Du Toit, Meyer and Shah have offered an excellent approach to cow's milk protein allergy (CMPA) and related disorders.(1)

There is evidence to suggest that an increasing number of infants are seeking medical attention with symptom-complex suggestive of gastro- oesophageal disease (GORD).(2) Infants with cow's milk protein allergy (CMPA), especially those with non-IgE mediated cow's milk-induced reactions, present with a variety of symptoms which may be clinically indistinguishable from those with primary GORD.(2,3)

CMPA and GORD occur frequently in young infants and various studies have demonstrated that CMPA may be present in up to 50% case of GORD and in a high proportion of the patients GORD symptoms may be induced by the underlying CMPA.(4)

Recognising the fact that there is a strong association between GORD and CMPA, all infants presenting with symptoms of GORD require careful evaluation to detect whether the GORD is primary or secondary to CMPA. A detailed history, observation of feeding and physical examination of the infant are always mandatory to detect signs of secondary GORD.(5) Oesophageal pH monitoring shows some typical characteristics and immunological tests may be helpful if an association is suspected (6); however the only clue to the diagnosis especially in non-IgE mediated CMPA, is often by elimination diet and milk challenge. The time interval between the milk intake and the suspected reaction to milk is of crucial importance; most infants with immediate symptoms may have IgE-mediated CMPA and should be referred for allergy evaluation with further delay and milk challenges should only be undertaken in a supervised environment.

Infants presenting with symptom-complex suggestive of GORD with the clinical history of atopy or cutaneous allergic reactions (as urticaria, angio-oedema, facial or buccal mucosal oedema), respiratory symptoms (cyanosis, croup, respiratory distress or wheeze) or symptoms suggestive of cardiopulmonary collapse (pallor, shock) or apparent life threatening event should alert the clinician that GORD is secondary to CMPA to initiate cow's milk-free diet and hypoallergic feeds.

Although soya-based infant formulas have been recommended as a first- choice alternative for infants with cow's milk allergy, it must be remembered that nearly half the children with CMPA also have an allergy to soya (7) and hence the symptoms may remain unchanged or show only partial improvement if the feeds are switched over from cow's milk to soya-based formula.

References:

1) du Toit G, Meyer R, Shah N, Identifying and managing cow's milk protein allergy. Arch Dis Child Educ Pract Ed 2010;95:134-144 doi:10.1136/adc.2007.118018

2) Mir Nisar. Epidemic of gastro-oesophageal reflux in young infants. Rapid response to: From Drugs and Therapeutics Bulletin. Managing gastro- oesophageal reflux in infants. Brit Med J 2010; 341:495-498 Doi:10,1136/bmj.c4420

3) Vandenplas Y, Brueton M, Dupont C et al. Guidelines for the diagnosis and management of cow's milk protein allergy in infants Arch Dis Child 2007;92:902-908 doi:10.1136/adc.2006.110999

4) Salvatore S, Vendenplas Y. Gastroesophageal Reflex and Cow Milk Allergy; Is There a Link? Pediatr 2002; 110; 972-984 Doi: 10.1542/peds.110.5.972

5) Mir, Nisar. Presentation and Diagnosis of Gastro-oesophageal Reflux in babies MIMS Advances. Infant Nutrition 2005;4:1-4

6) Cavataio F, Lacona G, Montalto G et al. Clinical and pH-metric characteristics of gastro-oesophageal reflex secondary to cows' milk protein allergy. Arch Dis Child 196; 75: 51-56 Doi; 10.1136/adc.75.1.51

7) Klemola T, Vanto T, Juntunen-Backman K et al. Allergy to soy formula and to extensively hydrolyzed whey formula in infants with cow's milk allergy: a prospective, randomized study with a follow-up to the age of 2 years. J Pediatr. 2002 ;140(2):219-24.

Nisar A Mir Consultant Paediatrician Warrington & Halton Hospitals NHS Foundation Trust

Clinical Lecturer (Hon) University of Liverpool

E-mail: nisar.mir@whh.nhs.uk

Conflict of Interest:

None declared