Practice of the Treatment of Milk Allergy in the UK: A National Audit

Abstract

Background: The management of cow's milk allergy (CMA) includes initial dairy exclusion with suitable dietary substitution, diagnostic challenges where indicated, and supervised re-introduction as the condition resolves. Information on clinician practice is limited. We audited the current practice of clinicians in the UK to evaluate adherence to international guidelines. Methods: An online questionnaire was sent to all clinicians whose practice included children identified on the national allergy society website. One hundred and sixty questionnaires were sent and 116 (73%) responded. Results: Skin prick tests were more commonly used than serum-specific IgE as diagnostic tests. Respective proportions selecting amino acid formulas (AAF) or extensively hydrolysed formulas (EHF) in severe versus mild/moderate presentations were 78 and 40% versus 20 and 88%; soya formula was the first choice in 8.6 and 24%. The criteria for selection of AAF as the first choice were predominantly severe IgE-mediated and non-IgE-mediated reactions, failure to thrive and if infants refused EHF. Oral challenges might be used to diagnose CMA in 69%, whereas nearly 90% performed challenges to assess tolerance. Most of these were open challenges, more commonly with fresh milk (90%) than baked milk (60%). Home baked milk challenges were frequently considered (70%), although only after consideration of the clinical scenario. Practice did not vary with experience. Conclusions: Current practice amongst UK clinicians of the management of CMA is broadly in line with current guidance, particularly the positioning of hypoallergenic milks as substitute milk choices. A notable deviation was the use of home baked milk challenges or re-introduction.

Knowledge and practice of pediatricians and nutritionists regarding treatment of cow’s milk protein allergy in infants

“…In addition to the regional character, professionals who participate in scientific events can be assumed to be more concerned with their scientific knowledge and therefore do not accurately represent the universe of professionals. However, our results are generally similar to the results from other studies [17][18][19][20][21][22][23][24][25] that evaluated the knowledge and practices of health professionals. These studies [17][18][19][20][21][22][23][24][25] used procedures for recruiting interviewees that were similar or different to the procedure used herein.…”

“…During the period of exclusion of CMP, a nutritional status assessment should be performed by the health professional to establish the adequacy of food consumption for the child's nutritional needs [1,4,5,8] and family members must be oriented to perform a thorough reading of the labels of industrialized foods offered to their children [1,5,7,9]. Despite the existence of several guidelines [1,[4][5][6][7][10][11][12][13] for the diagnosis and treatment of CMPA, some surveys [6,7,[14][15][16][17][18][19][20][21][22] have shown that the practices and knowledge of health professionals are not fully in line with these recommendations. Few studies have investigated the knowledge and practices of pediatricians and nutritionists about CMPA treatment.…”

Comparison between General Pediatricians and Other Sub-Specialty of Pediatrics Regarding Knowledge of CMPA

“…This can be performed as an open, single blind or double blind challenge, depending on clinical findings, history, and age of the child. However, there are conditions under which physicians may cancel a challenge procedure because either the diagnosis of CMPA is extremely high or the challenge procedure would be very risky if there is a history of anaphylaxis in a sensitized child (14) .…”

Cow's milk allergy guidelines promote over‐diagnosis of cow's milk disease

“…However, poor adherence to CMA guidelines has been reported in a number of studies. 8 Similarly, there is poor adherence to gastroesophageal reflux guidelines, the symptoms of which overlap with CMA. 9 Attention to all stages-from awareness of the guidelines through acceptance through applicability to adherence-is needed.…”