NHS Dorset Clinical Commissioning Group
Suspected Cow’s Milk Protein Allergy in
Infants - Guidelines for Health Professionals
in Primary Care
Supporting people in Dorset to lead healthier lives
1
PREFACE
This policy sets out the guidance for prescribing infant formula for cow’s milk protein
allergy in Dorset CCG.
All managers and staff (at all levels) are responsible for ensuring that they are viewing
and working to the current version of this procedural document. If this document is
printed in hard copy or saved to another location, it must be checked that the version
number in use matches with that of the live version on the CCG intranet.
All CCG procedural documents are published on the staff intranet and communication
is circulated to all staff when new procedural documents or changes to existing
procedural documents are released. Managers are encouraged to use team briefings
to aid staff awareness of new and updated procedural documents.
All staff are responsible for implementing procedural documents as part of their normal
responsibilities, and are responsible for ensuring they maintain an up to date
awareness of procedural documents.
2
A

SUMMARY POINTS
The aim of these guidelines is to promote a consistent approach across Dorset to
the management of non IgE mediated Cow’s Milk Protein Allergy (CMPA), and is
based on the Map of Medicine guideline developed by the Wessex Allergy Network
Group (WANG, 2013)
B

ASSOCIATED DOCUMENTS
State any CCG documents that need to be read in conjunction with this procedural
document.
C
DOCUMENT DETAILS
Procedural Document Number
ID 131
Author
Katherine Gough
Job Title
Head of Medicines Management
Directorate
Quality
Recommending committee or group
Medicines Optimisation Group
Approving committee or group
Medicines Optimisation Group
Date of recommendation (version 1)
February 2014
Date of approval (version 1)
March 2014
Version
2
Sponsor
Director of Strategy and Quality
Recommendation date
February 2016
Approval date
March 2016
Review frequency
2 yearly
Review date
February 2018
3
D
CONSULTATION PROCESS
Version
No
Review Date
Author and Job Title
Level of Consultation
2
February
2018
Hayley Howells,
Medicines Management
Technician
None – no material changes to
policy - updated into new
policy template plus minor
formatting changes only
E
Date of
issue
VERSION CONTROL
Version
No
10/3/2016 2
Date of
next
review
Nature of change
Approval
date
Approval
committee
/group
Complete
Updated into new
policy template plus
minor formatting
changes only
8/3/2016
Medicines
Optimisation
Group
F
SUPPORTING DOCUMENTS/EVIDENCE BASED REFERENCES
Evidence
Hyperlink (if
available)
British Dietetic Association. Complimentary Feeding:
Introduction of solid foods to an Infants Diet.
Department of Health . Infant Feeding
Recommendations.
Dorset Breastfeeding Policy Strategy Group, 2013
Dorset Breastfeeding Policy. Section 3 of The Child
and Maternal Nutrition Guidelines for Dorset. Dorset.
County of Dorset NHS Trusts.
Dorset Child & Maternal Nutrition Guidelines.
Du Toit et al Archives Dis Childhood Educ Pract Ed,
95:1 34-44
Fiocchi A, Brozek J, Schünemann M et al. World
Allergy Organisation (WAO) diagnosis and rationale
for action against cow’s milk allergy (DRACMA)
guidelines. Pediatric Allergy and Immunology,
2010;21 (supplement S21): 1-25.
Journal Pediatr Gastroenterol Nutr, 55(2):221-229.
Koletzko S, Niggemann B, Arato A, Dias JA,
Heuschkel R, Husby S. Diagnostic approach and
management of cow's-milk protein allergy in infants
and children: ESPGHAN GI Committee practical
guidelines.
4
Date
April
2013.
London
2003
Dorset
2009
2010
2010
2012
F
SUPPORTING DOCUMENTS/EVIDENCE BASED REFERENCES
Evidence
Hyperlink (if
available)
2012
Koletzko, YB, Niggemann, ZA. Arato, J.A et al
Diagnostic Approach and Management of Cow’s-Milk
Protein Allergy in Infants and Children: ESPGHAN GI
Committee Practical Guidelines. JPGN
NICE Guideline CG116 Food allergy in children and
young people
Vandenplas Y et al Archives Dis Childhood, 92:902-8
Venter et al. Diagnosis and management of non-IgE
mediated cow’s milk allergy in infancy – a UK primary
care practical guide. Clinical and Translational Allergy
3:23
Wessex Allergy Network (WANG) Map of Medicine
Local Care Map – Food allergy suspected.
WHO Guiding principles for complementary feeding
of the breastfed child
WHO Guiding principles for feeding non-breastfed
children 6-24 months of age
G
Date
2011
2007
2013
July
2013.
2003
2005
DISTIBUTION LIST
Internal CCG
Intranet
√
CCG Internet
Website
√
Communications
Bulletin
√
External
stakeholders
These guidelines have been developed by a joint organisation working group
comprising the following members:
Organisation
Name
Role
Dorset HealthCare University
NHS Foundation Trust
Sam Leonard
Lisa Perkins
Sue Gibson
Tina Taylor
Specialist Services Manager
Community Dietitian
Health Visitor
Health Visitor
Dorset County Hospital NHS
Foundation Trust
Angela Cocks
Dr Phil Wylie
Elizabeth Carter
Children’s Dietitian
Consultant Paediatrician
Breastfeeding advisor
Poole Hospital NHS
Foundation Trust
Sophie Puttock
Dr Mark Tighe
Children’s Dietitian
Consultant Paediatrician
Royal Bournemouth and
Christchurch NHS Foundation
Trust
Odette Rodda
Specialist Nurse in Paediatric
Dermatology
Dorset Clinical Commissioning
Group
Hayley Howells
Pharmacy Technician,
Medicines Management Team
5
CONTENTS
PAGE
1.0
Relevant to
8
2.0
Introduction
8
3.0
Scope
8
4.0
Purpose
8
5.0
Definitions
9
6.0
Roles and responsibilities
9
7.0
Breast Fed infants
10
8.0
Formula fed infants less than 6 months of age
10
9.0
Formula fed infants over 6 months of age
10
10.0 Secondary lactose intolerance
10
11.0 Training
11
12.0 Consultation
11
13.0 Recommendation and approval process
11
14.0 Communication/dissemination
11
15.0 Implementation
11
16.0 Monitoring compliance and effectiveness of the document
12
17.0 Document review frequency and version control
12
APPENDICES
A
Cows Milk Protein Allergy Pathways
12 / 13
B
Initial Assessment for possible Cow’s Milk Protein Allergy (CMPA)
and Signs and Symptoms of possible food allergy
14 / 15
C
Milk free diet for breastfeeding
16
D
Weaning onto a milk free diet
21
E
Guidelines for indications for using specialised infant formula for
infants aged 0-6 months and aged over 6 month
35
F
Milk reintroduction for breastfeeding mothers
39
G(i)
Milk reintroduction for babies under 6 months
40
G(ii) Milk reintroduction for babies over 6 months
41
H
Weaning onto a milk and soya free diet
50
I
Equality Impact Assessment Tool
58
6
SUSPECTED COW’S MILK PROTEIN ALLERGY IN INFANTS
GUIDELINES FOR HEALTH PROFESSIONALS IN PRIMARY CARE
1.
RELEVANT TO
1.1.
This strategy/procedure/policy/protocol is relevant to all healthcare
professionals in the Dorset area who may be involved in the care of infants
with Cow’s Milk Protein Allergy (CMPA), including prescribing suitable
alternative infant formula.
2.
INTRODUCTION
2.1.
The aim of these guidelines is to promote a consistent approach across Dorset
to the management of non IgE mediated Cow’s Milk Protein Allergy (CMPA),
and is based on the Map of Medicine guideline developed by the Wessex
Allergy Network Group (WANG, 2013)
2.2.
When considering a diagnosis of CMPA, it is important to note that it is the
protein component of cow’s milk that is likely to be the cause of the allergic
response. Lactose (milk sugar) does not cause an allergic response.
2.3.
The incidence of CMPA is on average 3%, whilst primary lactose intolerance is
extremely rare. If gastro-intestinal symptoms persist after a period of gastroenteritis, temporary secondary lactose intolerance may be responsible.
2.4.
If non IgE-mediated CMPA is suspected then an Extensively Hydrolysed
Formula (EHF) should be recommended (Koletzko et al, 2010). Parents
should be discouraged from changing brand of standard infant formula,
as this will not improve symptoms and may delay diagnosis.
2.5.
The use of formulas for ‘hungrier babies’ should also be discouraged, as there
is no evidence base for their use
3.
SCOPE
3.1.
The Cows Milk Protein Allergy pathways as detailed in Appendix A are
designed to be used by any healthcare professional who may be involved in
the diagnosis and management of infant milk allergy whether in primary or
secondary care.
3.2.
The guidelines include a range of resources and materials that can be used by
healthcare professionals to ensure the same advice is given across Dorset.
4.
PURPOSE
4.1.
The objectives of the guidelines are:


to provide a pathway to follow to assist with the diagnosis of CMPA
to provide practical documents to support healthcare professionals
when working with families with an infant with a suspected CMPA
7



to provide supporting evidence to healthcare professionals to help
families understand when symptoms are NOT those of CMPA and to
give reassurance to these parents
to recommend guidelines to the Pan Dorset Prescribing Formulary on
suitable infant formula to be used in the management of CMPA
to give guidance on how and when to reintroduce milk
4.2.
The associated formularies in appendix E assists prescribers to choose the
correct formula and promotes the use of this formula for an appropriate length
of time to avoid infants being left on a specialised formula unnecessarily.
4.3.
The milk reintroduction plans (also known as the milk ladder) in appendix G(i)
and appendix G(ii) describe a process for reintroducing milk into the diet of
infants presenting with non-IgE mediated CMPA, which can be advocated for
use in the community i.e. for trial at home (Venter, 2013). Those infants with
severe anaphylactic reactions should not be subject to such a challenge
without the supervision of a suitable healthcare professional in an agreed safe
environment
5.
DEFINITIONS
5.1.
Cow’s Milk Protein Allergy (CMPA) - an adverse health effect arising from an
immune response that occurs reproducibly following exposure to Cows milk
5.2.
Immunoglobulin E (IgE) - an antibody present in the blood
5.3.
Non IgE mediated reaction - a physiological process that involves the
immune system. The body does not make IgE antibodies against the allergens,
and the reactions are often slower onset (more than 2 hours)
5.4.
IgE mediated reaction - a physiological process that involves the immune
system. IgE antibodies are made in response to an allergen and reaction is
often rapid onset (within minutes to 2 hours)
5.5.
Lactose Intolerance – the inability to digest lactose (milk sugar). This may be
a permanent or temporary effect but is not related to an immune mediated
reaction
5.6.
Faecal reducing substances – a test undertaken on a stool sample to
diagnose carbohydrate malabsorption including lactose intolerance
5.7.
Extensively Hydrolysed Formula (EHF) – formula milk where proteins have
been broken down in to short chain peptides and free amino acids
6.
ROLES AND RESPONSIBILITIES
6.1.
Healthcare professionals who work with children who may have allergies
should:

be aware of the content of these guidelines and provide advice that is
consistent with the messages contained herein
8



6.2.
ensure that, where a need is identified, they access training sessions
linked to these guidelines
seek further guidance if they feel they need to provide any advice that
falls outside of this guidelines
only recommend the use of formula in line with the content of these
guidelines
Community Dietitians, Paediatric Dietitians, Paediatricians in Dorset
HealthCare will:



support the education and training of staff working with families with
possible cow’s milk allergy
keep appraised of any new evidence that comes to light and advise on
adjustments to these guidelines where required
ensure that formula advised (requested on prescription) is consistent
with these guidelines
7.
BREAST FED INFANTS
7.1.
Sometimes exclusively breast fed babies demonstrate CMPA as cow’s milk
protein passes from maternal diet into breast milk. If CMPA is suspected in a
breast fed baby the mother should be encouraged to continue to breast feed
whilst following a cow’s milk protein free diet herself. Supplementary Vitamin D
and Calcium may be necessary for the breastfeeding mother.
7.2.
Once the baby is old enough to be introduced to solid foods (6 months) the
weaning diet should also be cow’s milk protein free.
8.
FORMULA FED INFANTS LESS THAN SIX MONTHS OF AGE
8.1.
If non IgE-mediated CMPA is suspected in a formula fed infant under six
months of age then an Extensively Hydrolysed Formula (EHF) should be
given, as described in the pathway in appendix 1.
8.2.
Weaning should commence around 6 months of age. The introduction of solid
foods should start no later than 26 weeks of age but not before 17 weeks of
age. (Dept of Health 2003; BDA 2013)
9.
FORMULA FED INFANTS OVER SIX MONTHS
9.1.
If non IgE-mediated CMPA is suspected in a formula fed infant over six months
of age then an Extensively Hydrolysed Formula should be used. Soya formula
could be considered for infants over six months old who are presenting with
symptoms (Venter et al, 2013).
9.2.
See appendix E for list of specialised formula that can be prescribed.
10.
SECONDARY LACTOSE INTOLERANCE
10.1.
A diagnosis of temporary lactose intolerance should only be made if diarrhoea
persists for more than two weeks after an episode of gastro-enteritis. A clinical
diagnosis is required as testing for the presence of reducing sugars in stools is
unreliable. This is the only scenario where lactose free milk formula
9
should be used in primary care and, if used, the infant should be tried
back on normal formula after 6-8 weeks.
10.2.
At this stage, if the infant is not able to tolerate a change to normal formula, a
referral to secondary care should be made.
11.
TRAINING
11.1.
This policy and associated guidance is adopted from Dorset HealthCare.
Training, will be led by the Dietetic Service and will be arranged on a regular
basis to best meet staff group needs.
11.2.
Training of GPs and Primary Care staff is vital to ensure consistency of
practice across the county and Dorset Healthcare staff (Dietetics and Health
Visiting) will aim to support the wider dissemination of these guidelines to
ensure best patient care and cost effective prescribing.
12.
CONSULTATION
12.1.
The Head of Medicines Management/Chief Pharmacist at Dorset CCG will
communicate with the Risk manager and any relevant health professional
group to ensure appropriate CCG actions for risks and alerts about medicines
safety are implemented and communicated to member practices.
12.2.
All policies will be reviewed by the Medicines Optimisation Group. The head of
Medicines Management will present them as an agenda item for discussion,
comment and ratification.
13.
RECOMMENDATION AND APPROVAL PROCESS
13.1.
The Medicines Optimisation Group will approve policies related to prescribing
of infant formula and receive reports on analysis and activity on a regular
basis.
14.
COMMUNICATION/DISSEMINATION
14.1.
The CCG medicines management team will ensure that the policy and
associated documents (pathway and formulary) are available to all healthcare
professionals in Dorset.
14.2.
The policy will be accessible to via the Internal CCG Intranet and Internet
Websites and the Dorset Formulary website. Routine updates will be cascaded
via standard routes including the prescribing newsletter and Dorset Formulary
site.
15.
IMPLEMENTATION
15.1.
This policy and associated guidance is adopted from Dorset HealthCare,
therefore the Dorset HealthCare Dietetic Service will also take responsibility for
working with Children’s Services Leads to ensure dissemination to appropriate
staff groups.
10
16.
As in point 14.2, Dorset CCG will ensure the policy is available online and the
Dorset prescribing formulary will set out the agreed formulary for infant formula
(in appendix E) and include links to relevant documents.
17.
MONITORING COMPLIANCE AND EFFECTIVENESS OF THE DOCUMENT
18.
Audit against the standards in the policies provided should form part of a
contractor’s routine clinical audit.
18.1.
Any areas of concern or non-compliance with the formulary identified by
routine analysis of prescribing data will be highlighted to the CCG Medicines
Optimisation Group and to the DorsetHealthCare Dietetic Service and will be
reviewed by the appropriate committee/group. Actions will be recorded in the
committee/group minutes.
19.
DOCUMENT REVIEW FREQUENCY AND VERSION CONTROL
20.
This Medicine Code chapter will be reviewed in line with updates published by
the working group that maintains the guidance. The next scheduled review is
due in March 2017.
20.1.
The guidelines will be updated prior to the next scheduled review date if further
evidence from the Map of Medicine group is published, to ensure that any local
guidelines are consistent with the work of the Wessex Allergy Network Group
21.
EQUALITY IMPACT ASSESSMENT
21.1.
An Equality Impact Assessment can be found in appendix I.
11
Cows Milk Protein Allergy (CMPA) Diagnosis and Management Pathway
Appendix A
Refer to Paediatrician
Suspicion of Non IgE mediated CMPA
Slower onset over 2 hours or longer
One or more of the following:
• Skin symptoms
• Gastro symptoms
• Respiratory symptoms
Appendix B
If exclusive breast feeding
Check feeding technique
Strict maternal milk free diet
for 2-4 weeks
Appendix C
Milk free weaning from 6months
Appendix D
Allergy focused
history
Appendix A
Suspicion of IgE mediated CMPA
Rapid onset within minutes to 2
hours
One or more of the following:
• Urticaria
• Wheeze
• Anaphylaxis
Appendix B
If formula feeding
Extensively hydrolysed
formula (EHF) for 2-4 weeks
Appendix E
Milk free weaning from 6
months
Appendix D
Poole Hospital NHS
Foundation Trust
01202 665511
Bleep 0155
If mixed breast and formula
Strict maternal milk free diet
Appendix C
Plus Extensively hydrolysed formula (EHF)
for 2-4 weeks Appendix E
Milk free weaning from 6 months
Appendix D
Improvement
If exclusive breast feeding
Reintroduce cow’s milk into
maternal diet Appendix F
If symptoms return this
confirms CMPA diagnosis
Restart maternal milk free diet
Appendix C
Milk free weaning from 6 months
Appendix D
For Urgent advice or
Rapid Access Clinic
Telephone –
No improvement
If formula feeding or mixed
feeding
Reintroduce cow’s milk formula
Appendix G
If symptoms return this
confirms CMPA diagnosis
Continue with EHF and/or restart
maternal milk free diet Appendix E
Milk free weaning from 6 months
Appendix D
12
Partial improvement
Telephone advice from
Paediatrician (see
above)
or Children's Dietitian
West Dorset 01305
255535
Poole 01202 442840
Dorset County
Hospital
NHS Foundation Trust
01305 251150
Bleep 353
Eliminate soya as well for 2-4 weeks
Appendix H
Still no improvement
CMPA less likely
Gradual return to
normal diet
Refer to Paediatrician if
symptoms persist
Appendix A
Cows Milk Protein Reintroduction Pathway
NB Seek specialist advice first if initial presenting symptoms were severe/acute onset
Seek specialist advice from
Paediatrician
At around 12 months of age or 6 months after diagnosis
Attempt a planned reintroduction of Cows milk
If breastfeeding
Reintroduce cows milk in to
maternal diet
Appendix F
Poole Hospital NHS
Foundation Trust
01202 665511
Bleep 0155
If mixed feeding
Reintroduce milk in to the
infants diet
Appendix G
Dorset County Hospital
NHS Foundation Trust
01305 251150
Bleep 353
Children's Dietitian
West Dorset 01305 255535
No change
Return to normal
diet
Return of symptoms
Return to milk free diet and
repeat reintroduction of Cows
milk in a further 6 months time
13
If symptoms of eczema persist, seek
advice from Dermatology service or
Paediatrician
Appendix B – Initial Assessment for possible Cow’s Milk Protein Allergy (CMPA)
Name:………………………………………
Date of Birth: …………………………..
NHS No.:…………………………………
Assessor:…………………………………
This form has been designed for use by health visiting teams to assist in the assessment of
infants with symptoms that may be those of CMPA. Although these symptoms can be applied
to many allergic reactions, this checklist should guide the user on specific CMPA symptoms to
look for and the action required for correct early identification. NB – if there is any family
history of atopy (eg hayfever, eczema, asthma, food allergy) this may increase the chance of
the presenting symptoms being related to CMPA.
Instructions for use
 Refer to signs and symptoms of possible food allergy in Appendix B
 Use the guide below to assess symptoms and assist you to take appropriate action
 Record your findings on the form including type and period of onset of symptoms
 File the form in the patient’s HV records and use it to compare symptoms and
presentation at follow up appointments
URGENT REFERRAL TO EMERGENCY CARE if any of these rapid onset symptoms are
described (within minutes to 2 hours - suspect IgE mediated)
□ Anaphylaxis (shock/collapse/breathing difficulty)
□ Angioedema (swelling especially around lips, face and eyes)
□ Wheeze or shortness of breath (rapid onset)
URGENT REFERRAL TO Paediatrician or Rapid Access Clinic via GP if any of these
rapid onset symptoms are described (within minutes to 2 hours - suspect IgE mediated)
□ Skin symptoms -rapid onset erythema, pruritis, urticaria
□ GI symptoms –rapid onset vomiting/diarrhoea with blood and/or mucus in stools
Consider diagnosis of CMPA and assess symptoms further if any of these slower onset
symptoms are described (more than 2 hours - non IgE mediated symptoms)
□ Skin symptoms (describe type of reaction, any known or suspected triggers)
………………………………………………………………………………………….…………………
………………………………………………………………………………………….…………………
□ GI Symptoms (describe frequency/colour of stools, perianal soreness, colic, reflux)
………………………………………………………………………………………….…………………
………………………………………………………………………
□ Respiratory/Other e.g. growth issues (describe symptoms of pallor/ tiredness, runny nose)
………………………………………………………………………………………….……………
…………………………………………………………………………………………………………
……….
Date of Assessment:………………………Date of next review: ……………………….
14
Appendix B – Initial Assessment for possible Cow’s Milk Protein Allergy (CMPA)
Signs and Symptoms of possible food allergy
Non – IgE-mediated
Slower onset – more than 2 hours
IgE-mediated
Rapid onset – within minutes to 2 hours
The Skin



Pruritus
Erythema
Atopic eczema




Pruritus
Erythema
Acute urticaria (localised or generalised)
Acute angioedema (most commonly in
the lips and face, and around the eyes






Angioedema of the lips, tongue/palate
Oral pruritus
Nausea
Colicky abdominal pain
Vomiting
Diarrhoea
The gastrointestinal system










Gastro-oesophageal reflux disease
Loose or frequent stools
Blood and/or mucus in stools
Abdominal pain
Infantile colic
Food refusal or aversion
Constipation
Perianal redness
Pallor and tiredness
Faltering growth plus one or more
gastrointestinal symptoms above
(with or without significant atopic
eczema)
The respiratory system
(usually in combination with one or more of the above symptoms and signs)

Upper respiratory tract symptoms – nasal
itching, sneezing, rhinorrhoea or
congestion (with or without conjunctivitis)

Lower respiratory tract symptoms (cough,
chest tightness, wheezing or shortness of
breath
Other
Signs and symptoms of anaphylaxis or other
systematic allergic reactions
Note: this list is not exhaustive – the absence of these symptoms does not exclude
food allergy.
Reference: NICE Guideline CG116 Food allergy in children and young people 2011
15
Appendix C – Milk free diet for breastfeeding
Patient Information Sheet
Following a Milk Free Diet
when you are Breastfeeding
Name: _______________________ Date: ________
Breastfeeding provides the best source of nutrition for babies. It is suitable for most
babies with cow’s milk protein allergy. Occasionally breast fed babies can react to
cow’s milk proteins in breast milk from the mother’s diet – if that is the case you may
be advised to avoid milk and dairy products whilst you are breastfeeding. This may
only be for a short period of time or may be for a few months. Breastfeeding technique
should be checked first with your Health Visitor or Breastfeeding Counsellor as
sometimes a change in positioning can improve feeding and reduce some symptoms.
Which Milk Should You Exclude?
Cow’s milk and cow's milk products including dried milk. The diet should be
free of cow’s milk protein (casein and whey) and milk sugar (lactose).
Goat's, sheep and other mammalian milks are not recommended as they
contain a protein very similar to that found in cow's milk.
Replacing Cow's Milk
Milk is an important source of nutrition for breastfeeding mothers. When milk is
excluded from the diet, it is vital to replace it with a nutritionally complete alternative.
Try a soya alternative to milk:
 Supermarket own brand
 Alpro soya
 Plamil
 So Good
Other milk alternatives which could be suitable include those made from:
 Almonds
 Coconut
 Hazelnuts
 Hemp
 Oats
 Pea and other pea products
Always choose a milk alternative that is fortified or enriched with calcium – they
should provide at least 120mg of calcium /100mls. Organic versions do not
usually have calcium added.
16
Appendix C – Milk free diet for breastfeeding
Which Foods should you avoid?
Some of these foods are obvious, such as milk, cheese, cream, yoghurt and butter.
However, many other foods may contain cow's milk and these should be avoided too.
Look for the list of ingredients printed on the package and avoid foods containing -.













