-4 weeks, and sometimes sooner.2 To confirm or exclude the diagnosis, a controlled oral food challenge under medical supervision is often required. Learn more about food challenge here.



EXPERT CORNER: CMPA MANAGEMENT



In these videos, Professor Christophe Dupont provides an overview of CMPA and how to manage it effectively.



COMPLEMENTARY FEEDING AND CMPA



In the first six months of an infant’s life, exclusive breastfeeding is the preferred choice. In case breastfeeding is not possible for any reason, a special hypoallergenic formula for CMPA is recommended. Thereafter, it is time to introduce solid foods, as nutrient requirements increase.1-3,14


In infants with CMPA, whilst it is important to continue avoiding cow’s milk, other foods can be introduced just as it would be done with a non-allergic infant. There is no evidence that delaying the introduction of other potentially allergenic foods (e.g. wheat, soya, egg, fish, nuts…) will prevent the development of other food allergies. In fact, evidence is building that early rather than delayed introduction of these foods could be beneficial.15


A variety of different foods and flavours should be introduced into the weaning diet while still avoiding cow’s milk protein. During this time, specialty formula should still contribute a major part of an infant diet but it can also be used in recipes.



MONITORING LONG-TERM GROWTH IS ESSENTIALS



Elimination diets are necessary to prevent symptoms. However, they do increase the risk of nutritional deficiencies. In fact, several studies show how CMPA is linked to significantly lower growth in childhood if caregivers do not have professional dietetic support. It is therefore essential that caregivers are supported appropriately during this time. Nutrients at risk include calcium, vitamin D and iodine amongst others.16





WHEN AND HOW TO TEST FOR TOLERANCE



Half of all children with CMPA will outgrow it by 1-2 years of age, whilst the majority will outgrow it by 3 years of age, but it is difficult to predict when it will be achieved in each case.3,17 Non-IgE-mediated allergies tend to resolve more rapidly than IgE-mediated allergy or those with multiple food allergies.3


It is recommended to re-challenge children with CMPA every 6 to 12 months to assess whether they have developed tolerance to cow’s milk protein. Overly long dietary eliminations should be avoided as they might impair the quality of life of both the child and family, or increase the risk of impacting the child’s growth.2,3,14


Some guidelines recommend to start re-introduction with small amounts of milk in baked form (e.g. biscuits, cookies), as baking destroys a majority of epitopes causing the allergy. If the infant tolerates baked products well, introduction of products containing a larger amount of milk and/or in a less denatured form can be attempted.3 However, the practice differs between countries, and local recommendations about when and how to test for tolerance should be used.


Re-introduction may provoke allergic reactions and reappearance of symptoms. It should only be attempted with the guidance and under the supervision of a healthcare professional, as well as following local guidelines.





REAL-LIFE CASE STUDIES OF INFANTS WITH CMPA



Every infant is individual and the diversity of CMPA symptoms can make diagnosing and managing the condition particularly challenging. Here you will find several real-life case studies of infants with CMPA whose conditions have been successfully managed.


Daniel, 1 months old
Constipation and inconsolable crying

Joey, 4 months old
Severe eczema particularly on the face

Harry, 5 months old
Colic and immediate
gastrointestinal symptoms after feeding


Oliver, 2 weeks old
Constipation and unsettled

Vivian, 6 months old
Pale, lethargic, and dehydrated
with a weak cry

Emily, 7 months old
Symptoms of eczema and reflux

DANIEL
EMILY
HARRY
JOEY
OLIVER
VIVIAN


OUR RANGE OF TAILOR-MADE NUTRITIONAL SOLUTIONS



Nestlé Health Science has a range of nutritional solutions that are tailor-made to meet the specific needs of infants with CMPA. Our formulas are nutritionally complete to support normal growth and development in infants, with the addition of HMO* to support growing immune systems.




Althéra® HMO


VIEW PRODUCT


Alfaré® HMO


VIEW PRODUCT


Alfamino® HMO


VIEW PRODUCT


Alfamino® Junior HMO


VIEW PRODUCT


ADDITIONAL RESOURCES



VISIT OUR RESOURCE CENTRE


* Structurally identical Human Milk Oligosaccharides (HMO) are not sourced from human milk

REFERENCES



  1. Koletzko S, et al. Diagnostic Approach and Management of Cow’s-Milk Protein Allergy in Infants and Children: ESPGHAN GI Committee Practical Guidelines. J Pediatr Gastroenterol Nutr 2012;55(2):221-229.
  2. Prescott SL, et al. A global survey on changing patterns of food allergy burden in children. World Allergy Organ J. 2013;6(1) :21
  3. Cekola P, et al. Clinical use and safety of an amino acid-based infant formula in a real world setting. Abstract presented at NASPGHAN. Chicago, IL, USA, October 2019. 
  4. Høst A. Cow’s milk protein allergy and intolerance in infancy. Some clinical, epidemiological and immunological aspects. Pediatr Allergy Immunol. 1994;5:1-36.
  5. Jalonen T. Identical intestinal permeability changes in children with different clinical manifestations of cow’s milk allergy. J allergy Clin Immunol 1991;88(5):737-742.
  6. Crittenden RG and Bennett LE. Cow’s Milk Allergy: A Complex Disorder. J Am Coll Nutr 2005;24(6suppl):582S–591S.
  7. Maslin K, et al. Palatability of hypoallergenic formulas for cow’s milk allergy and healthcare professional recommendation. Pediatric Allergy and Immunol. 2018; 29:857-862.
  8. Francavilla R, et al. Effect of lactose on gut microbiota and metabolome of infants with cow’s milk allergy. Pediatr Allergy Immunol. 2012;23:420-427.
  9. Abrams SA, et al. Calcium and zinc absorption from lactose-containing and lactose-free infant formulas. Am J Clin Nutr. 2002;76(2):442-6.
  10. Petrus NCM, et al. Remaining symptoms in half the children treated for milk allergy. Eur J Pediatr. 2015; 174:759-765.
  11. Chauveau, A, et al. Immediate hypersensitivity to extensively hydrolysed formulas: An important reminder. Pediatric Allergy and Immunology. 2016;27(5):541-543.
  12. Nutten S, et al. Peptide size profile and residual immunogenic milk protein or peptide content in extensively hydrolysed infant formulas. Allergy. 2019
  13. Nowak-Wegrzyn A, et al. Confirmed Hypoallergenicity of a Novel Whey-Based Extensively Hydrolyzed Infant Formula Containing Two Human Milk Oligosaccharides. Nutrients. 2019;11(7):E1447.
  14. Nowak-Wegrzyn A, et al. Hypoallergenicity of a whey-based, extensively hydrolysed infant formula prepared with nonporcine enzymes. Allergy. 2019;74(8):1582-1584.
  15. Niggemann, B, et al. Safety and efficacy of a new extensively hydrolysed formula for infants with cow’s milk protein allergy. Pediatr Allergy Immunol. 2008. 19(4):348-54.
  16. Vandenplas Y, et al. A workshop report on the development of the Cow’s Milk-related Symptom Score awareness tool for young children. Acta Paediatr. 2015;104(4):334-339.
  17. Vandenplas Y, et al. Pooled analysis of the Cow’s Milk-related Symptom Score (CoMiSSTM) as a predictor for cow’s milk related symptoms. Pediatr Gastroenterol Hepatol Nutr. 2017;20(1):22-26.
  18. Vandenplas Y, et al. The Cow Milk Symptom Score (CoMiSSTM) in presumed healthy infants. PLoS One. 2018;13(7):e0200603.
  19. Nestlé Health Science, data on file. CINNAMON study.