Following on from Part 1 & 2 which included what is cows milk protein allergy and how we diagnose, this next chapter will discuss the importance of the role of the dietitian in milk free weaning.

Once an infant has been diagnosed with a delayed cows milk protein allergy, guidance is to follow a strict milk free diet for a minimum of 6 months, therefore this includes weaning on a cows milk protein free diet. A dietitian has an important role to play here as with any diet that eliminates a food group there comes the risk of nutritional deficiency and an impact on growth. The dietitian can support to ensure that this does not occur.

Management Phase <6 months old

• Baby

eHF (extensively hydrolysed formula) is recommended as the first line formula for the majority of babies with mild-moderate CMPA. Guidance of which formula to prescribe as the first line will depend on local prescribing criteria.

AAF (amino acid formula) should only be the first line choice for infants with severe symptoms, including faltering growth. It may also be provided if symptom relief is not seen within 2-4weeks of trialling eHF (awareness and clinical judgement is required from a dietitian as symptoms exhibited may not be in relation to CMPA).

• Breastfeeding

Mothers who are breastfeeding should be advised to follow a strict milk free diet. During breastfeeding, requirements for certain nutrients increase, including calcium and iodine. Again this is where the dietitian plays a crucial role to support both mum and baby.

Mothers should never be advised to stop breastfeeding if their baby has a diagnosed milk allergy, unless they request to include formula in their babies diet, or there are concerns with growth in which formula top-ups may be recommended by medical staff.

Milk free weaning

Prior to baby reaching weaning age, dietetic advice should be given regarding how to follow a milk free weaning diet to ensure nutritional balance. This can be completed as a group session as outlined in BDA Toolkit but should include (but not exhaustive to);

• Reading labels to ensure products are milk free, including medications, this should also include discussion around ‘may contain’ products.
• Utilising plant based fortified alternative (calcium, iodine, Vitamin B12) products in babies diet; e.g. soya, oat or coconut based that contain adequate kcal for babies growth.
• The introduction of other common allergens and what to do if an additional reaction is observed.
• Multivitamin use and when it is required to introduce to baby

The dietitian plays a crucial role in the management of cows milk protein allergy and a referral should always be complete to ensure nutritional balance and support appropriate growth.