- 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.
A message from the authors of MAP/iMAP guidelines
As the authors of the MAP guidance (2013), which has since been replaced by the iMAP guidance (2017) we wanted to highlight some important points. The iMAP guidelines were developed by the consensus expert opinion of 12 international clinicians each with a special interest in milk allergy. These MAP guidelines are published in open access, peer reviewed, scientific journals, which allows for maximum access, but also means permission is not required to reproduce them. The guidelines have found increasing acceptance amongst both UK and international healthcare professional colleagues, which has also resulted in industry electing to use them in marketing/educational initiatives. It is therefore important for us to emphasise that the guidelines were developed, published and remain free from any form of industry support.
The motivation for producing the guidance was the published under and delayed recognition of non IgE mediated milk allergy. Most of the authors were involved in the 2011 NICE Guideline for Assessment and Diagnosis of Food Allergy and thought that a more specific UK, primary care focussed, guideline for delayed-type milk allergy could make a real difference.
In using the MAP guidelines, it is critical to remember that milk allergy effects less than 2% of UK infants. Diagnosis is a particular challenge as most of the typical symptoms are very common in well babies – in fact, most babies will suffer from these symptoms from time to time and of course, the overwhelming majority do not have a milk allergy and do not need further assessment for this. However, in infants where these symptoms are multiple, significant, persistent as well resistant to medical treatment, it is important to consider this diagnosis. At this point, clinical judgement, together with discussion with parents, is required to decide if a diagnostic milk exclusion is warranted. This must be followed by reintroduction of cow’s milk, if the diagnosis is to be confirmed or excluded. This is now a NICE Quality Standard and failure to do this will lead to unnecessary over-diagnosis.
We have asked the charity, Allergy UK, to host the iMAP guideline to allow us to update it over time and provide useful accompanying resources.
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: