20022017

1

The many faces of Cowrsquos Milk Allergy

AProfessor John Sinn

MBBS (Syd) D Paed DCH M Med(Clin Epi) FRACP

Consultant Neonatologist amp Infant Allergist

The Paediatric Centre

University of Sydney

The Childrenrsquos Hospital Westmead

Royal North Shore Hospital

Take Home message

bull Cow milk allergy Ig E mediatedbull Potential Anaphylaxis

bull Cow milk Intolerance Non IgEbull Eczema

bull Blood in stools

bull Irritability

bull Lactose intolerance low lactase associated with diarrhoea and irritability

bull Cowrsquos milk protein is hydrolysed to decrease allergenicity which works for Allergy and intolerance

bull Treatment options EHF ERHF Soy AAF

Cowrsquos Milk Allergy

bull Babies are not Calves

Cases 1 Unsettle baby

bull 8 week old

bull Crying very unsettled

bull Breast fed

20022017

2

Case 2 Eczema

bull Severe eczema over the body

bull 2 months of age

bull Breast fed

Case 3 Crying possetting

bull 2 months of age

bull Bottle feeding

Case 4 Blood in stools

bull 4 week old

bull Breast fed

Australia consensus statement Cows milk protein allergy syndromes

bull Immediate allergic reactions

bull Food protein-induced enterocolitis syndrome (FPIES)

bull Atopic eczema

bull Gastrointestinal syndromes

bull Gastro-oesophageal reflux disease (GORD)

bull Allergic eosinophilic gastroenteritis

bull Food protein-induced enteropathy

bull Constipation

bull Severe irritability (colic)

bull Food protein-induced proctocolitis

bull Eosinophilic oesophagitis

20022017

3

Preparations available for treating cows milk protein allergy

bull Soy formulas bull Extensively hydrolysed formulas Alfareacute (Nestleacute) Pepti-Junior (Nutricia)

bull OTC Allerpro (prebiotics)bull Amino acid formulas EleCare (Abbott) Neocate (SHS) Alphamino (Nestle) bull Extensive Hydrolysed Rice formula Novalac (OTC)

bull Not recommendedbull Formulas Cows milk-based (including anti-regurgitation) bull Lactose-free cows milk-based bull Partially hydrolysed cows milk-based

bull (eg Karicare SensiKare [Nutricia] NAN HA [Nestleacute])

bull Goats milk-based formulabull Other preparations A2 milk (A2 Australia) Rice milk Oat milkbull Other mammalian milks (camel mare ass goat and ewe)

Continue BF

Elimination diet in mother - no

CM-protein egg peanut for 2

wks plus Ca-supplement + soy

milk

IMPROVEMENT

Reintroduction

one food per week after

4 weeks

NO IMPROVEMENT

SYMPTOMS

Maintain elimination diet

and calcium under

dietician supervision

Resume normal diet in mother

and consider other diagnosis ()

or consider referral to specialist

NO SYMPTOMS Resume normal diet in mother

and monitor

REFERRAL

Referral to paediatric specialist for

diagnosis and treatment Consider

elimination diet in mother (No CM-

protein egg peanut plus Ca-

supplement +SOY milk)

SUSPICION OF COWrsquoS MILK PROTEIN ALLERGY

eHF after BF solid foods

free of CMPegg refer to

specialist

Diagnosis and Management of CMPA in Breast-Fed Infants

GOR-

unresponsi

ve to

standard

reflux

therapy

Eczema ndash

moderate

severity

presenting

in first 12

months

Colic ndash

severe

andor

persistant

Proctocolitis ndash

otherwise well Allergic

enteropathy

with failure to

thrive +-

anaemia

Acute

allergic

reaction

to CMP

Eczema

ndashsevere

Severe

proctocolitis

+- anaemia

Diagnosis and Management of CMPA in Formula-Fed Infants

SUSPICION OF COWSrsquo MILK PROTEIN ALLERGY

Suspicion of mildmoderate CMPA

Trial of eHF

(consider soy if gt 6 mths)

for 4 weeks

Consider Trial of

Amino Acid Formula

(AAF)

URGENT

REFERRAL TO

PAEDIATRIC SPECIALIST

Colic ndash

severe

persistent

GOR- no

response

to

standard

reflux

therapy

Eczema ndash

moderate

severity

presenting

in first 12

months

Constipation

severerefrac

tory faecal

retention in

first 12

months of

life

Suspicion of severeacute CMPA

Allergic

enteropat

hy with

severe

failure to

thrive

Response No-response

ndash consider

AAF

FPIES

enteroc

olitis

FPIES

Procto-

colitis

Anaphylaxis

Non-anaphylactic

acute reaction

Soy Milk Phytoestrogen

bull Isoflavones a class of phytoestrogen can bind to estrogen receptors and exert estrogenic activity

bull Levels bull soy 18-47kgLbull Cow Milk 01-5kgLbull Breast milk 16-14KgL

bull Premature thelarche before 2 yrsbull 20 had soy formulae

bull Women had more menstrual bleeding if fed soy formula in infancy

Soy formula effect on puberty

7 co-twin marmoset monkeys fed Soy vs CM formula and study the testosterone levels testis size adult onset of puberty

bull Results

bull no difference in puberty onsetbull testicular weights and No sertoli and leydig cells number

increasedbull Testosterone rise levels were suppressed in soy group

(Leydig cell failure)bull Average of 26 increase in seminiferous epi volume per

tubule testis

bull Conclusion

bull exposure to soy formula should be reserve for gt 6 months of age

Tan Human Reproduction 2006 Vol 21 896-904

Soy in the prevention of atopy

bull Sinn J and Osborn D

bull 2006 Cochrane Review

vs

20022017

4

Soy vs Cowrsquos milk Eczema Use of soy in the community

bull Lactose intolerance (rare) radic

bull Post infectious Lactose intolerance radic

bull CMPI trial if gt612

bull Reflux x

bull Colic x

bull Galactosemia radic

bull Prevention of allergy x

Cowrsquos milk allergy

bull If CM allergic (2 of population)bull Antigen casein lactalbumin and lactoglobulin

bull Soy was discontinued in 47 casesbull 53 in infants lt 6 months and 35 in gt 1yr

bull Those with CMP allergy have a bull 10-35 chance of allergy to Soy and bull 22 to EHF

Iron deficiency Sensitisation of Milk allergenMilk allergen B lactoglobulin belongs to Lipcalins

And accommodate Iron complexes

If the CMP is unbound then it activates TH2

And IgE Ab develop against CMP

The Child then becomes sensitise to CMP

B lactoglubulin is an allergen when there is Fe deficiency

20022017

5

Goats milk

bull Lower lactose 41 vs 47 cow milk vs BM 69

bull More protein 34 vs 32

bull More omega 3 25 more

bull MCT 46 more vs CM

bull Casein 26 vs CM 24

bull Cysteine 53 more then CM use to protect GUT antioxidantbull Pasteurize the effect is null as a protein to convert to Glutathione

