Guidance for primary care practitioners on the safe detection and management of milk allergy in children.

Problem

Milk allergy affects 1% of children under 2 years old. Community prescriptions for specialised formula used to manage milk allergy have increased almost 3-fold in England between 2007 and 2018 costing the NHS approximately £60 million annually since 2016. Concerns have been raised that industry-influenced milk allergy guidelines promote over-diagnosis of milk allergy and medicalisation of normal infant behaviour. Most milk allergy guidelines are written by specialists with conflicts of interest in relation to the formula milk industry. Primary care often lacks access to specialist allergy services. This Delphi consensus study aimed to develop guidance for primary care practitioners for the safe detection and management of milk allergy in children by a wide range of healthcare professionals without conflicts of interest related to formula industry.

Approach

This Delphi study involved 2 rounds of anonymised consensus building with an open consensus meeting. Seventeen of 28 international invited experts participated with expertise in general practice, dietetics, midwifery, health visiting, lactation support, general paediatrics, paediatric dermatology and paediatric allergy. External consultation was undertaken with a non-voting panel of current guideline authors (5) and mothers (7) of children with milk allergy diagnosis or mis-labelling. Flowcharts were developed producing a practical tool for primary care practitioners to diagnose and manage milk allergy.

Findings

Thirty-eight initial statements produced 72 statements in round 2 and 38 final recommendations by consensus. Recommendations included clinical scenarios when milk allergy diagnosis was not likely and distinguished between exclusively breastfed children and those children directly consuming cow’s milk protein. Key recommendations included that maternal dietary restriction was not usually necessary to manage milk allergy and promotion of breastfeeding, with greater emphasis on supporting mothers physical and psychological health when undertaking elimination diets. Consideration of milk allergy diagnosis in exclusively breastfed infants with chronic symptoms was only recommended in specific rare circumstances. Consideration of milk allergy diagnosis was not recommended for children presenting with changes in stool colour or consistency, occasional spots of blood in the stool, aversive feeding or colic without a consistent history of symptom onset and reproducibility related to milk protein ingestion. Recommendations included specific criteria for the initiation or continuation of specialised formula to manage milk allergy and clinical scenarios when specialised formula was not necessary.The recommendations from this study provide clear guidance which will help primary care practitioners avoid overdiagnosis and over treatment of milk allergy. These recommendations are more supportive of breastfeeding and aim to reduce the burden of elimination diets on mothers.

Consequences

Guidance developed by a range of primary and secondary healthcare practitioners without conflicts of interest to formula industry, and including parent representatives, produces practical recommendations for use in daily clinical practice, which are more supportive of breastfeeding and avoid unnecessary use of specialised formula.