D2.83 - Management of Non IgE Cow's Milk Allergy: Current Practices and Challenges

Management of non-immunoglobulin E (non-IgE) mediated cow’s milk allergy (CMA) is complex due to symptom overlap with common functional infant conditions like gastro-oesophageal reflux disease (GORD). This audit measured compliance with local management guidelines and examined real-world patterns in acid-suppressive therapy and hypoallergenic formula use.

This retrospective clinical audit evaluated management practices for suspected non-IgE CMA against established standards within the NHS Greater Glasgow and Clyde area. Electronic secondary care records for 500 infants aged 0-24 months managed between December 2017 and December 2022 were reviewed. Data included demographics, pharmacological interventions (e.g., proton pump inhibitors (PPIs) and alginates), dietary transitions, and compliance with nine clinical standards.

Significant treatment overlap was found, as 52% of formula-fed infants received dietary and pharmacological interventions concurrently. High transition rates occurred: 86% of infants changed formula at least once and 60% twice or more, with a mean of 2.3 changes. Amino acid formula (AAF) was used by 36% of infants, often without documented failure of extensively hydrolysed formula (EHF). Regarding duration, 56% continued the hypoallergenic formula milk beyond 12 months (mean stopping age 62.3 weeks). Pharmacological use was high for alginates (56%) and PPIs (51%). While compliance was excellent for dietitian referrals (98%) and starting EHF as first-line (79%), compliance for "milk ladder" reintroduction was critically low at 21%.

CMA management is characterized by high intervention and heavy reliance on anti-reflux medications. A significant "drift" exists in later clinical stages, with infants remaining on specialized formulas well beyond recommended milk reintroduction points. Implementing structured pathways, such as mandated management proformas and prescribing protocols, is essential to reinforce guideline-adherent management, prevent over-prescription and support the timely development of immune tolerance.