A Pediatrician’s Guide to Cow’s Milk Protein Allergy

Announcer:
You’re listening to Clinician’s Roundtable on ReachMD. This episode is sponsored by Nestlé Health Science, makers of Alfamino®. Here’s your host, Dr. Charles Turck.

Dr. Turck:
Welcome to Clinician’s Roundtable on ReachMD. I’m Dr. Charles Turck, and joining me to investigate the clinical challenges and unmet needs of patients with cow’s milk protein allergy, or CMPA for short, is Dr. Anna Nowak-Wegrzyn. She is the Director of the Pediatric Allergy Program at Hassenfeld Children’s Hospital NYU Langone and a Professor in the Department of Pediatrics at NYU Grossman School of Medicine. Dr. Nowak-Wegrzyn, thanks for being here today.

Dr. Nowak-Wegrzyn:
Charles, thank you so much for your kind introduction. It is my pleasure to be here.

Dr. Turck:
Well to start us off, how prevalent is CMPA? And what kind of burden can it have on young patients and their families?

Dr. Nowak-Wegrzyn:
Cow’s milk protein allergy is one of the most common food allergies in childhood; it certainly seems to be the most common food allergy in the first six months of life. Some of the symptoms are purely gastrointestinal, but the majority of infants will have symptoms from the skin and from the respiratory tract, so it’s more immediate IgE-mediated. The burden is high because cow’s milk is the major source of calories and nutrition in early childhood, and even for the older patients, the nutritional avoidance is a risk factor for lower growth, so those children are shorter and lighter as well as there is a risk for accidental exposures. You know, we cannot really eliminate dairy from schools and from restaurants like we do sometimes with peanut or tree nuts, so patients have to be constantly vigilant and avoiding.

Dr. Turck:
As a quick follow-up to that, I was wondering if you’d share a caregiver or patient story that highlights the challenges they experience.

Dr. Nowak-Wegrzyn:
So for older patients who are teenagers, young adults, or even younger children who becoming more independent, eating out is a major risk situation, and I have several patients with significant milk allergy who developed anaphylaxis after eating in a vegan restaurant. So vegan restaurants are supposed to be free of dairy, yet there were products that were cross-contaminated. So wherever they go, they have to ask what’s in that food, and this is really very taxing. For younger patients, there’s an ongoing shortage of infant formula, so if they rely on the hypoallergenic infant formula for nutrition, this is an incredibly stressful time and difficult to secure adequate nutrition for their child.

Dr. Turck:
Now if we switch gears for just a moment, would you tell us about some of the obstacles clinicians face when managing these patients?

Dr. Nowak-Wegrzyn:
I think for the clinicians, the obstacles are sort of uncertainty of diagnosis. This is true for any food allergy, but also very much for milk allergy because there’s many gastrointestinal symptoms with milk allergy that are being diagnosed in infancy, and we don’t have a diagnostic test. So we have to rely on the diagnostic elimination diet followed by the range reduction of the food because some of those conditions like bloody stools are very short-lived and resolve very quickly, and we don’t want to over diagnose. We also don’t want to under diagnose because if we’re dealing with a patient who has an anaphylactic milk allergy, this will be very dangerous. So one is the lack of very accurate diagnostic tests. The second is limited access to places that offer oral food challenges to proactively manage cow’s milk protein allergy, to evaluate for resolution, and to evaluate for tolerance to milk that is baked in the baked products, as well as limited access to a registered dietician who are immensely helpful in managing all food allergies, but particularly cow’s milk protein allergy.

Dr. Turck:
For those just tuning in, you’re listening to Clinician’s Roundtable on ReachMD. I’m Dr. Charles Turck, and I’m speaking with Dr. Anna Nowak-Wegrzyn about cow’s milk protein allergy, or CMPA, and the challenges patients, caregivers, and clinicians face.

So, Dr. Nowak-Wegrzyn, now that we have a better understanding of the challenges associated with CMPA, let’s focus on how we manage these patients. What are the current recommendations from the American Academy of Pediatrics and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition tell us?

Dr. Nowak-Wegrzyn:
All professional societies internationally are recommending avoidance of the allergen, so proteins and all dairy products from the diet, and sort of the nitty gritty of avoidance really depends on the age of the patient. If we’re dealing with infants who are breastfed, then avoidance refers to avoidance in the maternal diet and supporting the breastfeeding woman to make sure that her nutrition is adequate and that she has enough calcium, protein, etc. For those babies who are not breastfed, there should be a supplementation with the infant formula that is hypoallergenic, and those infant formulas have to be nutritionally adequate and also safer for the infants. For older patients who don’t rely on formula, then nutritional instruction to include alternative sources of protein and calories as well as calcium and vitamin D is absolutely necessary, and, of course, we do teach patients how to recognize the symptoms of an allergic reaction, prescribe epinephrine auto-injectors if necessary, and explain how to manage those accidental exposures.

Dr. Turck:
And based on your experience, are there any management strategies you’d recommend to address the unmet needs of patients with CMPA?

Dr. Nowak-Wegrzyn:
I think it’s very important for clinicians to recognize that many children and infants who react to liquid milk might tolerate milk that is baked into a cookie or a muffin, up to 70 percent actually, and then those children that can tolerate baked products with milk, they usually have a milder form of milk allergy, and they outgrow it sooner than children who react to baked milk. So it will be important to do a food challenge to determine whether the child can tolerate baked products and then continue to reevaluate over time for resolution or tolerance development, which happens usually by school age. So by school age, the vast majority of children can tolerate milk in the liquid form.

Dr. Turck:
Now we’ve certainly covered a lot of ground today, so before we close, Dr. Nowak-Wegrzyn, what key lessons would you like learners to take away with them?

Dr. Nowak-Wegrzyn:
I would like you to remember that cow’s milk protein allergy is common – it’s one of the most common food allergies in infants and children – and that it generally has a very favorable natural history, although in a small percentage, it may be a permanent condition and that those patients have a very severe form of allergy. Once the diagnosis is made, appropriate substitution to make up for the eliminated dairy product as sources of calories, protein, vitamin D, and calcium should be secured, and then it’s important to reevaluate periodically for development of tolerance. Patients who had more severe reactions in the past or reacted to baked products should be equipped with the epinephrine auto-injector and be taught how to recognize serious allergic reactions.

Dr. Turck:
Well with those key takeaways in mind, I want to thank my guest, Dr. Anna Nowak-Wegrzyn, for joining me to take a closer look at the burden and clinical challenges associated with cow’s milk protein allergy. Dr. Nowak-Wegrzyn, it was great having you on the program.

Dr. Nowak-Wegrzyn:
My pleasure. Thank you for having me.

Announcer:
This episode of Clinician’s Roundtable was sponsored by Nestlé Health Science, makers of Alfamino®. To access this and other episodes in this series, visit ReachMD.com/Clinician’s Roundtable, where you can Be Part of the Knowledge. Thanks for listening!