Table 2 Average composition of basic nutrients in goat sheep cow and human milk

Filiz YANGILAR et al As a Potentially Functional Food Goatsrsquo Milk and Products Journal of Food and Nutrition

Research 2013 Vol 1 No 4 68-81 doi1012691jfnr-1-4-6

copy The Author(s) 2013 Published by Science and Education Publishing

Composition Goat Sheepa Cow Human

Fat () 38 79 36 40

Solids-non-fat () 89 120 90 89

Lactose () 41 49 47 69

Protein () 34 62 32 12

Casein () 24 42 26 04

Albumin globulin () 06 10 06 07

Non-protein N () 04 08 02 05

Ash () 08 09 07 03

Calories100 ml 70 105 69 68

Table 4 Average amino acid composition (gl00 g milk) in proteins of goat and cow milk

Filiz YANGILAR et al As a Potentially Functional Food Goatsrsquo Milk and Products Journal of Food and Nutrition

Research 2013 Vol 1 No 4 68-81 doi1012691jfnr-1-4-6

copy The Author(s) 2013 Published by Science and Education Publishing

Goat milk Cow milk Difference () for goat milk

Essential amino acids

Tryptophan 0044 0046

Threonine 0163 0149 +9

Isoleucine 0207 0199 +4

Leucine 0314 0322

Lysine 0290 0261 +11

Methionine 0080 0083

Cystine 0046 0030 +53

Phenylalanine 0155 0159

Tyrosine 0179 0159 +13

Valine 0240 0220 +9

Non-essential amino acids

Arginine 0119 0119

Histidine 0089 0089

Alanine 0118 0113

Aspartic acid 0210 0250

Glutamic acid 0626 0689

Glycine 0050 0070

Proline 0368 0319

Serine 0181 0179

Table 5 Average fatty acida composition (g100g milk) in lipids of goat and cow milk

Filiz YANGILAR et al As a Potentially Functional Food Goatsrsquo Milk and Products Journal of Food and Nutrition

Research 2013 Vol 1 No 4 68-81 doi1012691jfnr-1-4-6

copy The Author(s) 2013 Published by Science and Education Publishing

Goat milk Cow milk Difference () for goat milk

C40 butyric 013 011

C60 caproic 009 006

C80 caprylic 010 004

C100 capric 026 008

C120 lauric 012 009

C140 myristic 032 034

C160 palmitic 091 088

C180 stearic 044 040

C6-14 total MCT 089 061 +46

C4-18 total SAFA 267 208 +28

C161 palmitoleic 008 008

C181 oleic 098 084

C161-221 total MUFA 111 096 +16

C182 linoleic 011 008

C183 linolenic 004 005

C182-183 total PUFA 015 012 +25

aMCT medium chain triglycerides SAFA saturated fatty acids

MUFA monounsaturated fatty acids PUFA polyunsaturated fatty acids

An extensively hydrolysed rice protein-based formula in

infants CMA

Vandenplas Y1

eRHF in infants with a confirmed CMPA

RESULTS

39 (mean 34 months range 05-6 months)

All infants tolerated the eRHF and experienced a normal

growth

CONCLUSIONS

eRHF is tolerated by more than 90 of children with proven

CMPA with a 95 CI and is an adequate alternative to cows

milk-based eHF

Arch Dis Child 2014 Oct99(10)933-6 doi

Immediate allergic reactions

bull IgE sensitisation

bull 11-28 of anaphylactic reactions are due to CMA

bull 11 fatal are CMA

bull Cows milk protein allergy may manifest

bull erythema angioedema urticaria or vomiting

bull Symptoms develop within minutes to 2 hrs

bull Adrenaline Pens Generic Epi Pen off patent 2013

bull Current sales 600mil for Antares in 2015 it expect sales of 13bilbull Indicated especially those who has asthma teenages and nut allergies

20022017

2

Case 2 Eczema

bull Severe eczema over the body

bull 2 months of age

bull Breast fed

Case 3 Crying possetting

bull 2 months of age

bull Bottle feeding

Case 4 Blood in stools

bull 4 week old

bull Breast fed

Australia consensus statement Cows milk protein allergy syndromes

bull Immediate allergic reactions

bull Food protein-induced enterocolitis syndrome (FPIES)

bull Atopic eczema

bull Gastrointestinal syndromes

bull Gastro-oesophageal reflux disease (GORD)

bull Allergic eosinophilic gastroenteritis

bull Food protein-induced enteropathy

bull Constipation

bull Severe irritability (colic)

bull Food protein-induced proctocolitis

bull Eosinophilic oesophagitis

20022017

3

Preparations available for treating cows milk protein allergy

bull Soy formulas bull Extensively hydrolysed formulas Alfareacute (Nestleacute) Pepti-Junior (Nutricia)

bull OTC Allerpro (prebiotics)bull Amino acid formulas EleCare (Abbott) Neocate (SHS) Alphamino (Nestle) bull Extensive Hydrolysed Rice formula Novalac (OTC)

bull Not recommendedbull Formulas Cows milk-based (including anti-regurgitation) bull Lactose-free cows milk-based bull Partially hydrolysed cows milk-based

bull (eg Karicare SensiKare [Nutricia] NAN HA [Nestleacute])

bull Goats milk-based formulabull Other preparations A2 milk (A2 Australia) Rice milk Oat milkbull Other mammalian milks (camel mare ass goat and ewe)

Continue BF

Elimination diet in mother - no

CM-protein egg peanut for 2

wks plus Ca-supplement + soy

milk

IMPROVEMENT

Reintroduction

one food per week after

4 weeks

NO IMPROVEMENT

SYMPTOMS

Maintain elimination diet

and calcium under

dietician supervision

Resume normal diet in mother

and consider other diagnosis ()

or consider referral to specialist

NO SYMPTOMS Resume normal diet in mother

and monitor

REFERRAL

Referral to paediatric specialist for

diagnosis and treatment Consider

elimination diet in mother (No CM-

protein egg peanut plus Ca-

supplement +SOY milk)

SUSPICION OF COWrsquoS MILK PROTEIN ALLERGY

eHF after BF solid foods

free of CMPegg refer to

specialist

Diagnosis and Management of CMPA in Breast-Fed Infants

GOR-

unresponsi

ve to

standard

reflux

therapy

Eczema ndash

moderate

severity

presenting

in first 12

months

Colic ndash

severe

andor

persistant

Proctocolitis ndash

otherwise well Allergic

enteropathy

with failure to

thrive +-

anaemia

Acute

allergic

reaction

to CMP

Eczema

ndashsevere

Severe

proctocolitis

+- anaemia

Diagnosis and Management of CMPA in Formula-Fed Infants

SUSPICION OF COWSrsquo MILK PROTEIN ALLERGY

Suspicion of mildmoderate CMPA

Trial of eHF

(consider soy if gt 6 mths)

for 4 weeks

Consider Trial of

Amino Acid Formula

(AAF)

URGENT

REFERRAL TO

PAEDIATRIC SPECIALIST

Colic ndash

severe

persistent

GOR- no

response

to

standard

reflux

therapy

Eczema ndash

moderate

severity

presenting

in first 12

months

Constipation

severerefrac

tory faecal

retention in

first 12

months of

life

Suspicion of severeacute CMPA

Allergic

enteropat

hy with

severe

failure to

thrive

Response No-response

ndash consider

AAF

FPIES

enteroc

olitis

FPIES

Procto-

colitis

Anaphylaxis

Non-anaphylactic

acute reaction

Soy Milk Phytoestrogen

bull Isoflavones a class of phytoestrogen can bind to estrogen receptors and exert estrogenic activity

bull Levels bull soy 18-47kgLbull Cow Milk 01-5kgLbull Breast milk 16-14KgL

bull Premature thelarche before 2 yrsbull 20 had soy formulae

bull Women had more menstrual bleeding if fed soy formula in infancy

Soy formula effect on puberty

7 co-twin marmoset monkeys fed Soy vs CM formula and study the testosterone levels testis size adult onset of puberty

bull Results

bull no difference in puberty onsetbull testicular weights and No sertoli and leydig cells number

increasedbull Testosterone rise levels were suppressed in soy group

(Leydig cell failure)bull Average of 26 increase in seminiferous epi volume per

tubule testis

bull Conclusion

bull exposure to soy formula should be reserve for gt 6 months of age

Tan Human Reproduction 2006 Vol 21 896-904

Soy in the prevention of atopy

bull Sinn J and Osborn D

bull 2006 Cochrane Review

vs

20022017

4

Soy vs Cowrsquos milk Eczema Use of soy in the community

bull Lactose intolerance (rare) radic

bull Post infectious Lactose intolerance radic

bull CMPI trial if gt612

bull Reflux x

bull Colic x

bull Galactosemia radic

bull Prevention of allergy x

Cowrsquos milk allergy

bull If CM allergic (2 of population)bull Antigen casein lactalbumin and lactoglobulin

bull Soy was discontinued in 47 casesbull 53 in infants lt 6 months and 35 in gt 1yr

bull Those with CMP allergy have a bull 10-35 chance of allergy to Soy and bull 22 to EHF

Iron deficiency Sensitisation of Milk allergenMilk allergen B lactoglobulin belongs to Lipcalins

And accommodate Iron complexes

If the CMP is unbound then it activates TH2

And IgE Ab develop against CMP

The Child then becomes sensitise to CMP

B lactoglubulin is an allergen when there is Fe deficiency

20022017

5

Goats milk

bull Lower lactose 41 vs 47 cow milk vs BM 69

bull More protein 34 vs 32

bull More omega 3 25 more

bull MCT 46 more vs CM

bull Casein 26 vs CM 24

bull Cysteine 53 more then CM use to protect GUT antioxidantbull Pasteurize the effect is null as a protein to convert to Glutathione

Table 2 Average composition of basic nutrients in goat sheep cow and human milk

Filiz YANGILAR et al As a Potentially Functional Food Goatsrsquo Milk and Products Journal of Food and Nutrition

Research 2013 Vol 1 No 4 68-81 doi1012691jfnr-1-4-6

copy The Author(s) 2013 Published by Science and Education Publishing

Composition Goat Sheepa Cow Human

Fat () 38 79 36 40

Solids-non-fat () 89 120 90 89

Lactose () 41 49 47 69

Protein () 34 62 32 12

Casein () 24 42 26 04

Albumin globulin () 06 10 06 07

Non-protein N () 04 08 02 05

Ash () 08 09 07 03

Calories100 ml 70 105 69 68

Table 4 Average amino acid composition (gl00 g milk) in proteins of goat and cow milk

Filiz YANGILAR et al As a Potentially Functional Food Goatsrsquo Milk and Products Journal of Food and Nutrition

Research 2013 Vol 1 No 4 68-81 doi1012691jfnr-1-4-6

copy The Author(s) 2013 Published by Science and Education Publishing

Goat milk Cow milk Difference () for goat milk

Essential amino acids

Tryptophan 0044 0046

Threonine 0163 0149 +9

Isoleucine 0207 0199 +4

Leucine 0314 0322

Lysine 0290 0261 +11

Methionine 0080 0083

Cystine 0046 0030 +53

Phenylalanine 0155 0159

Tyrosine 0179 0159 +13

Valine 0240 0220 +9

Non-essential amino acids

Arginine 0119 0119

Histidine 0089 0089

Alanine 0118 0113

Aspartic acid 0210 0250

Glutamic acid 0626 0689

Glycine 0050 0070

Proline 0368 0319

Serine 0181 0179

Table 5 Average fatty acida composition (g100g milk) in lipids of goat and cow milk

Filiz YANGILAR et al As a Potentially Functional Food Goatsrsquo Milk and Products Journal of Food and Nutrition

Research 2013 Vol 1 No 4 68-81 doi1012691jfnr-1-4-6

copy The Author(s) 2013 Published by Science and Education Publishing

Goat milk Cow milk Difference () for goat milk

C40 butyric 013 011

C60 caproic 009 006

C80 caprylic 010 004

C100 capric 026 008

C120 lauric 012 009

C140 myristic 032 034

C160 palmitic 091 088

C180 stearic 044 040

C6-14 total MCT 089 061 +46

C4-18 total SAFA 267 208 +28

C161 palmitoleic 008 008

C181 oleic 098 084

C161-221 total MUFA 111 096 +16

C182 linoleic 011 008

C183 linolenic 004 005

C182-183 total PUFA 015 012 +25

aMCT medium chain triglycerides SAFA saturated fatty acids

MUFA monounsaturated fatty acids PUFA polyunsaturated fatty acids

An extensively hydrolysed rice protein-based formula in

infants CMA

Vandenplas Y1

eRHF in infants with a confirmed CMPA

RESULTS

39 (mean 34 months range 05-6 months)

All infants tolerated the eRHF and experienced a normal

growth

CONCLUSIONS

eRHF is tolerated by more than 90 of children with proven

CMPA with a 95 CI and is an adequate alternative to cows

milk-based eHF

Arch Dis Child 2014 Oct99(10)933-6 doi

Immediate allergic reactions

bull IgE sensitisation

bull 11-28 of anaphylactic reactions are due to CMA

bull 11 fatal are CMA

bull Cows milk protein allergy may manifest

bull erythema angioedema urticaria or vomiting

bull Symptoms develop within minutes to 2 hrs

bull Adrenaline Pens Generic Epi Pen off patent 2013

bull Current sales 600mil for Antares in 2015 it expect sales of 13bilbull Indicated especially those who has asthma teenages and nut allergies