all types of milk, including fresh, dried, UHT, condensed and evaporated
cheese
cream, ice cream, crème fraiche
yoghurt, fromage frais
butter/margarine/ghee
buttermilk
lactose/milk sugar
milk powder/skimmed milk powder/non fat milk solids
milk protein/milk solids
whey/whey syrup sweetener
shortening containing whey
casein/caseinate/hydrolysed casein
lactalbumin/lactoglobulin
Milk Free Foods
Foods to avoid
or check the ingredients
Fats
Milk free margarines e.g. Pure,
Dairy free Tomor, Vitalite. Pure
vegetable fats such as vegetable
oil, sunflower oil and olive oil, lard,
cocoa butter
Butter, ordinary margarine,
low fat spread
Eggs and
Dairy Products
Eggs. Soya cheese, soya yoghurt,
soya desserts, soya cream, soya
ice cream. Milk substitutes.
Oat cream e.g. Oatly. Coconut
cream
Milk, cheese including
vegetarian cheese, yoghurt,
fromage frais, crème
fraiche, cream
Meat &
alternatives
All fresh and frozen beef, lamb,
pork, ham, bacon, veal, rabbit.
Offal: liver, kidney
Poultry: chicken, turkey
Tofu, soya mince
Check the ingredients of
sausage, burgers, tinned
meats, meat pies and other
processed meats. Breaded
meats and quorn products.
Baked beans
Fish
Fresh and frozen fish without
coating or sauce
Avoid fish in white sauces
and fish fingers in batter.
Check ingredients of tinned
fish
Cereals
Wheat, rye, barley, oats, rice,
maize,flour, cornflour, macaroni,
spaghetti, dried pasta
Tinned spaghetti containing
cheese, macaroni cheese.
Fresh filled pasta
17
Appendix C – Milk free diet for breastfeeding
Milk Free Foods
Foods to avoid
or check the ingredients
Breakfast Cereals
Rice Krispies, Shredded Wheat,
Shreddies, All Bran, Weetabix,
Ready Brek, Porridge made with
milk alternative, Branflakes,
Frosties
Avoid Special K and Swiss
type cereals. Check
ingredients of muesli and
other cereals
Bakery
Produce
Wholemeal, Hovis Best of Both,
plain white, Granary, Vitbe breads.
Home-made bread, cakes, biscuits
and pastry made with milk free
margarine
Milk breads, cakes, biscuits,
pastries. Check labels as
some biscuits/hot cross
buns/teacakes are milk free
Puddings
Rice, semolina, sago, tapioca and
custard made using custard
powder and a suitable milk
alternative
Ice lollies, sorbet, jelly, soya
yoghurt, soya desserts, and soya
frozen desserts e.g. Swedish
glace, Tofutti, First Foods oat
based dairy free ice cream
Tinned milk puddings, Instant
Whip, Angel Delight, Yoghurts,
Ice-cream, including non- fat
dairy types. Ready-made
custard and Instant custard
Fruit &Vegetables
All types of fruit, fresh, dried, tinned
in juice or syrup. All vegetablesfresh, tinned or frozen without
added ingredients.
Avoid potato mashed with
milk or butter. Check
ingredients of vegetable and
potato salad, instant potato,
oven chips, frozen roast
potatoes, potato croquettes,
crisps and other savoury
snacks
Drinks
Tea, coffee, cocoa, , fruit juices,
fruit squash, fizzy drinks, Bovril,
Marmite
Avoid Horlicks, Ovaltine,
drinking chocolate, Milo and
instant hot chocolate drinks.
Check ingredients of soups
and avoid cream soups
Confectionery
Boiled sweets, fruit gums, fruit
pastilles, marshmallows. Dairy free
chocolate
Avoid fudge, toffee, milk &
white chocolate.
Check ingredients of
plain/after dinner mint
chocolate
OtherProducts
Sugar, jam, honey, syrup, Bisto,
Oxo, salt, pepper, herbs, spices,
essences, salad cream,
Avoid sugar substitutes
containing lactose e.g. Sweet
'n' Low, Canderel,
18
Appendix C – Milk free diet for breastfeeding
Milk Free Foods
Foods to avoid
or check the ingredients
mayonnaise, gravy, tomato
ketchup
monosodium glutamate
powder. Non-dairy creamers.
Light/low calorie salad cream
& mayonnaise
Please note this is not an exhaustive list and as ingredients can change, always check
the label.
If you are eating out, ask the restaurant before you order if you are unsure if meals will
be milk free. You can phone ahead and check before you visit to make sure there are
suitable dishes available for you.
Check with your pharmacist about tablets or medicines which may contain lactose.
Adapting Recipes?
Many ordinary recipes can be adapted by using your milk alternatives. Use a milk
free margarine instead of butter, a milk alternative in place of milk, and soya cheese
in place of ordinary cheese.
Ask for the leaflet ‘Adapting recipes’ for further information.
What About Calcium?
Calcium is needed for strong teeth and bones. Lack of calcium can increase risk of
osteoporosis (fragile bones) and fractures later in life. Calcium requirements while
breastfeeding are 1250mg per day.
1 pint of calcium fortified/enriched milk alternative will provide around 700mg calcium
per day. Even though you can include other calcium rich non-milk sources of foods in
your diet, most breastfeeding women on a milk free diet will need a calcium
supplement. You can use the ‘Sources of Calcium’ table to help you choose calcium
rich foods.
Vitamin D is needed by the body to absorb calcium and the best source is from the
action of sunlight on the skin. The Department of Health recommends that all
breastfeeding women should take a vitamin D supplement. Speak to your local
pharmacist about which supplements are suitable. Calcium and Vitamin D
supplements are available to purchase in pharmacies and supermarkets.
Sources of Calcium
Foods providing 250mg of Calcium
Sardines/pilchards-canned (including bones)
Soya cheese
Tofu
Calcium-enriched milk alternative
19
Portion Size
60g or half a tin
55g
50g
200mls
Appendix C – Milk free diet for breastfeeding
Calcium fortified orange juice
e.g. Tropicana Essentials - Calcium
Foods providing 150mg of Calcium
Curly Kale/spring greens
Tahini paste (sesame seed paste)
Anchovies
Fortified breakfast cereal
Soya yogurt/dessert
Foods providing 100mg of Calcium
Tinned salmon
Broccoli
Baked beans/kidney beans
Foods providing 50mg of Calcium
White bread
White flour products e.g. milk free hot cross
bun
Cabbage
Dried figs
Sesame seeds (1 tbsp)
Foods providing 25mg of Calcium
Dried apricots
Nuts e.g. brazil, almonds, walnuts
Chapatti x 1
Egg
Fish fingers x 2
Hummus
Dried fruit e.g. sultanas
Sunflower seeds (2 tbsp)
White fish poached in water
Wholemeal bread (2 x slices)
200mls
Portion Size
90g
20g (1 tsp)
60g or half a tin
35g
125ml pot
Portion Size
115g or half a tin
90g
200g or half a tin
Portion Size
60g (2 slices)
1
90g
20g or 1 dried
10g
Portion Size
50g or small handful
30g or small handful
55g
1 medium
56g
50g
50g or 2 tablespoons
25g
170g
60g
Contact Details
Dietitian__________________________________________________
Health Visitor _____________________________________________
Produced in Partnership with Dorset County Hospital NHS Foundation Trust, Dorset Healthcare
University NHS Foundation Trust & Poole Hospital NHS Foundation Trust. March 2014
20
Appendix D – Weaning onto a milk free diet
Patient Information Sheet
Weaning onto a
Milk Free Diet
Name: _________________________Date: ____________
Why A Milk Free Diet?
Around 3% of children develop cow’s milk protein allergy. In most cases a strict cow’s
milk free diet is needed to treat the allergy. This information will help you avoid cow’s
milk whilst making sure your child gets all the nutrition they need to grow and develop
well. Cow’s milk protein allergy may cause a variety of symptoms. It can take longer
for children to recover, but many ‘grow out’ of cow’s milk protein allergy. Reviews with
your health care professional can guide you on how long your child needs to continue
avoiding cow’s milk in the diet.
Which Milk And Cow’s Milk Products Should Be Excluded?
Cow's milk including dried milk. The diet should be free of cow’s milk protein
(casein and whey) and milk sugar (lactose).
Goat's, sheep and other mammalian milks are not recommended as they
contain lactose and a protein very similar to that found in cow's milk.
Replacing Cow's Milk
Milk is an important source of nutrition for babies and children. If infants are
breastfeeding they can continue to do so alongside weaning onto cow’s milk protein
free solid. If a child is not breastfeeding but taking an infant formula it is vital to
replace the formula with a nutritionally complete alternative.
Soya Alternative to Dairy Milk
For children over 6 month’s of age soya based infant formulas are available to buy
from pharmacies and larger supermarkets. Examples include: Infasoy (Cow & Gate)
 Wysoy (SMA)
For older infants, soya alternatives to milk that are fortified with calcium are available
to buy from most supermarkets. They can be used in cooking from six months of age
or as a main drink after one year old. Examples include: Supermarket own brands
 Granose
21
Appendix D – Weaning onto a milk free diet




Alpro soya
Alpro 1+
Plamil
So Good
Other Alternatives
Other milk alternatives which could be suitable include those made from:
 Almonds
 Coconut
 Hazelnut s
 Hemp
 Oats
 Pea and other pea products
Please check with your Dietitian before using any milk alternative as some may not be
suitable for other allergies and some may be low in calories, protein, calcium and/or
other vitamins and minerals. Rice milk should NOT be given to children under 5
years old.
Always choose a milk alternative that is fortified or enriched with calcium – they
should provide at least 120mg of calcium /100mls. Organic versions do not
usually have calcium added.
Prescribed Milk Alternatives
Alternatively your child may have been prescribed an Extensively Hydrolysed Formula
such as Nutramigen Lipil, Alimentum, Pepti-Junior, Aptamil Pepti or Neocate LCP.
They should continue on this until advised otherwise by your health care professional.
Most infants aged 6-12 months need approximately 600ml (20oz) each day to ensure
they are meeting their nutritional needs. Over 1 year this amount reduces to around
350ml (12oz). These amounts do vary according to the child and their diet. Check
with your Doctor, Health Visitor or Dietitian if you have concerns about their calcium
needs.
Which Foods Should You Avoid
Some of these foods are obvious, such as milk, cheese, cream, yoghurt and butter.
However, many other foods may contain cow’s milk and these should be avoided too.
Look for the list of ingredients printed on the package and avoid foods which contain 







all types of milk, including fresh, dried, UHT, condensed and evaporated
cheese
cream, ice cream
yoghurt, fromage frais
butter/margarine/ghee
buttermilk
lactose/milk sugar
milk powder/skimmed milk powder/non fat milk solids
22
Appendix D – Weaning onto a milk free diet





