"Pan-Mersey Prescribing Guidelines for Specialist Infant Formula Feeds in Lactose Intolerance and Cows' Milk Protein Allergy" - United Kingdom

This "Pan-Mersey Prescribing Guidelines for Specialist Infant Formula Feeds in Lactose Intolerance and Cows' Milk Protein Allergy" is a part of the paperwork released by the United Kingdom National Health Service specifically for United Kingdom residents.

The latest fillable version of the document was released on November 1, 2016 and can be downloaded through the link below or found through the department's forms library.

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This policy statement is approved by Halton, Knowsley, Liverpool, Southport and Formby, South Sefton, St Helens, Warrington and West Lancashire
CCGs
Halton
Knowsley
Liverpool
Southport and Formby
South Sefton
St Helens
Warrington
West Lancashire
Pan Mersey
Area Prescribing Committee
Pan-Mersey
Prescribing Guidelines for Specialist
Infant Formula Feeds in
Lactose Intolerance and Cows’ Milk
Protein Allergy
With acknowledgement to NHS Cumbria
CCG, NHS Blackpool CCG, Staffordshire and
Lancashire CSU, Lancashire Infant Feeding
Board, Bridgewater Community Healthcare
NHS Foundation Trust, Dietetics
Department Alder Hey Children's NHS
Foundation Trust
November 2014 (ref G16 V01)
Review date: November 2016
[Type text]
This policy statement is approved by Halton, Knowsley, Liverpool, Southport and Formby, South Sefton, St Helens, Warrington and West Lancashire
CCGs
Halton
Knowsley
Liverpool
Southport and Formby
South Sefton
St Helens
Warrington
West Lancashire
Pan Mersey
Area Prescribing Committee
Pan-Mersey
Prescribing Guidelines for Specialist
Infant Formula Feeds in
Lactose Intolerance and Cows’ Milk
Protein Allergy
With acknowledgement to NHS Cumbria
CCG, NHS Blackpool CCG, Staffordshire and
Lancashire CSU, Lancashire Infant Feeding
Board, Bridgewater Community Healthcare
NHS Foundation Trust, Dietetics
Department Alder Hey Children's NHS
Foundation Trust
November 2014 (ref G16 V01)
Review date: November 2016
[Type text]
Contents
1. INTRODUCTION ............................................................................................................... 2
2. SUMMARY ........................................................................................................................ 2
3. LACTOSE INTOLERANCE ............................................................................................... 5
3.1 Signs and Symptoms ...................................................................................................... 5
3.2 Breast-fed infants ........................................................................................................... 5
3.3 Formula-fed infants ......................................................................................................... 5
3.4 Stopping lactose free formula ......................................................................................... 6
3.5 Suitable products ............................................................................................................ 6
4. NON-IgE MEDIATED COWS’ MILK PROTEIN ALLERGY (COWS’ MILK PROTEIN
INTOLERANCE) ...................................................................................................................... 6
4.1 Breast-fed infants ........................................................................................................... 7
4.2 Formula-fed infants ......................................................................................................... 7
4.3 Suitable products ............................................................................................................ 7
4.4 Stopping prescription formula ......................................................................................... 7
5. IgE MEDIATED COWS’ MILK PROTEIN ALLERGY ......................................................... 8
6. SOY BASED FORMULA ................................................................................................... 8
7. OTHER SPECIALIST INFANT FORMULA ........................................................................ 8
8. PREMATURE AND LOW BIRTH WEIGHT INFANTS ....................................................... 9
9. QUANTITIES TO PRESCRIBE ....................................................................................... 10
10. REFERENCES ................................................................................................................ 10
11. ACKNOWLEDGEMENTS……………………………………………………………………….10
N.B. OTHER SPECIALIST INFANT FORMULA
Secondary care will lead in prescribing for several special groups of infants such as:
Pre-term and low birth weight infants (may also require iron and vitamin supplements)
Disease specific conditions
Complex food intolerances and allergies
Faltering growth
Complex medical cases
Cystic fibrosis
and these are outside of the scope of this guidance.
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1. INTRODUCTION
The purpose of this guidance is to outline recommendations for the prescribing of infant formula feeds
in lactose intolerance and cows’ milk protein allergy in the Pan-Mersey area.
Breastfeeding is the best form of nutrition for infants and this should be promoted, supported
and protected wherever possible.
This guidance covers all infants; including those who breastfeed, who are formula-fed or those who do
a combination of both. For breast-fed babies who present with cows’ milk protein allergy,
breastfeeding should be protected as this is usually the best management. Specialist milks should
only be considered when there is truly a clinical need after thorough assessment. Assessment should
include and consider that formula feed products are being correctly prepared. The objectives of this
guidance are to:
 Aid diagnosis and improve access to special infant formula where needed, minimising distress to
the baby and anxiety to the parents/carers.
 Provide guidance on the nature, prescribing and cost effective supply of milk substitutes for
babies.
 Provide advice on suitable quantities for prescribing, duration of supply and guidance on
stopping prescribing.
 Maintaining awareness that breast milk is considered best for babies and not initiating a change
from breast to formula milk if the mother is happy to continue breastfeeding the infant.
This guidance should be used in conjunction with:
-
NICE Clinical Guideline 116, Food allergy in children and young people: Diagnosis and
assessment of food allergy in children and young people in primary care and community
settings,
-
NICE Clinical Guideline 37, Postnatal care: Routine postnatal care of women and their babies
-
NICE Quality Standard 37, Postnatal
care.
2. SUMMARY
2.1 In general, all cases of milk intolerance should be referred for specialist dietetic advice with the
exception of simple cases of secondary lactose intolerance, for which a lactose free formula
should be advised, and a re-challenge carried out in 2-4 months. Lactose intolerance is due to
enzyme deficiency; it is not an allergy.
2.2 Lactose free milks can be bought at a similar cost to standard infant formula, and prescribers
should not routinely prescribe. Parents can purchase lactose free formula from their chosen
retailer; however they are less commonly used than standard formula and may have to be
ordered. Most pharmacies and many supermarkets can obtain stock in a few days.
2.3 Soya products should not be recommended for purchase unless advised by a paediatric
consultant or dietitian due to the high incidence of soya sensitivity (10-35%) in infants intolerant
of cows’ milk protein, and never for infants under 6 months of age unless on specialist advice
e.g. for galactosaemia. Infants of vegan mothers who choose not to breastfeed should not
receive soya formula on the NHS as products are available at the same cost as standard
formula.
2.4 Paediatric consultants and/or dietitians are asked to advise on suitable formula and the length
of treatment for specialist infant formula in all cases except secondary lactose intolerance.
2.5 Powdered milks should be the norm. Liquid feeds are a convenience product and should be
purchased if preferred, unless they are clinically indicated by a dietician or specialist.
2.6 Infants requiring specialist milks other than those for lactose intolerance should be referred to a
dietitian or paediatric consultant. Prescribing can be initiated in primary care in the short-term
whilst waiting for specialist referral. If longer-term use is required dietician/specialist opinion
must be sought and there should be a clear plan for weaning and discontinuation included in
the care plan from the dietician/specialist. In the absence of written guidance to the contrary,
the recommended maximum ages detailed in this guidance should be applied.
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THE PRESCRIBING OF INFANT FORMULA FEED IN LACTOSE INTOLERANCE and COWS’ MILK PROTEIN ALLERGY
NON-IgE MEDIATED COWS’ MILK PROTEIN
LACTOSE INTOLERANCE
IgE MEDIATED COWS’ MILK PROTEIN
ALLERGY (Cows’ milk protein intolerance)
ALLERGY
Diarrhoea
NB There are many other
Frequent regurgitation or vomiting, gastro-
Oral pruritis
causes of diarrhoea & colic
Colic
oesophageal reflux
Nausea
Transient nature, usually
Persistent distress or colic (for more than 3 hr/day at
Colic/abdominal pain
secondary to GI insult,
least 3 days/week for at least 3 weeks)
Vomiting
e.g. post infective
Diarrhoea or constipation (with/without perianal
Diarrhoea
Diagnosis confirmed by
rash)
Pruritis, erythema
improvement within 2-3 days of
Blood and/or mucus in stool which may be
Acute urticaria
starting lactose-free diet
associated with iron-deficiency anaemia
Acute angio-oedema (most commonly lips,
Colic/abdominal pain
Resolution within two weeks
tongue, palate face and around the eyes)
Food refusal/ aversion
Pallor and tiredness
Nasal itching, sneezing, rhinorrhoea,
Faltering growth plus one or more gastrointestinal
congestion
TREAT
symptoms above
Cough, wheezing, shortness of breath
Breast-fed infants:
Atopic eczema (which may be triggered or an
Signs or symptoms of anaphylaxis
Mild symptoms: consider advising
exacerbation of existing condition), erythema,
purchase of lactase enzyme drops (e.g.
pruritis
Colief). Pan Mersey APC does not
Runny nose, chronic cough, wheeze, shortness of
recommend prescribing lactase
breath
enzyme drops on the NHS but may be
purchased.
In individual patients where
lactose intolerance is a longer-term condition
REFER to paediatric consultant and/or dietitian
and it has been confirmed by testing, it may be
REFER to paediatric consultant and/or dietitian for
for secondary care evaluation, diagnosis and
considered for prescribing on the NHS
(prescription endorsed “ACBS”). Such
advice on cows’ milk protein exclusion and
support.
prescribing should be reviewed for continued
reintroduction.
need at regular intervals.
TREAT infant as below whilst waiting for referral
Severe symptoms: consider advising
TREAT infant as below whilst waiting for referral
appointment.
parents purchase lactose free formula
appointment.
Endorse prescription for formula feed with
feed.
Endorse prescription for formula feed with ‘ACBS’.
‘ACBS’.
Formula-fed infants:
Parents to purchase lactose free formula
feed, to use during episode (temporary
use only). Re-challenge in 2-4 months.
SEE BELOW FOR PRODUCTS
SEE BELOW FOR PRODUCTS
SEE BELOW FOR PRODUCTS
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THE PRESCRIBING OF INFANT FORMULA FEED IN LACTOSE INTOLERANCE and COWS’ MILK PROTEIN ALLERGY
NON-IgE MEDIATED COWS’ MILK PROTEIN
IgE MEDIATED COWS’ MILK PROTEIN
LACTOSE INTOLERANCE
ALLERGY (Cows’ milk protein intolerance)
ALLERGY
Lactase enzyme drops (e.g.
Colief) Dose: 4 drops per feed for
Breast-fed infants:
Breast-fed infants:
4-8 weeks or until can be gradually
Continue breastfeeding.
Continue breastfeeding.
withdrawn without return of
Consider exclusion of cow’s milk products from
Consider exclusion of cow’s milk products from
symptoms.
Pan Mersey APC does
mother’s diet (advise a calcium supplement if mother
mother’s diet (advise a calcium supplement if mother
not recommend prescribing lactase
remains on dairy-free diet long term)
remains on dairy-free diet long term)
enzyme drops on the NHS but may
be purchased.
In individual patients
Formula-fed infants:
Formula-fed infants:
where lactose intolerance is a longer-term
condition and it has been confirmed by
Trial of extensively hydrolysed feed (hypo-allergenic
Trial of extensively hydrolysed feed feed (hypo-
testing, it may be considered for prescribing
milk formulas) for four weeks.
allergenic milk formulas) for four weeks.
on the NHS (prescription endorsed
- Infant up to 6 months of age:
- Infant up to 6 months of age:
“ACBS”). Such prescribing should be
For example Aptamil Pepti 1 or Nutramigen 1
For example Aptamil Pepti 1 or Nutramigen 1
reviewed for continued need at regular
Seek lactation support
- Infant over 6 months of age:
- Infant over 6 months of age:
intervals.
from experienced source to
For example Aptamil Pepti 2 or Nutramigen 2
For example Aptamil Pepti 2 or Nutramigen 2
improve breastfeeding
effectiveness.
If not resolved, or if the reaction is very severe, trial
If not resolved, or if the reaction is very severe, trial an
Lactose free formula
an amino acid supplement for further four weeks.
amino acid supplement for further four weeks.
e.g. SMA LF or Enfamil O-Lac
For example Nutramigen AA or Neocate LCP
For example Nutramigen AA or Neocate LCP
Infants taking solid foods:
Avoid solids containing lactose.
Children with enterocolitis/proctitis or blood in stools
Children with worrying symptoms including
Offer referral to dietitian for dietary
with faltering growth, severe atopic dermatitis and
potential anaphylaxis, oral angioedema and severe
advice. Avoid lactose-containing
symptoms during exclusive breastfeeding are more
skin reaction should be treated with amino acid
medicines.
likely to require amino acid based formula.
based feed as initial treatment.
-
Most infants should be able to
revert to a normal diet in 4-8
weeks: gradually reintroduce
usual formula/breast milk.
With a specialist confirmed diagnosis, children are
With a specialist confirmed diagnosis, children are
May last 3 – 6 months. If longer
-
usually challenged at 18 months to 3 years of age,
usually challenged at 18 months to 3 years of age,
term, use as necessary and
depending on presentation and symptoms. Specialist
with varying degrees of success. Specialist formula
refer to dietitian and/or
formula may be necessary until 18 months of age or
may be necessary until 18 months of age or longer
paediatric consultant.
longer on advice of dietitian/paediatric consultant.
on advice of dietitian/paediatric consultant.
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