Understanding the diagnosis/management pathwaysInteractive MAP Guideline

The MAP Guideline includes a number of terms which you may need to familiarise yourself with. See below for more information on the diagnosis and management pathways referred to within the MAP Guideline.

The NICE guideline recommends asking questions about1:

  • Any family history of atopic disease in parents or siblings, i.e. atopic eczema, allergic rhinitis, asthma, food allergy
  • Any personal history of early atopic disease
  • The infant's feeding history
  • Presenting symptoms and signs that may be indicating possible CMA
  • Details of previous management, including any medication and the perceived response to any management
  • Was there any attempt to change the diet and what was the outcome?

Next is the important step to attempt to differentiate between possible IgE- and non-IgE-mediated allergies and which “tests” to do.

IgE-mediated CMA

For the diagnosis of IgE-mediated CMA, the use of skin prick tests (SPT) or specific serum IgE tests are recommended, but these should only be performed by those competent to interpret the results1. It is important to understand that a positive SPT or specific serum IgE test merely indicates sensitisation and does not confirm clinical allergy. However, a positive test coupled with a clear history of a reaction should usually be sufficient to confirm a diagnosis. If there is still doubt, the patient should be referred to secondary or tertiary care.

Although a diagnostic oral food challenge (after a short period of cow’s milk avoidance) may not be required in most of these cases, if such a challenge is conducted, it will need to be performed in a supervised setting in the majority of cases. Liaison with, or referral to, a local paediatric allergy team is recommended.

Non-IgE-mediated CMA

There are no validated tests for the diagnosis of non-IgE CMA, apart from a period of avoidance of cow’s milk and cow’s milk containing foods, followed by exposure or challenge. This challenge can be carried out at home for those infants with mild to moderate non-IgE-mediated CMA.

If the decision is made to remove all cow’s milk and cow’s milk containing foods from the maternal and/or infant diet, this should be discussed with a dietitian, who will be able to provide guidance on the initial home challenge to confirm the diagnosis, and then to give the necessary support as the cow’s milk protein-free diet is maintained.

Challenges at home may however not be advisable in children with severe forms of non-IgE-mediated CMA, and these children should be referred to secondary/tertiary care. Should the diagnosis then need to be confirmed by a food challenge in these more severely affected infants, it will usually be carried out in hospital.

Reintroduction will take place at a later stage, to determine when the child has acquired a natural tolerance to CMA such as a home reintroduction to determine the development of tolerance in infants with non-IgE-mediated CMA.

This can be performed using a Milk Ladder.

1. NICE. Diagnosis and assessment of food allergy in children and young people in primary care and community settings [Online]. 2011. Available at: www.nice.org.uk/CG116 [Accessed Sept 2013].