20022017

3

Preparations available for treating cows milk protein allergy

bull Soy formulas bull Extensively hydrolysed formulas Alfareacute (Nestleacute) Pepti-Junior (Nutricia)

bull OTC Allerpro (prebiotics)bull Amino acid formulas EleCare (Abbott) Neocate (SHS) Alphamino (Nestle) bull Extensive Hydrolysed Rice formula Novalac (OTC)

bull Not recommendedbull Formulas Cows milk-based (including anti-regurgitation) bull Lactose-free cows milk-based bull Partially hydrolysed cows milk-based

bull (eg Karicare SensiKare [Nutricia] NAN HA [Nestleacute])

bull Goats milk-based formulabull Other preparations A2 milk (A2 Australia) Rice milk Oat milkbull Other mammalian milks (camel mare ass goat and ewe)

Continue BF

Elimination diet in mother - no

CM-protein egg peanut for 2

wks plus Ca-supplement + soy

milk

IMPROVEMENT

Reintroduction

one food per week after

4 weeks

NO IMPROVEMENT

SYMPTOMS

Maintain elimination diet

and calcium under

dietician supervision

Resume normal diet in mother

and consider other diagnosis ()

or consider referral to specialist

NO SYMPTOMS Resume normal diet in mother

and monitor

REFERRAL

Referral to paediatric specialist for

diagnosis and treatment Consider

elimination diet in mother (No CM-

protein egg peanut plus Ca-

supplement +SOY milk)

SUSPICION OF COWrsquoS MILK PROTEIN ALLERGY

eHF after BF solid foods

free of CMPegg refer to

specialist

Diagnosis and Management of CMPA in Breast-Fed Infants

GOR-

unresponsi

ve to

standard

reflux

therapy

Eczema ndash

moderate

severity

presenting

in first 12

months

Colic ndash

severe

andor

persistant

Proctocolitis ndash

otherwise well Allergic

enteropathy

with failure to

thrive +-

anaemia

Acute

allergic

reaction

to CMP

Eczema

ndashsevere

Severe

proctocolitis

+- anaemia

Diagnosis and Management of CMPA in Formula-Fed Infants

SUSPICION OF COWSrsquo MILK PROTEIN ALLERGY

Suspicion of mildmoderate CMPA

Trial of eHF

(consider soy if gt 6 mths)

for 4 weeks

Consider Trial of

Amino Acid Formula

(AAF)

URGENT

REFERRAL TO

PAEDIATRIC SPECIALIST

Colic ndash

severe

persistent

GOR- no

response

to

standard

reflux

therapy

Eczema ndash

moderate

severity

presenting

in first 12

months

Constipation

severerefrac

tory faecal

retention in

first 12

months of

life

Suspicion of severeacute CMPA

Allergic

enteropat

hy with

severe

failure to

thrive

Response No-response

ndash consider

AAF

FPIES

enteroc

olitis

FPIES

Procto-

colitis

Anaphylaxis

Non-anaphylactic

acute reaction

Soy Milk Phytoestrogen

bull Isoflavones a class of phytoestrogen can bind to estrogen receptors and exert estrogenic activity

bull Levels bull soy 18-47kgLbull Cow Milk 01-5kgLbull Breast milk 16-14KgL

bull Premature thelarche before 2 yrsbull 20 had soy formulae

bull Women had more menstrual bleeding if fed soy formula in infancy

Soy formula effect on puberty

7 co-twin marmoset monkeys fed Soy vs CM formula and study the testosterone levels testis size adult onset of puberty

bull Results

bull no difference in puberty onsetbull testicular weights and No sertoli and leydig cells number

increasedbull Testosterone rise levels were suppressed in soy group

(Leydig cell failure)bull Average of 26 increase in seminiferous epi volume per

tubule testis

bull Conclusion

bull exposure to soy formula should be reserve for gt 6 months of age

Tan Human Reproduction 2006 Vol 21 896-904

Soy in the prevention of atopy

bull Sinn J and Osborn D

bull 2006 Cochrane Review

vs

20022017

4

Soy vs Cowrsquos milk Eczema Use of soy in the community

bull Lactose intolerance (rare) radic

bull Post infectious Lactose intolerance radic

bull CMPI trial if gt612

bull Reflux x

bull Colic x

bull Galactosemia radic

bull Prevention of allergy x

Cowrsquos milk allergy

bull If CM allergic (2 of population)bull Antigen casein lactalbumin and lactoglobulin

bull Soy was discontinued in 47 casesbull 53 in infants lt 6 months and 35 in gt 1yr

bull Those with CMP allergy have a bull 10-35 chance of allergy to Soy and bull 22 to EHF

Iron deficiency Sensitisation of Milk allergenMilk allergen B lactoglobulin belongs to Lipcalins

And accommodate Iron complexes

If the CMP is unbound then it activates TH2

And IgE Ab develop against CMP

The Child then becomes sensitise to CMP

B lactoglubulin is an allergen when there is Fe deficiency

20022017

5

Goats milk

bull Lower lactose 41 vs 47 cow milk vs BM 69

bull More protein 34 vs 32

bull More omega 3 25 more

bull MCT 46 more vs CM

bull Casein 26 vs CM 24

bull Cysteine 53 more then CM use to protect GUT antioxidantbull Pasteurize the effect is null as a protein to convert to Glutathione

Table 2 Average composition of basic nutrients in goat sheep cow and human milk

Filiz YANGILAR et al As a Potentially Functional Food Goatsrsquo Milk and Products Journal of Food and Nutrition

Research 2013 Vol 1 No 4 68-81 doi1012691jfnr-1-4-6

copy The Author(s) 2013 Published by Science and Education Publishing

Composition Goat Sheepa Cow Human

Fat () 38 79 36 40

Solids-non-fat () 89 120 90 89

Lactose () 41 49 47 69

Protein () 34 62 32 12

Casein () 24 42 26 04

Albumin globulin () 06 10 06 07

Non-protein N () 04 08 02 05

Ash () 08 09 07 03

Calories100 ml 70 105 69 68

Table 4 Average amino acid composition (gl00 g milk) in proteins of goat and cow milk

Filiz YANGILAR et al As a Potentially Functional Food Goatsrsquo Milk and Products Journal of Food and Nutrition

Research 2013 Vol 1 No 4 68-81 doi1012691jfnr-1-4-6

copy The Author(s) 2013 Published by Science and Education Publishing

Goat milk Cow milk Difference () for goat milk

Essential amino acids

Tryptophan 0044 0046

Threonine 0163 0149 +9

Isoleucine 0207 0199 +4

Leucine 0314 0322

Lysine 0290 0261 +11

Methionine 0080 0083

Cystine 0046 0030 +53

Phenylalanine 0155 0159

Tyrosine 0179 0159 +13

Valine 0240 0220 +9

Non-essential amino acids

Arginine 0119 0119

Histidine 0089 0089

Alanine 0118 0113

Aspartic acid 0210 0250

Glutamic acid 0626 0689

Glycine 0050 0070

Proline 0368 0319

Serine 0181 0179

Table 5 Average fatty acida composition (g100g milk) in lipids of goat and cow milk

Filiz YANGILAR et al As a Potentially Functional Food Goatsrsquo Milk and Products Journal of Food and Nutrition

Research 2013 Vol 1 No 4 68-81 doi1012691jfnr-1-4-6

copy The Author(s) 2013 Published by Science and Education Publishing

Goat milk Cow milk Difference () for goat milk

C40 butyric 013 011

C60 caproic 009 006

C80 caprylic 010 004

C100 capric 026 008

C120 lauric 012 009

C140 myristic 032 034

C160 palmitic 091 088

C180 stearic 044 040

C6-14 total MCT 089 061 +46

C4-18 total SAFA 267 208 +28

C161 palmitoleic 008 008

C181 oleic 098 084

C161-221 total MUFA 111 096 +16

C182 linoleic 011 008

C183 linolenic 004 005

C182-183 total PUFA 015 012 +25

aMCT medium chain triglycerides SAFA saturated fatty acids

MUFA monounsaturated fatty acids PUFA polyunsaturated fatty acids

An extensively hydrolysed rice protein-based formula in

infants CMA

Vandenplas Y1

eRHF in infants with a confirmed CMPA

RESULTS

39 (mean 34 months range 05-6 months)

All infants tolerated the eRHF and experienced a normal

growth

CONCLUSIONS

eRHF is tolerated by more than 90 of children with proven

CMPA with a 95 CI and is an adequate alternative to cows

milk-based eHF

Arch Dis Child 2014 Oct99(10)933-6 doi

Immediate allergic reactions

bull IgE sensitisation

bull 11-28 of anaphylactic reactions are due to CMA

bull 11 fatal are CMA

bull Cows milk protein allergy may manifest

bull erythema angioedema urticaria or vomiting

bull Symptoms develop within minutes to 2 hrs

bull Adrenaline Pens Generic Epi Pen off patent 2013

bull Current sales 600mil for Antares in 2015 it expect sales of 13bilbull Indicated especially those who has asthma teenages and nut allergies

20022017

4

Soy vs Cowrsquos milk Eczema Use of soy in the community

bull Lactose intolerance (rare) radic

bull Post infectious Lactose intolerance radic

bull CMPI trial if gt612

bull Reflux x

bull Colic x

bull Galactosemia radic

bull Prevention of allergy x

Cowrsquos milk allergy

bull If CM allergic (2 of population)bull Antigen casein lactalbumin and lactoglobulin

bull Soy was discontinued in 47 casesbull 53 in infants lt 6 months and 35 in gt 1yr

bull Those with CMP allergy have a bull 10-35 chance of allergy to Soy and bull 22 to EHF

Iron deficiency Sensitisation of Milk allergenMilk allergen B lactoglobulin belongs to Lipcalins

And accommodate Iron complexes

If the CMP is unbound then it activates TH2

And IgE Ab develop against CMP

The Child then becomes sensitise to CMP

B lactoglubulin is an allergen when there is Fe deficiency

20022017

5

Goats milk

bull Lower lactose 41 vs 47 cow milk vs BM 69

bull More protein 34 vs 32

bull More omega 3 25 more

bull MCT 46 more vs CM

bull Casein 26 vs CM 24

bull Cysteine 53 more then CM use to protect GUT antioxidantbull Pasteurize the effect is null as a protein to convert to Glutathione

Table 2 Average composition of basic nutrients in goat sheep cow and human milk

Filiz YANGILAR et al As a Potentially Functional Food Goatsrsquo Milk and Products Journal of Food and Nutrition

Research 2013 Vol 1 No 4 68-81 doi1012691jfnr-1-4-6

copy The Author(s) 2013 Published by Science and Education Publishing

Composition Goat Sheepa Cow Human

Fat () 38 79 36 40

Solids-non-fat () 89 120 90 89

Lactose () 41 49 47 69

Protein () 34 62 32 12

Casein () 24 42 26 04

Albumin globulin () 06 10 06 07

Non-protein N () 04 08 02 05

Ash () 08 09 07 03

Calories100 ml 70 105 69 68

Table 4 Average amino acid composition (gl00 g milk) in proteins of goat and cow milk

Filiz YANGILAR et al As a Potentially Functional Food Goatsrsquo Milk and Products Journal of Food and Nutrition

Research 2013 Vol 1 No 4 68-81 doi1012691jfnr-1-4-6

copy The Author(s) 2013 Published by Science and Education Publishing

Goat milk Cow milk Difference () for goat milk

Essential amino acids

Tryptophan 0044 0046

Threonine 0163 0149 +9

Isoleucine 0207 0199 +4

Leucine 0314 0322

Lysine 0290 0261 +11

Methionine 0080 0083

Cystine 0046 0030 +53

Phenylalanine 0155 0159

Tyrosine 0179 0159 +13

Valine 0240 0220 +9

Non-essential amino acids

Arginine 0119 0119

Histidine 0089 0089

Alanine 0118 0113

Aspartic acid 0210 0250

Glutamic acid 0626 0689

Glycine 0050 0070

Proline 0368 0319

Serine 0181 0179

Table 5 Average fatty acida composition (g100g milk) in lipids of goat and cow milk

Filiz YANGILAR et al As a Potentially Functional Food Goatsrsquo Milk and Products Journal of Food and Nutrition

Research 2013 Vol 1 No 4 68-81 doi1012691jfnr-1-4-6

copy The Author(s) 2013 Published by Science and Education Publishing

Goat milk Cow milk Difference () for goat milk

C40 butyric 013 011

C60 caproic 009 006

C80 caprylic 010 004

C100 capric 026 008

C120 lauric 012 009

C140 myristic 032 034

C160 palmitic 091 088

C180 stearic 044 040

C6-14 total MCT 089 061 +46

C4-18 total SAFA 267 208 +28

C161 palmitoleic 008 008

C181 oleic 098 084

C161-221 total MUFA 111 096 +16

C182 linoleic 011 008

C183 linolenic 004 005

C182-183 total PUFA 015 012 +25

aMCT medium chain triglycerides SAFA saturated fatty acids

MUFA monounsaturated fatty acids PUFA polyunsaturated fatty acids

An extensively hydrolysed rice protein-based formula in

infants CMA

Vandenplas Y1

eRHF in infants with a confirmed CMPA

RESULTS

39 (mean 34 months range 05-6 months)

All infants tolerated the eRHF and experienced a normal

growth

CONCLUSIONS

eRHF is tolerated by more than 90 of children with proven

CMPA with a 95 CI and is an adequate alternative to cows

milk-based eHF

Arch Dis Child 2014 Oct99(10)933-6 doi

Immediate allergic reactions

bull IgE sensitisation

bull 11-28 of anaphylactic reactions are due to CMA

bull 11 fatal are CMA

bull Cows milk protein allergy may manifest

bull erythema angioedema urticaria or vomiting

bull Symptoms develop within minutes to 2 hrs

bull Adrenaline Pens Generic Epi Pen off patent 2013

bull Current sales 600mil for Antares in 2015 it expect sales of 13bilbull Indicated especially those who has asthma teenages and nut allergies

20022017

5

Goats milk

bull Lower lactose 41 vs 47 cow milk vs BM 69

bull More protein 34 vs 32

bull More omega 3 25 more

bull MCT 46 more vs CM

bull Casein 26 vs CM 24

bull Cysteine 53 more then CM use to protect GUT antioxidantbull Pasteurize the effect is null as a protein to convert to Glutathione

Table 2 Average composition of basic nutrients in goat sheep cow and human milk

Filiz YANGILAR et al As a Potentially Functional Food Goatsrsquo Milk and Products Journal of Food and Nutrition

Research 2013 Vol 1 No 4 68-81 doi1012691jfnr-1-4-6

copy The Author(s) 2013 Published by Science and Education Publishing

Composition Goat Sheepa Cow Human

Fat () 38 79 36 40

Solids-non-fat () 89 120 90 89

Lactose () 41 49 47 69

Protein () 34 62 32 12

Casein () 24 42 26 04

Albumin globulin () 06 10 06 07

Non-protein N () 04 08 02 05

Ash () 08 09 07 03

Calories100 ml 70 105 69 68

Table 4 Average amino acid composition (gl00 g milk) in proteins of goat and cow milk

Filiz YANGILAR et al As a Potentially Functional Food Goatsrsquo Milk and Products Journal of Food and Nutrition

Research 2013 Vol 1 No 4 68-81 doi1012691jfnr-1-4-6

copy The Author(s) 2013 Published by Science and Education Publishing

Goat milk Cow milk Difference () for goat milk

Essential amino acids

Tryptophan 0044 0046

Threonine 0163 0149 +9

Isoleucine 0207 0199 +4

Leucine 0314 0322

Lysine 0290 0261 +11

Methionine 0080 0083

Cystine 0046 0030 +53

Phenylalanine 0155 0159

Tyrosine 0179 0159 +13

Valine 0240 0220 +9

Non-essential amino acids

Arginine 0119 0119

Histidine 0089 0089

Alanine 0118 0113

Aspartic acid 0210 0250

Glutamic acid 0626 0689

Glycine 0050 0070

Proline 0368 0319

Serine 0181 0179

Table 5 Average fatty acida composition (g100g milk) in lipids of goat and cow milk

Filiz YANGILAR et al As a Potentially Functional Food Goatsrsquo Milk and Products Journal of Food and Nutrition

Research 2013 Vol 1 No 4 68-81 doi1012691jfnr-1-4-6

copy The Author(s) 2013 Published by Science and Education Publishing

Goat milk Cow milk Difference () for goat milk

C40 butyric 013 011

C60 caproic 009 006

C80 caprylic 010 004

C100 capric 026 008

C120 lauric 012 009

C140 myristic 032 034

C160 palmitic 091 088

C180 stearic 044 040

C6-14 total MCT 089 061 +46

C4-18 total SAFA 267 208 +28

C161 palmitoleic 008 008

C181 oleic 098 084

C161-221 total MUFA 111 096 +16

C182 linoleic 011 008

C183 linolenic 004 005

C182-183 total PUFA 015 012 +25

aMCT medium chain triglycerides SAFA saturated fatty acids

MUFA monounsaturated fatty acids PUFA polyunsaturated fatty acids

An extensively hydrolysed rice protein-based formula in

infants CMA

Vandenplas Y1

eRHF in infants with a confirmed CMPA

RESULTS

39 (mean 34 months range 05-6 months)

All infants tolerated the eRHF and experienced a normal

growth

CONCLUSIONS

eRHF is tolerated by more than 90 of children with proven

CMPA with a 95 CI and is an adequate alternative to cows

milk-based eHF

Arch Dis Child 2014 Oct99(10)933-6 doi

Immediate allergic reactions

bull IgE sensitisation

bull 11-28 of anaphylactic reactions are due to CMA

bull 11 fatal are CMA

bull Cows milk protein allergy may manifest

bull erythema angioedema urticaria or vomiting

bull Symptoms develop within minutes to 2 hrs

bull Adrenaline Pens Generic Epi Pen off patent 2013

bull Current sales 600mil for Antares in 2015 it expect sales of 13bilbull Indicated especially those who has asthma teenages and nut allergies

20022017

6

Atopic eczema

bull Associated with high levels of IgE to bull milk egg and peanut

bull Egg is the most frequently involved allergen followed by cows milk protein

bull IgE antibodies have been implicated in most cases of cows milk protein- induced eczema about 10 of cases are not IgE associated

bull Sleep disturbances

bull For the severe eczema 35 would benefit from Food elimination

CM protein induced enteropathy

bull Not IgE

bull Diarrhoea

bull Vomiting

bull 80 respond to EHF

bull Often allergic to soy chicken rice and fish

bull Mx mother avoid CMP Egg Nuts

Gastro-oesophageal reflux disease (GORD)

bull Not IgE

bull 40 reach specialist have CMPA

bull intestinal biopsy commonly shows partial villous atrophy

bull H2 blockers changes gut flora

bull Aggravate the problem

bull May cause more food allergies

Severe irritability (colic)

bull Non IgE

bull Persistent crying is a common problem that may affect about a third of young infants

bull gradually abates by 4 months of age

bull Systematic reviewbull Hypoallergic formula reduce colic

bull No role of soy in the prevention or management of infantile colic or regurgitation

Constipation

bull Non IgE

bull At tertiary referral levelbull 70 of chronic constipation can be due to CMA

20022017

7

Size of the molecule

bull Allergen 10000-70000 daltons

bull Intact Soy 28000 daltons

bull Partial hydrolysed 1100-10000 daltons

bull Extensive hydrolysed lt 1500

bull Can be Allergenic if gt1300 daltons

bull Amino acid lt 1000 daltons2 Human 3 CM

Resolution of CMA

Delayed reaction vs immediate

bull 2yr 64 31 3yr 92 53 4yr 96 63

bull Over estimation due to delay reintroduction

bull Persistency bull Infants reacting to lt10 mL of milk

bull larger wheal size on SPT are at increased risk for persistence

bull J Pediatr 2012 Apr 4

Decreasing IgE and Increase IgG4 Early recovery of CMPA

bull 23 Children CMA and 6 controls follow to 9yrs

bull Those who recover from CMAbull IgE binding decreases and IgG4 increase binding

bull This shows IgG4 induces tolerance by blocking the binding of specific IgE binding sites

bull Future immunotherapy

bull Savilahti E Sampson H JACI 2010

Immunotherapy

bull No licensed immunotherapy products are available for the treatment of food allergy

bull Investigators are pursuing bull via several different routes

bull oral sublingual and epicutaneous

Cow milk allergy

bull If SPT is positive to CM protein

bull Then we offer gradual oral desensitisation

bull Tablets made with increasing amounts

bull If on Elemental formula can starting taking daily extensive hydrolysedformula tablets with a dalton size of 1500

bull Take daily till develop symptoms

bull This is the dose to commence desensitisation

bull Using gradual dalton size incrementation 2000 3000 4000 till 20000

20022017

8

Patterns of response to food OIT

Nowak-Wegrzyn JACI March 2011

SLIT

bull Allergy drops

bull Lower rate of severe reactions

bull Weak strength may take 4-5 years to desensitise

SCIT

bull SCIT high rates of adverse events particularly systemic reactions during the build-up phase

bull including one fatality that occurred when a subject received an injection of peanut SCIT

bull Those who complete the regimen ~50 experience some degree of desensitization

