Book
Cow Milk Protein allergy
- Recommendations
Table 3. Recommendations |
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A. Management of Cow Milk Allergy |
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N | Health questions | Source Guideline | Recommendations | Quality of evidence | Strength of Recommendation |
A1 | When to suspect cow milk allergy (CMA)? | BSACI 2014 | Cow’s milk allergy may be defined as a reproducible adverse reaction of an immunological nature induced by cow’s milk protein. | High | Strong |
| Sub questions |
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1a | What is the classification of CMA?
| BSACI 2014
| CMA can be classified into immediate onset and delayed onset according to timing of symptoms and organ involvement | High | Strong |
1b | When are symptoms expected in the immediate onset hypersensitivity to CMP or acute onset CMA? | BSACI 2014
| Symptoms of immediate onset hypersensitivity present within minutes to less than 2hours
| Moderate | Strong |
1c | What are the symptoms of the immediate hypersensitivity? | BSACI 2014
| IgE mediated symptoms affect several target organs Skin (urticaria, angioedema) Respiratory (rhinitis/rhino conjunctivitis/asthma/ wheeze, angioedema / stridor) GIT (oral allergy syndrome , vomiting, pain, flatulence and diarrhea) And or CVS ( anaphylactic shock) | Moderate | Strong |
1d | When are symptoms expected in delayed hypersensitivity to CMP? | BSACI 2014
| Delayed hypersensitivity symptoms to CMP appear more than 2 hours (usually several hours) up to 8 days. | Moderate | Strong |
1e | What are the symptoms of delayed hypersensitivity to CMP? | BSACI 2014
| Non-IgE mediated disease varies widely in clinical presentation from eczema exacerbations to life-threatening shock from gastrointestinal fluid loss secondary to inflammation [Food Protein Induced Enterocolitis Syndrome (FPIES)] - Gastrointestinal symptoms of non-IgE mediated CMA are variable and affect the entire gastrointestinal tract. CMA should be considered in these circumstances where symptoms fail to respond to standard therapy or where other features of allergy are present. | Moderate | Strong |
Table 4. Recommendations |
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B. Management of Cow Milk Allergy |
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N | Health questions | Source Guideline | Recommendations | Quality of evidence | Strength of Recommendation |
2 | When should lactose intolerance be considered? | BSACI 2014 | Lactose intolerance can be confused with non-IgE mediated cow’s milk allergy as symptoms overlap. Lactose intolerance should be considered where patients present only with typical gastrointestinal symptoms. | Moderate | Strong |
3 | What is the value of skin prick test in the diagnosis of suspected IgE-mediated CMPA?
| BSACI 2014
BSACI 2014
| A skin prick test (SPT) weal size ≥ 5 mm or ≥ 2 mm in younger infants) is strongly predictive of CMPA.
Negative skin test results are useful for confirming the absence of IgE-mediated reactions, with negative predictive values exceeding 95% |
Low
Low | Conditional
Conditional |
4 | Should in vitro specific IgE determination be used for the diagnosis of suspected IgE-mediated CMPA? | BSACI 2014
DRACMA 2022 | In settings where oral food challenge is not a requirement (no expertise or not well prepared), the clinical diagnosis of IgE mediated disease is made by a combination of typically presenting symptoms, e.g. urticaria and/or angio-oedema with vomiting and/or wheeze, soon after ingestion of cow’s milk, and evidence of sensitization (presence of specific IgE).
In patients with low pretest probability of IgE-mediated CMA we suggest using milk-specific IgE measurement with a cut-off value of ‡0.35 IU/L as a triage test to avoid oral food challenge | Moderate
Low | Strong
Conditional |
5 | What is the role of diagnostic elimination diet after suspicion of CMPA? | BSACI 2014 | The use of milk elimination is an integral step toward the diagnosis of CMA | Very low | Conditional
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5a | What to eliminate? | BSACI 2014
| The treatment following the diagnosis of cow’s milk allergy is complete avoidance of cow’s milk and foods containing cow’s milk | Very low | Conditional
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5b | For how long? | BSACI 2014
| Diagnostic dietary elimination should be maintained for at least 6 weeks | Low
| Conditional
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6 | What is the role of oral food challenge (OFC) test in CMPA diagnosis? |
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| Sub questions |
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6a | When to do a diagnostic OFC? | DRACMA 2022
BSACI 2014
BSACI 2014
BSACI 2014
| In settings where an oral food challenge is a requirement (routinely done) in all patients suspected of IgE mediated CMA, we recommend using oral food challenge with cow’s milk as the only test without measuring a cow’s milk-specific IgE level as a triage or an add-on test to establish a diagnosis
In practice, OFC is rarely required to make the diagnosis of CMPA
A food challenge may be necessary to confirm the diagnosis in IgE-mediated disease where there is conflict between the history and diagnostic tests.
