Home Milk Challenge guide to diagnose Non-IgE Cow’s Milk Protein Allergy in Infants

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Home Milk Challenge guide to diagnose Non-IgE Cow’s Milk Protein Allergy in Infants (257kB pdf)

Introduction

This leaflet is written for parents/carers of babies with a possible diagnosis of non-IgE mediated (also called delayed) cow’s milk protein allergy (CMPA), in order to explain how to reintroduce small amounts of milk back into baby’s diet to test this diagnosis. It is important to try your baby with some milk to make sure that any improvement in their troublesome symptoms is due to cutting out the cow’s milk protein. It will inform you if your baby can be given dairy containing products which is important especially when you start weaning your baby.

Reintroducing cow’s milk into your baby’s diet should be done in a planned way and only after having been advised to do so by your baby’s healthcare provider.

This guide is NOT for children who have IgE mediated CMPA. IgE mediated CMPA is rare. The symptoms of IgE mediated CMPA are immediate and severe and include:

Urticaria, also called hives or nettle rash
Swelling of the lips and face. Itching eyes.
Anaphylaxis – this is a rare but severe reaction. Symptoms include any of the above plus difficulty breathing, coughing and change in behaviour.

With non-IgE mediated CMPA your baby may have symptoms of vomiting, reflux, being unsettled, loose stools or constipation. Your baby may have eczema but not an urticarial rash or swelling of lips/face.

Do NOT start this challenge:

if your baby ever has had signs of IgE mediated CMPA (urticaria, swelling of lips/face, anaphylaxis).
if your baby has had a positive skin prick or blood test (RAST) to cow’s milk unless specifically advised by your doctor.
if your baby has a cold, fever, tummy/bowel symptoms or even ‘teething’ that is upsetting your baby.
if your baby is on a medication which may cause a tummy upset such as antibiotics.

Do discuss with your health practitioner before starting the home challenge if you are concerned that your baby may have any of the above and you are not sure if you should start the home challenge.

Do NOT introduce any other new foods during this challenge.

Do NOT stop any medication that your baby may be on including any reflux medication.

Home challenge for an exclusively breastfed infant

Ideally, before you remove dairy from your own diet you should try to express some breast milk to freeze. This can be used at a later date, when your baby needs to complete a milk challenge. Principles of which will be discussed at your baby’s follow up review. If you are unable to, or do not wish to express and freeze some breast milk that is ok. As a breast-feeding mother you could gradually reintroduce milk and milk containing foods back into your diet over a period of 5 days to the same levels as before starting the exclusion diet.

Home challenge for a formula or mixed (formula and breast) fed infant

The home challenge is done over 5 days by gradually introducing more standard (containing cow’s milk), formula in your baby’s milk, replacing some of the prescribed (hypoallergenic) formula. On day 1, 1 oz (30ml) of the prescribed formula is replaced with 1 oz (30ml) of standard formula in the 1st bottle of the day only. Each following day and for the 1^st bottle of the day only, one more ounce (30ml) of a standard formula replaces an extra ounce of the prescribed formula. The total number of scoops used to prepare your baby’s bottle does NOT change.

Day 1	1 oz of a standard, cow’s milk containing, formula
Day 2	2 oz of a standard, cow’s milk containing, formula
Day 3	3 oz of a standard, cow’s milk containing, formula
Day 4	4 oz of a standard, cow’s milk containing, formula
Day 5	5 oz of a standard, cow’s milk containing, formula
Day 6 and onwards	if no symptoms noted, all bottles can be given with the standard formula only

Table showing number of ounces of standard formula in baby’s 1^st bottle for each day of the challenge.

What happens if symptoms return?

At any time, your baby develops symptoms, such as tummy pains, a rash, loose stools or increased vomiting, you STOP the re-challenge and revert to a dairy free diet if breast feeding or to the prescribed hypoallergenic formula if bottle or mixed feeding. Your baby’s symptoms should settle within the following 2-5 days. The return of symptoms confirms the diagnosis of cow’s milk protein allergy.

What happens if no symptoms occur?

If you have not seen any symptoms in your child by day 5 (when your baby has taken 150 mls or 5 ounces of a standard, cow’s milk formula) you can try giving the standard formula for each feed they would usually have from a bottle.

If no symptoms occur after 14 days of starting in the home challenge, then your baby does not have a cow’s milk protein allergy which means dairy does no longer needs to be avoided in your baby’s diet and a hypoallergenic formula is no longer required.

What do I do next?

It is important to discuss the outcome of the rechallenge with your health care professional. Babies with a confirmed diagnosis of non-IgE cow’s milk protein allergy will need referral to a community paediatric dietitian.

This leaflet only gives general information. You must always discuss the individual treatment of your child with the appropriate member of staff. Do not rely on this leaflet alone for information about your child’s treatment.

This information can be made available in other languages and formats if requested.