EPIT

bull In EPIT via patch

bull present antigen to dendritic cells which are thought to induce pathways of the immune system

bull Used in milk allergy

bull So far not successful in inducing desensitization to milk

bull Studies using EPIT to treat other food allergies (eg peanut) are ongoing

CMA desensitisation

bull SPT gt 3mm Sample size 20

bull 15yr to 11 yr

bull 55 allergic to other foods

bull During challenge 60 had anaphylaxis and 30 had skin rash

bull Increase IgG4 and decrease IgE decrease IL13

Adjuvant

bull Prebiotics

bull Probiotics

bull Traditional Chinese medicine

bull Omalizumab improves OIT for CMA

bull SCIT Peanut absorbed with aluminium hydroxide safer then without

bull Polyphenols flavonoids resveratrol

20022017

9

Cochrane Review HA Primary Prevention CMA PH Whey vs CMF

Probiotic versus no probiotic Infant eczema 13 trials 1911 infants

Heterogeneity P = 037 Isup2 = 8 Test for overall effectP = 0001 RR 079 95CI 068 091

Cases 1 Unsettle baby

bull 8 week old

bull Crying very unsettled

bull Breast fed

Case 2 Eczema

bull Severe eczema over the body

bull 2 months of age

bull Breast fed

Case 3 Crying possetting

bull 2 months of age

bull Bottle feeding

20022017

10

Case 4 Blood in stools

bull 4 week old

bull Breast fed

Summary

bull Many faces of cowrsquos milk allergy

bull Diagnosis Exclusion

bull Treatment used Hydrolysed formula

bull Immunotherapy slow increase in size of molecule

bull Resolution time but increase with some exposure rather then none

Take Home message

bull Cow milk allergy Ig E mediatedbull Potential Anaphylaxis

bull Cow milk Intolerance Non IgEbull Eczema bull Blood in stoolsbull Irritability

bull Lactose intolerance lack of lactase associated with diarrhoea and irritability

bull Cowrsquos milk protein is hydrolysed to decrease allergenicity which works for Allergy and intolerance

The Paediatric Centre St Leonards

OUR SERVICESbull Paediatric Allergy Allergy testing and Immunotherapy

bull Neonatology

bull Paediatric Nephrologist Dr Fiona Mackie

bull Allied Health

bull Clinical Psychologist Occupational therapist Physiotherapist Speech therapist Dietician

Any practical advice on your patient care please email or telephone

bull infothepaediatriccentrecomau Tel 94052386 Fax 94052387

bull wwwthepaediatriccentrecomau

20022017

7

Size of the molecule

bull Allergen 10000-70000 daltons

bull Intact Soy 28000 daltons

bull Partial hydrolysed 1100-10000 daltons

bull Extensive hydrolysed lt 1500

bull Can be Allergenic if gt1300 daltons

bull Amino acid lt 1000 daltons2 Human 3 CM

Resolution of CMA

Delayed reaction vs immediate

bull 2yr 64 31 3yr 92 53 4yr 96 63

bull Over estimation due to delay reintroduction

bull Persistency bull Infants reacting to lt10 mL of milk

bull larger wheal size on SPT are at increased risk for persistence

bull J Pediatr 2012 Apr 4

Decreasing IgE and Increase IgG4 Early recovery of CMPA

bull 23 Children CMA and 6 controls follow to 9yrs

bull Those who recover from CMAbull IgE binding decreases and IgG4 increase binding

bull This shows IgG4 induces tolerance by blocking the binding of specific IgE binding sites

bull Future immunotherapy

bull Savilahti E Sampson H JACI 2010

Immunotherapy

bull No licensed immunotherapy products are available for the treatment of food allergy

bull Investigators are pursuing bull via several different routes

bull oral sublingual and epicutaneous

Cow milk allergy

bull If SPT is positive to CM protein

bull Then we offer gradual oral desensitisation

bull Tablets made with increasing amounts

bull If on Elemental formula can starting taking daily extensive hydrolysedformula tablets with a dalton size of 1500

bull Take daily till develop symptoms

bull This is the dose to commence desensitisation

bull Using gradual dalton size incrementation 2000 3000 4000 till 20000

20022017

8

Patterns of response to food OIT

Nowak-Wegrzyn JACI March 2011

SLIT

bull Allergy drops

bull Lower rate of severe reactions

bull Weak strength may take 4-5 years to desensitise

SCIT

bull SCIT high rates of adverse events particularly systemic reactions during the build-up phase

bull including one fatality that occurred when a subject received an injection of peanut SCIT

bull Those who complete the regimen ~50 experience some degree of desensitization

EPIT

bull In EPIT via patch

bull present antigen to dendritic cells which are thought to induce pathways of the immune system

bull Used in milk allergy

bull So far not successful in inducing desensitization to milk

bull Studies using EPIT to treat other food allergies (eg peanut) are ongoing

CMA desensitisation

bull SPT gt 3mm Sample size 20

bull 15yr to 11 yr

bull 55 allergic to other foods

bull During challenge 60 had anaphylaxis and 30 had skin rash

bull Increase IgG4 and decrease IgE decrease IL13

Adjuvant

bull Prebiotics

bull Probiotics

bull Traditional Chinese medicine

bull Omalizumab improves OIT for CMA

bull SCIT Peanut absorbed with aluminium hydroxide safer then without

bull Polyphenols flavonoids resveratrol

20022017

9

Cochrane Review HA Primary Prevention CMA PH Whey vs CMF

Probiotic versus no probiotic Infant eczema 13 trials 1911 infants

Heterogeneity P = 037 Isup2 = 8 Test for overall effectP = 0001 RR 079 95CI 068 091