Food elimination and reintroduction is recommended for the assessment of non-IgE mediated cow’s milk allergy where there is diagnostic uncertainty. | High
Very low
Very low
Low | Strong
Conditional
Conditional
Conditional
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6b | When not to do a diagnostic OFC? | Panel Consensus
| OFC is not indicated in initial diagnosis of CMPA if: 1- History of anaphylaxis 2- History of Severe delayed reaction (Food Protein Induced Enterocolitis) 3- Generalized immediate allergic reaction with positive specific IgE |
Very low
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Conditional
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6c | Where to do OFC diagnostic test? | BSACI 2014
| Reintroduction can be performed at home or may need to be supervised in hospital. | Very low
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Table 4. Recommendations |
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B. Management of Cow Milk Allergy |
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N | Health questions | Source Guideline | Recommendations | Quality of evidence | Strength of Recommendation |
7 | What are the milk substitutes? | In breast-fed infants breast milk (with elimination of CM from the mother’s diet) is suitable for most infants with cow’s milk allergy. In children after 2 years of age, a substitute formula may not be necessary. In infants and children less than 2 years of age, replacement with a substitute formula is mandatory. The different types of formulas used in CMPA are: 1. Amino acid formula (AAF) 2. Extensively hydrolyzed formula of cow's milk proteins (eHF). 3. Soy formula (SF) more than 6 months of age | Very low | Conditional | |
7a | When it is preferred to use AAF over eHf in IgE-mediated CMPA? | DRACMA 2022 | In children with IgE-mediated CMPA at high risk of anaphylactic reactions, we suggest amino acid formula rather than extensively hydrolyzed milk formula. | Very low
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7b | When it is preferred to use eHF over AAF in IgE-mediated CMPA | DRACMA 2022 | In children with IgE-mediated CMPA at low risk of anaphylactic reactions, we suggest extensively hydrolyzed milk formula over amino acid formula. | Very low | Conditional
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7c | Which is preferred in IgE-mediated CMPA eHF or SF? | DRACMA 2022 | In children with IgE-mediated CMA, we suggest extensively hydrolyzed milk formula rather than soy formula. | Very low | Conditional
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| 8-When and how to test for tolerance? Population: children with CMPA |
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8a | when to test for tolerance ? | BSACI 2014
| Individuals should be reassessed at 6-12 monthly intervals from 12 months of age to assess for suitability of reintroduction. | Moderate
| Strong
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8b | How to do it? | BSACI 2014
| The reintroduction is achieved by a graded exposure according to the milk ladder with the less allergenic baked milk) | Very low | Conditional
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8c | Where to do it? | BSACI 2014
| Reintroduction can be performed at home or may need to be supervised in hospital. | Very low | Conditional
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Evidence to recommendations: Considerations
The GDG/ GAG was guided by the results of the AGREE II appraisals of the eligible CPGs and thoroughly reviewed the recommendations of the original source WHO CPGs in consideration of local contextual factors related to the national Egyptian health system like burden of the disease, equity, acceptability, feasibility, and other relevant factors. The GDG decided through an informal consensus process to adopt most recommendations however, there was a need to change the strength of 2 recommendations (B2 and B3) as they lack feasibility. Also, GDG/ GAG develops group of good practice statements to improve acceptability and feasibility.
Implementation Tools and Considerations
To improve healthcare provision, quality, safety, and patient outcome, evidence-based recommendations must not only be developed, but also disseminated and implemented at national and local levels and integrated into clinical practice.
Dissemination involves educating related healthcare providers to improve their awareness, knowledge and understanding of the guideline’s recommendations. It is one part of implementation, which involved translation of evidence-based guidelines into real life practice with improvement of health outcomes for the patients.
Implementation requires an evidence-based strategy involving professional groups and stakeholders and should consider the local cultural and socioeconomic conditions. Cost-effectiveness of implementation programs should be assessed.
Specific steps need to be followed before clinical practice recommendations can be integrated into local clinical practice, particularly in low resource settings.
Steps of implementing cow milk protein allergy (CMPA) diagnosis, treatment, and prevention strategies into the Egyptian health system:
1. Develop a multidisciplinary working group.
2. Assess the status of nutritional care delivery, care gaps and current needs.
3. Select the material to be implemented, agree on the main goals, identify the key recommendations for diagnosis, treatment and prevention and adapt them to the local context or environment.
4. Identify barriers to, and facilitators of implementation.
5. Select an implementation framework and its component strategies.
6. Develop a step-by-step implementation plan:
▪️ Select the target populations and evaluate the outcome.
▪️ Identify the local resources to support the implementation.
▪️ Set timelines.
▪️Distribute the tasks to the members.
▪️ Evaluate the outcomes.
7. Continuously review the progress and results to determine if the strategy requires modification.
Guideline implementation strategies will focus on the following: -
1. For Practitioners
▪️ Educational meetings: conferences, lectures, workshops, grand rounds, seminars, and symposia.
▪️Educational materials: printed or electronic information (software).
▪️ Web-based education: computer-based educational activities.
▪️ A trained person meets with providers in their practice setting to provide information with the intention of changing the provider’s practice. The information may include feedback on the performance of the provider(s).
▪️ Reminders: the provision of information verbally, on papers or on a computer screen to prompt a health professional to recall information or to perform or avoid a particular action related to patient care.
▪️ Optimize professional-patient interactions, through mass media campaigns, reminders, and education materials.
▪️ Practice tools: tools designed to facilitate behavioral/practice changes, e.g., flow charts.
2. For Patients and care givers
▪️Patient education materials (Arabic booklet): Printed/electronic information aimed at the patient/consumer, family, caregivers, etc.
▪️ Reminders: the provision of information verbally, on papers or electronically to remind a patient/consumer to perform a particular health-related behaviors.
▪️ Mass media campaigns.
3. For Nurses
▪️Educational meetings: lectures, workshops or traineeships, seminars, and symposia.
▪️ Educational materials: printed.
▪️ A trained person meets with nurses in their practice setting to provide information with the intention of changing the provider’s practice.
▪️ Reminders: the provision of information verbally, on paper or on a computer screen to prompt them to recall information or to perform or avoid a particular action related to patient care.
▪️ Practice tools: tools designed to facilitate behavioral/practice changes.
4. For Stakeholders
Plans have been made to contact with all the health sectors in Egypt including all sectors of the Ministry of Health and Population, National Nutrition Institute, University Hospitals, Ministry of Interior, Ministry of Defense, Non-Governmental Organizations, Private sector, and all Health Care Facilities.
▪️ Information and communication technology: Electronic decision support, order sets, care maps, electronic health records, office-based personal digital assistants, etc.
▪️ Any summary of clinical provision of health care over a specified period may include recommendations for clinical action. The information is obtained from medical records, databases, or observations by patients. Summary may be targeted at the individual practitioner or the organization.
▪️ Administrative policies and procedures.
▪️ Formularies: Drug safety programs, electronic medication administration records.
5. Other activities to assist the implementation of the adapted guideline’s recommendations include:
▪️ International initiative: Dissemination of the presented adapted CPG internationally via sending the final adapted CPG to the Guidelines International Network (GIN) Adaptation Working Group and contacting the CPG developers.
▪️ Gantt chart has been designed to manage the dissemination and implementation stages for the adapted CPG over an accurate time frame (Appendix).
➡️Guideline Implementation Tools
Educational materials based on this Adapted CPG for treatment of CAP in children have been made available in several forms including:
1. Manual for physician for diagnosis and algorithm for management of acute malnutrition
3. Arabic Educational materials for nurses and mothers
