Cows Milk Protein Allery


Cows Milk Protein Allergy (CMPA)

  • Infants with a diagnosis of CMPA should remain on a cow’s milk protein free diet until 9-12 months of age and for at least 6 months prior to re-introduction of cow’s milk
  • It is advisable that re-introduction should be done with the support of a paediatric dietitian
  • How and when re-introduction should be done depends on whether the infant has IgE or non-IgE mediated allergy
  • Children with non-IgE mediated cow’s milk allergy will be tolerant sooner than children with IgE mediated allergy
  • Most children with non IgE allergy mediated will be tolerant by 3 years and over half of children with an IgE mediated allergy will be tolerant by 5 years

Lactose intolerance

  • This is a non-immune mediated adverse reaction to food, it is not due to an allergy but a lack of the enzyme lactase
  • It is sometimes confused with CMPA
  • Congenital lactose intolerance is extremely rare and primary lactose intolerance does not usually present until later in childhood
  • Secondary lactose intolerance can occur when the intestine is damaged, for example following gastroenteritis
  • Symptoms may present as loose, frequent stool, increased wind and abdominal bloating
  • It is a transient condition
  • If persistent lactose intolerance
Cow’s Milk Protein Allergy    

Extensively Hydrolysed Formulae These are hypoallergenic and offer complete nutrition for infants who cannot digest intact cow's milk protein. They also help infants who are intolerant or allergic to intact cow's milk protein

Similac Alimentum (from birth onwards

SMA Althera (from birth onwards)

Nutramigen 1 (from birth to 6 months 

Nutramigen 2 (from 6 months onwards)

prescribed by GP

Extensively Hydrolysed Formulae containing lactose These are better tolerated in older infants where refusal is more common due to taste

AptamilPepti 1 (from birth to 6 months 

Aptamil Pepti 2 (from 6 months onwards)

prescribed by GP

Amino Acid Formulae If a patient presents with clear anaphylactic reaction to cow’s milk these formula should be commenced in primary care, with immediate onward referral to secondary or specialist care 

SMA Alfamino  (from Birth) - cost - effective

Nutramigen Puramino (From Birth)

Neocate LCP (Birth – 12 months)

Neocate Junior (>1yr)

initiated by specialist

Malabsorption < 1 year    
Malabsorption +/- CMPI

Pepti-junior (Cow & Gate) ( 6-12 months.)

Pregestimil Lipil (Mead Johnson) (from birth onwards)

Initiated by expert only
Energy Dense Formula with medium chain triglycerides for malabsorption /CMPI  Infatrini Peptisorb (from birth up to 18 months or <9kg in body weight)  Initiated by expert only
Pre-term Formulas    
Pre term infants (born ​<35 weeks)

Nutriprem 2 Powder

SMA Gold Prem 2

Nutriprem 2 liquid (restricted)

SMA Gold Prem Liquid (restricted)

Babies born <35 weeks weighing<2kg may be initiated on the powder formulas by specialist

GP to continue prescribing until baby reaches 6 months corrected age (expected date of delivery + 26 weeks)

Liquids are used when baby immunocomprimised or parents cannot make up milk

Weight monitored monthly by health visitor - stop if excessive weight gain

Faltering Growth < 1 year    
Energy Dense ready-touse formula


Similac High Energy

SMA High Energy

Initiated by specialist

Patient should be under care of Paediatric Dietitian

Energy Dense Formula, extensively hydrolysed with medium chain triglycerides for malabsorption /CMPI  Infatrini Peptisorb 

Initiated by specialist

Patient should be under care of Paediatric Dietitian

Faltering Growth > 1 year    
Paediatric Oral Nutritional Supplements (ONS) When taken orally not via feeding tube
  • Frebini
    • Energy Drink
    • Energy Drink Fibre
  • Fortini
    • Compact
    • Smoothie 
    • Multifibre
    • 1.0 Multifibre (lower levels of calories and protein)
  • Paediasure
    • Plus
    • Plus Juce
    • Fibre
    • Pepdite
  • Resource Junior



Ensure regular weight / length monitoring

Patient should be under care of Paediatric Dietitian

Initiated by specialist only

Paediatric formula available to purchase (do not prescribe)    
Gastro-oesophageal reflux disease

Pre-thickened formula

  • Enfamil A.R.
  • SMA Staydown

Thickening formula

  • Aptamil Anti-Reflux
  • Cow & Gate Anti-Reflux

Not to be used with Gaviscon Infant sachets or medication for GORD.

Pre-thickened formula will require use of fast flow teat.

Thickening formula thickens in stomach, therefore no need to use fast flow teat. Preparation with cooled boiled water.

Lactose free formula Aptamil Lactose Free SMA LF Lactose intolerance likely temporary. Recommend for up to 8 weeks at a time. Lactose needs to be re-introduced to build up tolerance.
Soya formula



SMA Wysoy

For greater than 6 months and if no allergy to soya More palatable than extensively hydrolysed formula. Lactose freeCMPA or secondary lactose intolerance.

Soya protein based formulas are not suitable as first line products for CMPA and should not be used in any infant under 6 months of age.

There is a 40-60% chance of cross-reaction with soya formula in infants with non-IgE mediated allergy and a 10-15% chance in infants with IgE mediated allergy

Soya formula can however be used in infants over 6 months of age who do not tolerate the extensively hydrolysed formula. 

 ance is suspected refer to secondary care.

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