Cases 1 Unsettle baby

bull 8 week old

bull Crying very unsettled

bull Breast fed

Case 2 Eczema

bull Severe eczema over the body

bull 2 months of age

bull Breast fed

Case 3 Crying possetting

bull 2 months of age

bull Bottle feeding

20022017

10

Case 4 Blood in stools

bull 4 week old

bull Breast fed

Summary

bull Many faces of cowrsquos milk allergy

bull Diagnosis Exclusion

bull Treatment used Hydrolysed formula

bull Immunotherapy slow increase in size of molecule

bull Resolution time but increase with some exposure rather then none

Take Home message

bull Cow milk allergy Ig E mediatedbull Potential Anaphylaxis

bull Cow milk Intolerance Non IgEbull Eczema bull Blood in stoolsbull Irritability

bull Lactose intolerance lack of lactase associated with diarrhoea and irritability

bull Cowrsquos milk protein is hydrolysed to decrease allergenicity which works for Allergy and intolerance

The Paediatric Centre St Leonards

OUR SERVICESbull Paediatric Allergy Allergy testing and Immunotherapy

bull Neonatology

bull Paediatric Nephrologist Dr Fiona Mackie

bull Allied Health

bull Clinical Psychologist Occupational therapist Physiotherapist Speech therapist Dietician

Any practical advice on your patient care please email or telephone

bull infothepaediatriccentrecomau Tel 94052386 Fax 94052387

bull wwwthepaediatriccentrecomau

20022017

8

Patterns of response to food OIT

Nowak-Wegrzyn JACI March 2011

SLIT

bull Allergy drops

bull Lower rate of severe reactions

bull Weak strength may take 4-5 years to desensitise

SCIT

bull SCIT high rates of adverse events particularly systemic reactions during the build-up phase

bull including one fatality that occurred when a subject received an injection of peanut SCIT

bull Those who complete the regimen ~50 experience some degree of desensitization

EPIT

bull In EPIT via patch

bull present antigen to dendritic cells which are thought to induce pathways of the immune system

bull Used in milk allergy

bull So far not successful in inducing desensitization to milk

bull Studies using EPIT to treat other food allergies (eg peanut) are ongoing

CMA desensitisation

bull SPT gt 3mm Sample size 20

bull 15yr to 11 yr

bull 55 allergic to other foods

bull During challenge 60 had anaphylaxis and 30 had skin rash

bull Increase IgG4 and decrease IgE decrease IL13

Adjuvant

bull Prebiotics

bull Probiotics

bull Traditional Chinese medicine

bull Omalizumab improves OIT for CMA

bull SCIT Peanut absorbed with aluminium hydroxide safer then without

bull Polyphenols flavonoids resveratrol

20022017

9

Cochrane Review HA Primary Prevention CMA PH Whey vs CMF

Probiotic versus no probiotic Infant eczema 13 trials 1911 infants

Heterogeneity P = 037 Isup2 = 8 Test for overall effectP = 0001 RR 079 95CI 068 091

Cases 1 Unsettle baby

bull 8 week old

bull Crying very unsettled

bull Breast fed

Case 2 Eczema

bull Severe eczema over the body

bull 2 months of age

bull Breast fed

Case 3 Crying possetting

bull 2 months of age

bull Bottle feeding

20022017

10

Case 4 Blood in stools

bull 4 week old

bull Breast fed

Summary

bull Many faces of cowrsquos milk allergy

bull Diagnosis Exclusion

bull Treatment used Hydrolysed formula

bull Immunotherapy slow increase in size of molecule

bull Resolution time but increase with some exposure rather then none

Take Home message

bull Cow milk allergy Ig E mediatedbull Potential Anaphylaxis

bull Cow milk Intolerance Non IgEbull Eczema bull Blood in stoolsbull Irritability

bull Lactose intolerance lack of lactase associated with diarrhoea and irritability

bull Cowrsquos milk protein is hydrolysed to decrease allergenicity which works for Allergy and intolerance

The Paediatric Centre St Leonards

OUR SERVICESbull Paediatric Allergy Allergy testing and Immunotherapy

bull Neonatology

bull Paediatric Nephrologist Dr Fiona Mackie

bull Allied Health

bull Clinical Psychologist Occupational therapist Physiotherapist Speech therapist Dietician

Any practical advice on your patient care please email or telephone

bull infothepaediatriccentrecomau Tel 94052386 Fax 94052387

bull wwwthepaediatriccentrecomau

20022017

9

Cochrane Review HA Primary Prevention CMA PH Whey vs CMF

Probiotic versus no probiotic Infant eczema 13 trials 1911 infants

Heterogeneity P = 037 Isup2 = 8 Test for overall effectP = 0001 RR 079 95CI 068 091

Cases 1 Unsettle baby

bull 8 week old

bull Crying very unsettled

bull Breast fed

Case 2 Eczema

bull Severe eczema over the body

bull 2 months of age

bull Breast fed

Case 3 Crying possetting

bull 2 months of age

bull Bottle feeding

20022017

10

Case 4 Blood in stools

bull 4 week old

bull Breast fed

Summary

bull Many faces of cowrsquos milk allergy

bull Diagnosis Exclusion

bull Treatment used Hydrolysed formula

bull Immunotherapy slow increase in size of molecule

bull Resolution time but increase with some exposure rather then none

Take Home message

bull Cow milk allergy Ig E mediatedbull Potential Anaphylaxis

bull Cow milk Intolerance Non IgEbull Eczema bull Blood in stoolsbull Irritability

bull Lactose intolerance lack of lactase associated with diarrhoea and irritability

bull Cowrsquos milk protein is hydrolysed to decrease allergenicity which works for Allergy and intolerance

The Paediatric Centre St Leonards

OUR SERVICESbull Paediatric Allergy Allergy testing and Immunotherapy

bull Neonatology

bull Paediatric Nephrologist Dr Fiona Mackie

bull Allied Health

bull Clinical Psychologist Occupational therapist Physiotherapist Speech therapist Dietician

Any practical advice on your patient care please email or telephone

bull infothepaediatriccentrecomau Tel 94052386 Fax 94052387

bull wwwthepaediatriccentrecomau

20022017

10

Case 4 Blood in stools

bull 4 week old

bull Breast fed

Summary

bull Many faces of cowrsquos milk allergy

bull Diagnosis Exclusion

bull Treatment used Hydrolysed formula

bull Immunotherapy slow increase in size of molecule

bull Resolution time but increase with some exposure rather then none

Take Home message

bull Cow milk allergy Ig E mediatedbull Potential Anaphylaxis

bull Cow milk Intolerance Non IgEbull Eczema bull Blood in stoolsbull Irritability

bull Lactose intolerance lack of lactase associated with diarrhoea and irritability

bull Cowrsquos milk protein is hydrolysed to decrease allergenicity which works for Allergy and intolerance

The Paediatric Centre St Leonards

OUR SERVICESbull Paediatric Allergy Allergy testing and Immunotherapy

bull Neonatology

bull Paediatric Nephrologist Dr Fiona Mackie

bull Allied Health

bull Clinical Psychologist Occupational therapist Physiotherapist Speech therapist Dietician

Any practical advice on your patient care please email or telephone

bull infothepaediatriccentrecomau Tel 94052386 Fax 94052387

bull wwwthepaediatriccentrecomau