- Food allergy is defined as an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food. It is then clinically subdivided into either immediate onset IgE antibody mediated where the adverse effects appear usually within minutes (can be up to 2 hours) after ingestion or delayed onset Non-IgE antibody mediated where the effects develop ≥ 2 hours or even days after ingestion.
- 2-3% of 1-3 year olds in the UK have confirmed Cow’s Milk Allergy (CMA) - a substantial burden to the NHS. The UK currently has the highest prevalence of CMA in Europe.
- Typically CMA presents in the early weeks and months of life with either symptoms of IgE-mediated allergy or Non-IgE mediated allergy (uncommonly it presents with a mix of both).
- In 2010 a review of 1000 infants with CMA randomly chosen from a UK primary care database showed that most presented with suspected mild-to-moderate Non-IgE CMA and there was evidence of significant delayed diagnosis, missed diagnosis, and over diagnosis.
The UK Department of Health have subsequently commissioned NICE to produce several important publications related to the better recognition, diagnosis and management of food allergy and in particular CMA:
2011 - Clinical guideline 116 on the initial diagnosis and assessment in primary care and community settings of food allergy from any food trigger – it is clinical members of this guideline development group who initially came together to produce an actual management guideline on milk allergy for primary care - known as the MAP guideline (2013)
2015 - Clinical Knowledge Summary (CKS) on managing cow’s milk allergy in children
Signposting to MAP in order to guide on the management of mild-to-moderate Non-IgE mediated milk allergy in primary care settings
2016 - Quality Standard for food allergy in children.
New iMAP Milk Allergy Guideline
The updated version (2017) of the MAP guideline is authored by the original UK clinicians and supported by 7 international experts in milk allergy and contains:
- All the essential advice within the recent UK NICE publications.
- Amendments to reflect the constructive feedback received from the increasing use of MAP in the UK.
- It continues to be set out in 2 key easy to follow algorithms.
- Updated milk ladder with new recipes that comply with the World Health Organization recommendations for refined sugar and salt content
- Practical Guidance Sheets on CMA
- Setting out all the possible clinical presentations.
- Guidance on which presentations should be referred on.
- Guidance on which form of diet all suspected infants need to be started on.
e.g. if formula fed - an extensively hydrolysed formula or an amino acid-based formula.
Diagnosis and Management Algorithm
FOR MILD-TO-MODERATE SUSPECTED NON-IGE CMA ONLY - i.e. THOSE PATIENTS MOST COMMONLY SEEN AND WHO CAN BE MANAGED IN PRIMARY CARE
- Clinically distinguishing between the exclusively breast fed and the mixed or formula fed.
- The initial diagnostic Elimination-Reintroduction dietary exclusion trial to confirm or exclude the diagnosis.
- When referral for dietetic support is advised.
- When and how to test for later naturally reacquired tolerance to milk protein.
Supporting Tools for the Algorithms
Allergy-focused History (found here)
The key questions that need to be addressed when milk allergy is suspected.
Healthcare Professional Factsheet (found here)
A clinician’s guide to using the iMAP guideline.
Patient Factsheet (found here)
To explain the diagnosis and the need to confirm it with a planned reintroduction at home.
Home Reintroduction Protocol to Confirm or Exclude Diagnosis (found here)
The practical details for the family of how to carry out the reintroduction at home.
iMAP Milk Ladder (found here)
The practical details of testing for naturally reacquired tolerance to milk protein with time.
iMAP Published Recipes (found here)
The published practical details with regard to the baking/preparing of each Step of the Milk Ladder at home.
Additionally – The Recipes for Steps 1, 2 and 3 have also been set out in a more user-friendly format for bakers at home to follow: