PAEDIATRIC
Dr Rosan Meyer, RD,PhD Paediatric Research Dietitian, Honorary Senior Lecturer, Imperial College, London and Chair of the BDA Food Allergy and Intolerance Specialist Group
Dr Lisa Waddell, RD,PhD Specialist Community Paediatric Allergy Dietitian and Director of Food Allergy Nottingham Service (FANS)
Dr Carina Venter RD,PhD Assistant Professor, University of Colorado Denver School of Medicine, USA
REFERENCES Please visit the Subscriber zone at NHDmag.com
WHERE NEXT AFTER PUBLICATION OF IMAP GUIDELINES FOR NON-IGE MEDIATED COW’S MILK ALLERGY? The successful iMAP guidelines provide suitable guidance for any child with a mild-to-moderate presentation of non-IgE mediated cow's milk allergy (CMA). This article reports on the updated guidelines and revised six-step milk ladder and looks at next steps in future improvements. CMA remains one of the most common food allergies worldwide, with a prevalence in the United Kingdom of 2-3% in one- to three-year-olds.1 This allergy can present with immediate onset of symptoms; including pruritus and eczema flares, urticaria (hives) and angioedema and, in the most severe cases, anaphylaxis.2 These type of reactions are referred to as Immunoglobulin E (IgE)-mediated food allergy and the pathophysiologic mechanism is well described, with tests available to support the diagnosis. However, this allergy can also present with delayed symptoms, called non-IgE mediated CMA, which can include symptoms like vomiting, feeding difficulties, colic-like abdominal pain, faltering growth, diarrhoea, blood in stools, constipation and exacerbation of atopic eczema.3 The latter group of symptoms overlap with other common disorders in early childhood, such as infantile colic and gastro-oesophageal reflux, lactose intolerance, constipation and atopic eczema, which complicates the recognition and diagnosis of cow’s milk allergy. The pathophysiology of non-IgE mediated CMA is not well established and no accurate non-invasive tests exist to support the healthcare professional (HCP) to make the diagnosis, which includes a spectrum of gastrointestinal conditions (i.e. food induced proctocolitis, enterocolitis, enteropathy).3 It was, therefore, not surprising that in 2010, Sladkevicius et al4 reported that it took on average 4.5 visits to a general practitioner (GP)
over an average of 2.2 months in the UK for children with atopic eczema and gastrointestinal symptoms to be started on the correct treatment. The delayed nature of diagnosis of non-IgE mediated CMA was recognised by a group of HCPs as a particular area that required improvement in the UK and, therefore, the Milk Allergy in Primary (MAP) guidelines were published, targeting mild to moderate non-IgE mediated CMA.5 These guidelines have proven to be extremely successful, not only in the UK, but worldwide, with more than 74,000 downloads (download and citation history is available from http://citations.springer.com/item?d oi=10.1186/2045-7022-3-23), providing the authors with four years of feedback to allow for publication of the improved international (i)MAP guidelines.6 WHAT HAS CHANGED IN THE IMAP GUIDELINES?
The iMAP guideline authors consisted of well-known allergists and dietitians from all over the world, including from resource-poor countries, to provide guidance suitable for any child with a mild-to-moderate presentation of nonIgE mediated CMA. The diagnosis and management of the severe spectrum of non-IgE mediated CMA, including eosinophilic oesophagitis (EoE), food protein enterocolitis syndrome (FPIES) and food protein induced enteropathy with faltering growth, were, therefore, not covered in these guidelines.6 www.NHDmag.com June 2018 - Issue 135
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