Annina Whipp is a senior specialist paediatric dietitian. In this Q&A she tells us about how she manages cow’s milk allergy management in practice.
I was fortunate enough to secure a paediatric rotational post that enabled me to develop a foundation skillset across a range of specialties. I have held a variety of paediatric-focused roles, with extensive experience within gastroenterology. I currently work part-time for the NHS and also as a freelance dietitian, specialising in health writing.
Cow’s milk protein allergy is the leading cause of food allergy in infants and children younger than three years, with a prevalence of 1.9-4.9%.1,2 The diagnosis and management can often be challenging with dietetic input central to this. Despite advancements in the field of allergy, there continues to exist misconceptions from both HCPs and parents/carers around CMPA (particularly non-IgE mediated CMPA). The gold standard approach to diagnosis is by the identification of symptoms, followed by an exclusion diet trial followed by a reintroduction phase to either confirm or exclude the allergy. This is not an easy task; therefore within this challenge also lies the opportunity for dietitians to play an integral role in supporting parents/carers to do this effectively.
Dietary exclusions and specialist formulas can be difficult to comply with. Maternal dietary exclusions may act as a barrier to breastfeeding; therefore supportive counselling by dietitians and other HCPs plays a significant role. Dietitians are best placed to provide evidence-based and practical nutritional advice to ensure that exclusion diets remain nutritionally adequate for breastfeeding mothers, infants and children. Working as a dietitian and having had to navigate food allergy as a mum has given me a unique perspective which has definitely influenced my own clinical practice.
In recent years the prescribing of specialist formulas for the management of CMPA has increased within primary care.3 It is thought that this may be due to an increased research focus on allergy; however it’s also suggested to be the result of misinterpretation of symptoms causing the misdiagnosis of cow’s milk allergy.4 This is an area that dietitians are aiming to target by introducing interventions to improve cost efficiencies and patient outcomes for infants with suspected non-IgE cow’s milk allergy.
It is important to educate parents/carers to be able to confidently interpret food labels, alongside providing tips and inspiration for creating suitable and balanced meals. Parents/carers may feel the burden of the additional costs of ‘free-from’ foods. Dietitians can explore suitable supermarket own brands for calcium- and iodine-fortified cow’s milk-free milks, as these tend to be cheaper options.
It is vital that, during the weaning phase, an infant continues to meet their nutritional requirements, despite following an exclusion diet. Cow’s milk contains calcium, vitamin B2 (Riboflavin), vitamin B12 and iodine; therefore education should be provided in choosing dairy-alternative milks which are fortified with these vitamins and minerals.
In clinical practice, children often report feeling isolated because of their food allergy; empowering them to be prepared with suitable snacks/treats is key to minimising this. It is also important that you try to engage older children in managing their food allergy by helping children take appropriate levels of accountability. This may include educating the child to ask an adult if a food is cow’s milk-free and learning to recognise cow’s milk-containing foods.