Eczema symptoms and more
Alison, mother of 4-month-old Rosa, comes to see you about Rosa’s eczema. It is moderately severe and present mainly on her cheeks.
Her symptoms have been present for about 2 months and Alison looks worried. “Rosa has to wear mittens at night to prevent her from scratching,” says Alison.
Rosa was prescribed emollients, which have not helped, and a weak corticosteroid cream that has temporarily eased symptoms. “But when I stop using the steroids, the eczema comes right back,” adds Alison.
You ask Alison whether Rosa has any other symptoms. She says “Well, she has loose stools; she’s a pretty sickly child.”
Upon questioning you discover Rosa also suffers some gastric reflux.
Failure to thrive
Rosa’s notes indicate that she was switched from breast milk to formula at about 8 weeks as she was struggling to latch on and her weight was not increasing satisfactorily.
You look at Rosa’s growth chart and see that since starting formula, she has gained weight, but at a low rate, and has dropped from the 25th to the 2nd percentile in the last 6 weeks.
Whilst weighing Rosa, you ask Alison how things are going. “Well, to be honest, I feel exhausted as she is often up at night scratching”.
She also tells you that Rosa’s poor health is putting a strain on her relationship with her husband who thinks she is “obsessed and worrying too much”.
You wonder whether Rosa might have cows’ milk protein allergy (CMPA).
Question:
Most patients with cows’ milk protein allergy (CMPA) present with both gastrointestinal and atopic symptoms
Which formula is appropriate?
You propose that Rosa does a 2-week cows’ milk exclusion diet with a non-dairy formula to help diagnose the condition; now that you have taken a detailed clinical history.
You explain to Alison that the scientific literature supports diagnosis of cows’ milk protein allergy through dietary exclusion using a hypoallergenic formula, followed by a rechallenge.2
Question:
Which of the following formulas would be suitable for Rosa?
Formula facts
According to the European Society for Paediatric Gastroenterology, Hepatology and Nutrition, up to 50% of infants given a soya-based formula for the management of cows’ milk protein allergy (CMPA) develop a cross reaction to soya.3
What’s more, the UK Chief Medical Officer states that soya-based infant formulas should not be used as a first choice for the management of infants with proven cows’ milk protein sensitivity below the age of 6 months.4
In addition, up to 29% of cows’ milk protein allergy (CMPA) patients have shown intolerance to extensively hydrolysed formulas (eHFs).1,5
You prescribe an amino acid formula (AAF) that is 100% non-allergenic and free from milk proteins.
Diagnosis
Alison returns with Rosa 2 weeks later. Her eczema and gastrointestinal symptoms have abated considerably.
You tell Alison that the improvement strongly suggests that Rosa has cows’ milk protein allergy (CMPA). Rosa’s weight has now stabilised and looking at the growth chart you can see that her weight is beginning to increase again.
“I feel so relieved,” says Alison. “I couldn’t have imagined that all these symptoms were related.”
You discuss giving Rosa a rechallenge with dairy products in 2 weeks’ time to see if Rosa develops symptoms.
Rosa’s eczema symptoms resurged a few days after the rechallenge, confirming a cows’ milk allergy. So you decide to continue with your choice of hypoallergenic formula.
References
1 Sladkevicius E et al. J Med Econ. 2010;13:119-128
2 Vandenplas Y et al. Arch Dis Child 2007;92:902-908
3 ESPGHAN Committee on Nutrition. JPGN 2006;42:352-361
4 Dept of Health, CMO Update 37 Jan 2004
5 Latcham F et al. J Pediatr 2003;143:39-47
6 Meyer R. J Family Health Care 2008;18:27-30
7 Høst A, Halken S. Allergy 1990;45:587-59
8 Hill D et al. J Pediatr 2000;136:641-647
9 Iacono G et al. J Allergy Clin Immunol 1996;97:822-827
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