milk protein/milk solids
whey/whey syrup sweetener
shortening containing whey
casein/caseinate/hydrolysed casein
lactalbumin/lactoglobulin
Milk Free Foods
Foods to avoid
or check the ingredients
Fats
Milk free margarines e.g. Pure,
Dairy free Tomor, Vitalite. Pure
vegetable fats such as
vegetable oil, sunflower oil and
olive oil, lard, cocoa butter
Butter, ordinary margarine,
low fat spread
Eggs and
Dairy Products
Eggs. Soya cheese, soya
yoghurt, soya desserts, soya
cream, soya ice cream. Milk
substitutes.
Oat cream e.g. Oatly. Coconut
cream
Milk, cheese including
vegetarian cheese, yoghurt,
fromage frais, crème
fraiche, cream
All fresh and frozen beef, lamb,
pork, ham, bacon, veal, rabbit.
Offal: liver, kidney
Poultry: chicken, turkey.
Tofu, soya mince
Check the ingredients of
sausages, burgers, tinned
meats, meat pies and other
processed meats. Breaded
meats, Quorn products,
baked beans
Fish
Fresh and frozen fish without
coating or sauce
Avoid fish in white sauces
and fish fingers in batter.
Check ingredients of tinned
fish
Cereals
Wheat, rye, barley, oats, rice,
maize, flour, cornflour,
macaroni, spaghetti, dried
pasta
Tinned spaghetti containing
cheese, macaroni cheese.
Check ingredients of fresh
filled pasta
Breakfast
Cereals
Rice Krispies, Shredded Wheat,
Shreddies, All Bran, Weetabix,
Ready Brek, Porridge made
with milk alternative,
Branflakes, Frosties
Avoid Special K and Swiss
type cereals. Check
ingredients of muesli and
other cereals
Bakery
Produce
Wholemeal, Hovis Best of Both,
plain white, Granary, Vitbe
breads. Home-made bread,
cakes, biscuits and pastry made
Milk breads, cakes, biscuits,
pastries. Check labels as
some biscuits/hot cross
buns/teacakes are milk free.
Meat &
Alternatives
23
Appendix D – Weaning onto a milk free diet
with milk free margarine
Puddings
Rice, semolina, sago, tapioca
and custard made using custard
powder and a suitable milk
alternative.
Ice lollies, sorbet, jelly, soya
yoghurt, soya desserts, and soya
frozen desserts e.g. Swedish
glace, Tofutti, First Foods oat
based dairy free ice cream
Tinned milk puddings,
Instant Whip, Angel Delight,
Yoghurts, Ice-cream,
including non- fat dairy
types. Ready-made custard
and Instant custard
Fruit &
Vegetables
All types of fruit - fresh, dried,
tinned in juice or syrup. All
vegetables - fresh, tinned or
frozen without added ingredients
Avoid potato mashed with
milk or butter. Check
ingredients of vegetable and
potato salad, instant potato,
oven chips, potato
croquettes, crisps and other
savoury snacks
Drinks
Tea, coffee, cocoa, , fruit juices,
fruit squash, fizzy drinks, Bovril,
Marmite
Avoid Horlicks, Ovaltine,
drinking chocolate, Milo and
instant hot chocolate drinks.
Check ingredients of soups
and avoid cream soups.
Confectionery
Boiled sweets, fruit gums, fruit
pastilles, marshmallows. Dairy
free chocolate
Avoid fudge, toffee, milk &
white chocolate.
Check ingredients of
plain/after dinner mint
chocolate
Baby foods
Some brands of baby rice and
rusks are milk free but this does
change – check labels
Avoid Robinsons Baby
Rice, Milupa Breakfast
Cereals, Boots Baby
Cereals. Check ingredients
of other baby foods
Other
Products
Sugar, jam, honey, syrup, Bisto,
Oxo, salt, pepper, herbs, spices,
essences, salad cream,
mayonnaise, gravy, tomato
ketchup
Avoid sugar substitutes
containing lactose e.g.
Sweet 'n' Low, Canderel,
monosodium glutamate
powder. Light/low calorie
salad cream/mayonnaise
Please note this is not an exhaustive list and as ingredients can change, always check
the label.
24
Appendix D – Weaning onto a milk free diet
If you are eating out, ask the restaurant before you order if you are unsure if meals will
be milk free. You can phone ahead and check before you visit to make sure there are
suitable dishes available for you.
Check with your pharmacist about tablets or medicines which may contain lactose.
Weaning
Weaning a baby who has cow’s milk protein allergy should be the same as weaning a
non-allergic baby, except that you must not give any foods that contain cow’s milk or
dairy products (e.g. yoghurt, fromage frais, cheese, cream or butter – see list). Aim to
start giving solid foods around six months but not before four months (17 weeks).
Begin weaning with low allergenic foods such as pureed rice, potatoes, root and green
vegetables and fruit. Use a little of your baby’s usual milk (breast or hypoallergenic
formula) to mix the food to the desired consistency. Introduce new allergenic foods
such as egg and fish one at a time. Allergenic foods should be given for 3 days to
ensure adequate exposure and leave a couple of days between new foods to be able
to ascertain if there is any reaction. Keeping a food diary can be useful.
First foods include:



soft fruits and cooked vegetables (e.g. cooked apple or pear, avocado, banana,
carrot, parsnip, sweet potato or yam)
milk free baby cereals made with your child’s milk alternative (e.g. baby rice, baby
porridge. Please note some of these products may contain milk so carefully check
the ingredients list on the label)
pureed or mashed up meat, chicken or lentils
As your baby progresses with weaning, food can become more ‘chopped’ in texture.
Stage Two is mashed with soft lumps and soft finger foods. Stage Three is minced or
chopped family foods and hard finger foods. Eventually your baby will be managing
family meals.
Suggested meal plan Breakfast
 milk free breakfast cereal or porridge with milk alternative and fruit puree or
mashed banana
 toast *fingers with milk free margarine
Snacks and Finger foods
 small pieces of soft, ripe fruit (e.g. banana, peach, mango, melon)
 dried apricots or raisins
 raw vegetable sticks (e.g. cucumber sticks, peppers)
 lightly cooked vegetable pieces (e.g. broccoli & cauliflower florets, carrot, parsnip
& courgette sticks, green beans)
 dairy free cheese slices or cubes
25
Appendix D – Weaning onto a milk free diet



bread sticks* or rice cakes* with hummus, mashed avocado or dairy free cheese
spread
sandwiches with ham/chicken/tuna/egg mayonnaise*/dairy free cheese, cucumber
slices and milk free margarine
toast* with baked beans* and well-cooked scrambled egg (made with milk
alternative) and milk free margarine
Main Meals
 minced or finely chopped meat or flaked fish or tofu served with;
o pasta in a roasted vegetable and tomato based sauce or a milk free white
sauce (see recipe). Grated dairy free cheese could be added to the sauce.
Alternatively, a soya cheese spread could be added to cooked pasta to
make a sauce
o mashed potatoes/chopped roast or new potatoes, mashed/chopped
vegetables
 flaked fish poached in a milk alternative, mashed potato and vegetables
 mashed, cooked lentils/dhal, chickpeas or other pulses with well-cooked boiled
rice
Puddings
 soft ripe or dried fruit
 dairy free desserts/dairy free ice cream or sorbet with fruit
 rice pudding, semolina or custard (powder not instant) made with milk alternative
 milk jelly or egg custard made with milk alternative
 fruit crumble made with milk free margarine
Remember to carefully read the label of ready-made dishes/ foods to check that
they are milk free, especially those marked with a *. Ingredients do change so it
is important to always check the label.
Adapting Recipes?
Many ordinary recipes can be adapted by using your milk alternative. Use a milk free
margarine instead of butter, milk alternatives in place of milk, and soya cheese in
place of ordinary cheese. Try making up batches of milk free meals/puddings and
freezing them in ice-cube trays to allow you to serve small portions with less waste.
Ask for ‘Adapting recipes’ leaflet for further ideas.
What about Calcium?
Calcium is needed for strong teeth and bones. Lack of calcium can increase risk of
osteoporosis (fragile bones) and fractures later in life. Calcium requirements for
infants under 1 year old is 525mg/day and for 1-3 year olds is 350mg/day.
Most babies aged 6-12 months need approximately 600ml (20oz) of milk alternative
each day to ensure they are meeting their nutritional needs. Over 1 year of age this
amount reduces to around 350ml (12oz). These amounts do vary according to the
child and their diet. Check with your Doctor, Health Visitor or Dietitian if you have
concerns about their calcium needs.
26
Appendix D – Weaning onto a milk free diet
Use the ‘Sources of Calcium’ table to help you choose calcium rich weaning foods.
Please note the portion sizes listed in the table are based on adult portions, so you
will need to adapt the portion size accordingly.
Vitamin D is needed by the body to absorb calcium and the best source is from the
action of sunlight on the skin.
The Department of Health recommend that a supplement containing vitamin A, C and
D should be given to all children aged six months to five years. This is a precaution
because growing children may not get enough of these vitamins, especially those not
eating a varied diet, such as fussy eaters. Supplements are available to purchase in
pharmacies and supermarkets, or may be available on prescription. Ask your Health
Visitor for advice.
Sources of Calcium
Foods providing 250mg of Calcium
Sardines/pilchards - canned (including bones)
Soya cheese
Tofu
Calcium-enriched milk alternative
Calcium fortified orange juice
e.g. Tropicana Essentials - Calcium
Foods providing 150mg of Calcium
Curly Kale/spring greens
Tahini paste (sesame seed paste)
Fortified breakfast cereal
Soya yogurt/dessert
Foods providing 100mg of Calcium
Tinned salmon
Broccoli
Baked beans/kidney beans
Foods providing 50mg of Calcium
White bread
White flour products e.g. milk free hot cross
bun
Cabbage
Dried figs
Foods providing 25mg of Calcium
Dried apricots
Chapatti x 1
Egg
Fish fingers x 2
Hummus
Dried fruit e.g. sultanas
White fish poached in water
Wholemeal bread (2 x slices)
27
Portion Size
60g or half a tin
55g
50g
200mls
200mls
Portion Size
90g
20g (1 tsp)
35g
125ml pot
Portion Size
115g or half a tin
90g
200g or half a tin
Portion Size
60g (2 slices)
1
90g
20g or 1 dried
Portion Size
50g or small handful
55g
1 medium
56g
50g
50g or 2 tablespoons
170g
60g
Appendix D – Weaning onto a milk free diet
Contact Details
Dietitian__________________________________________________
Health Visitor _____________________________________________
Produced in Partnership with Dorset County Hospital NHS Foundation Trust, Dorset Healthcare
University NHS Foundation Trust & Poole Hospital NHS Foundation Trust. March 2014
28
Appendix D – Weaning onto a milk free diet
Adapting Recipes for a Cow’s Milk Protein free diet
Many items that usually contain cows’ milk protein can be adapted by using a suitable
milk alternative and a dairy free margarine. Then all the family can eat the same
meals.
Helpful hints
Use a calcium fortified milk alternative (e.g. soya, oat, coconut) to make sauces,
pancakes, batter and desserts. Do not use rice milk for children Under 5 years old.
 Allow hot drinks to cool a little before adding soya milk as it may curdle.

Grate soya hard cheeses on the fine part of the grater if they are not melting very
well.

Use plain dairy free yogurts or coconut milk alternative to make curries, raita,
stroganoffs, creamy sauces and dips.

Try Soyatoo™ whipping cream (spraycan), or Oatly cream as an alternative to
cream.

Use a dairy free melting cheese (Cheezly super-melting mozzarella™) on pizza,
cheese on toast and on lasagne.

Use a hard dairy free cheese (Sheese™) to make cheese sauces. Grate on the
fine part of the grater so that it melts more easily. Using a microwave will save it
sticking to the bottom of the saucepan (which also works for dairy free custard &
porridge).

Use dairy free cream cheese/sour cream or dairy free plain yogurt in dips,
cheesecakes, quiches and savoury and sweet sauces.
Recipes
Savoury
Desserts
Snacks
Basic White sauce
Custard
Sponge cake
Fish pie
Rice pudding
Cherry muffins
Shepherd’s Pie
Pancakes
Flapjacks
Ice cream
Ginger biscuits
Appendix D – Weaning onto a milk free diet
Basic White Sauce
Ingredients:
20g (¾oz, 1tbsp) dairy free margarine
20g (¾oz, 1tbsp) plain flour or corn flour
300ml (½pint) milk alternative
Salt and pepper to taste
Hob Method:
Place all ingredients in a pan and heat gently, whisking continuously until the sauce
thickens.
Microwave Method:
Place all ingredients in a bowl. Whisk to remove lumps. Microwave it for 30 seconds
and then whisk. Repeat this until it makes a smooth sauce. Flavour with cooked
mushrooms, vegetables or parsley.
Fish Pie
(For family of four)
Ingredients:
300 g (12oz) fillet of haddock or cod
300g (12oz) potatoes
1 hard boiled egg
2 tomatoes
50ml (2 fl oz) milk alternative
15 g (1/2 oz) milk free spread
300ml parsley sauce (use white sauce recipe and add 2 tbsp parsley)
Oven temperature: 350°F / 180°C / Gas Mark 4
Method:
Bake fish for 20 minutes. Boil potatoes and make parsley sauce . Flake coked fish
and add to sauce, season and place in ovenproof casserole dish. Skin and slice
tomatoes, slice hard boiled egg and place on top of fish. Cream potatoes with milk free
spread and alternative milk, season and place on top of fish mixture. Bake in the oven
for 20 minutes.
Appendix D – Weaning onto a milk free diet
Shepherd’s Pie
(for family of four)
Ingredients:
450g minced lamb
1 large onion
½ courgette
4 medium mushrooms
Tin of chopped tomatoes
2 tbsp tomato puree
Beef stock cube (milk free)
1 garlic clove
2 large potatoes
1 desertspoon milk free spread
1 tbsp milk alternative
Method:
Fry the mince in the frying or saucepan with oil if needed. When brown, drain off
excess fat. Add chopped onion and garlic, cook for 2 minutes then add chopped
courgette and mushrooms. Cook for 5 minutes. Add chopped tomatoes, tomato puree,
season with salt and pepper. Mix well. Leave to simmer for 20 minutes. Meanwhile
peel, slice and boil the potatoes for 15 minutes. Once cooked mash with milk
alternative and milk free spread. Place meat sauce in an ovenproof dish and spread
the mashed potato on top. Cook in the oven at 350°F / 180°C / Gas Mark 4 for 10
minutes.
Custard (Hob or microwave)
Ingredients:
150ml (¼pint) milk alternative
15g (½oz, ½tbsp) milk free custard powder
Method:
Mix the custard powder with 2 tablespoons of the milk alternative. Gently warm the
remaining milk alternative on the hob or in the microwave until almost boiling. Remove
from the hob/ microwave and pour over the custard paste, stirring continuously. Return
to the hob/ microwave and heat for 2-3 minutes stirring regularly.
Rice Pudding
Ingredients:
50g (2oz) pudding rice
600ml (1 pint) milk alternative
25g (1oz) caster sugar
Appendix D – Weaning onto a milk free diet
Method:
Put rice and milk into a pan. Heat gently for 2 hours, stirring occasionally. Add sugar
and serve.
Or, put rice, milk and sugar into a greased ovenproof dish and bake in an oven at
150ºC (300ºF, gas mark 2) for 2 hours, stirring occasionally.
Pancakes
Ingredients:
300ml milk alternative
1 egg
125 g plain flour
4tsp sunflower oil
Method:
Sieve the flour, make a well and crack the egg into it. Mix together and gradually add
the milk alternative until smooth.
Heat the oil in a non-stick frying pan, add a ladle of mixture, tip the pan so its just
enough to cover the base, cook for 30 seconds. Use a spatula to flip the pancake over
and cook for another 30 seconds. Repeat until used up the batter. Serve with sugar
and lemon juice.
Easy Ice Cream
Use soya ready-made custard (e.g. Alpro™, Provamel™), put in ice-cream machine
(according to volume specified by the manufacturer) and select the standard ice cream
setting. Alternatively, put the custard in the freezer and stir or whisk once an hour until
almost frozen.
Sponge Cake
Ingredients:
120g (4oz) dairy free margarine
120g (4oz) caster sugar
120g (4oz) plain sifted flour
1 teaspoon baking powder
2 eggs
Method:
Blend the margarine and sugar together until light and fluffy. Beat in the eggs slowly.
Stir in the flour and baking powder, place in a greased and floured 18cm/7inch cake
tin and bake at 180ºC (360ºF, gas mark 4) for 30 –40 minutes.
Adaption for chocolate cake - replace 2 dessertspoons of flour with cocoa (milk free).
Appendix D – Weaning onto a milk free diet
Muffins – orange & cherry
Ingredients:
1 orange
125ml (4 fl oz) orange juice
1 egg
185 g (6 oz) plain flour
170 g castor sugar
125 g milk free spread
1 tsp bicarbonate of soda
1 tsp baking powder
¼ tsp salt
125 g cherries (washed)
Preheat oven to 220°C (400°F, gas mark 6)
Method:
Peel rind from orange, remove all pith, cut rind into small pieces. Remove membrane
and seeds from orange and cut into small segments.
In a food processor, place orange rind, segments and orange juice, milk free spread
and egg and process until combined and mixture has curdled. Transfer into a large
bowl. Sift in flour, bicarbonate of soda, baking powder and salt and mix lightly to
combine. Batter should be lumpy. Fold in cherries. Divide batter between 12-16
greased muffin tins or cases, filling two thirds full. Bake for 18-20 minutes and cool on
a wire rack.
Flapjacks
Ingredients:
100 g (4oz) milk free margarine
200g (8oz) rolled oats
4 level tbsp golden syrup
Pinch of salt
75g (3oz) granulated sugar
Oven temperature: 335°F / 170°C / Gas mark 3
Method:
Grease a square shallow tin (approx 18cm/7inch)
Melt margarine and syrup in a pan over a gentle heat
Remove from heat; add sugar, oats and salt
Mix thoroughly, turn into prepared tin
Bake for 30-40 mins until golden brown
Leave to cool in the tin for 5 minutes then cut into bars and cool on a wire rack.
Appendix D – Weaning onto a milk free diet
Ginger biscuits
Ingredients:
75 g (3oz) golden syrup
150 g (6oz) self raising flour
100g (4 oz) milk free margarine
10ml (2 level tsp) ground ginger
75 g (3 oz) caster sugar
Large pinch of bicarbonate of soda
Oven temperature: 375°F / 190°C / Gas Mark 5
Method:
Grease two baking sheets
Sieve flour, ginger and bicarbonate of soda into a bowl
Melt syrup, margarine and sugar in a pan
Stir and leave to cool for 5 minutes
Form into balls, place on baking sheet and flatten slightly
Bake for 10 minutes. Transfer to wire rack to cool whilst still warm.
Some recipes taken from ‘Cow’s milk free diet for infants and children’ Produced by FAISG of
the BDA (2012)
Contact Details
Dietitian__________________________________________________
Health Visitor _____________________________________________
Produced in Partnership with Dorset County Hospital NHS Foundation Trust, Dorset Healthcare
University NHS Foundation Trust & Poole Hospital NHS Foundation Trust. March 2014
Appendix E – Guidelines for indications for using specialised infant formula for infants aged 0-6 months
Extensively hydrolysed formula
Feed
Manufacturer Type of formula
Clinical Indication for use
Additional ACBS
Indications
Nutramigen Lipil 1
400g
First Line Choice
Mead
Johnson
Extensively hydrolysed formula
(EHF), lactose free
Cow’s milk protein allergy
Galactosaemia
Lactose and / or whole protein
intolerance where additional MCT
not needed
Alimentum
400g
Abbott
Extensively hydrolysed formula
(EHF), Clinically lactose free
Cow’s milk allergy and
conditions requiring an EHF
Pepti Junior
450g
Cow & Gate
Extensively hydrolysed formula
(EHF), with 50% MCT fat, lactose
free
Cow’s milk protein allergy.
Malabsorption conditions
including fat and disaccharide
intolerance
Lactose / whole protein intolerance
or where amino acid peptides are
indicated in conjunction with MCT
Aptamil Pepti 1
400g or 900g
Milupa
Extensively hydrolysed formula
(EHF). Residual lactose
Cow’s milk protein allergy
Established cow’s milk protein
intolerance
Amino acid based formula
Feed
Manufacturer Type of formula
Clinical Indication for use
Additional ACBS
Indications
Neocate LCP
400g
On advice of
Dietitian or
Hospital Specialist
SHS
Amino acid based
Cow’s milk protein allergy
Severe malabsorption
If EHF not tolerated
Cow’s milk protein allergy
Multiple food protein intolerance
Conditions requiring an elemental
diet
Amino acid based
Cow’s milk protein allergy
Severe malabsorption
Cow’s milk protein allergy
Multiple food protein intolerance
Conditions requiring an elemental
diet
Nutramigen AA
Mead
Johnson
400g
Please check name
carefully as similar
named products
35
Appendix E – Guidelines for indications for using specialised infant formula for infants aged 0-6 months
Colour Code Guide
Green products = can be prescribed by
hospital doctor, GP or other person with
extended prescribing
Amber Products = Started by Dietitian or hospital Red products =
specialist and continued by Primary Care with request Acute Trusts
from a Paediatrician or Dietitian for GP to prescribe.
only
NB Please remember to write ACBS on prescription. This product list is not exhaustive – see BNF for further information.
36
Appendix E - Guidelines for indications for using specialised infant formula for infants aged over 6 months
Soya formula (available to buy over the counter) could be considered for infants over 6 months who are presenting with
symptoms.
Additional ACBS
Indications
Feed
Manufacturer
Type of formula
Clinical Indication for use
Infasoy
900g
Cow & Gate
Soya based (whole protein)
lactose free
Simple cow’s milk protein
allergy. Galactosaemia
Wysoy
430g or 860g
Wyeth
Soya based (whole protein)
Lactose free
Simple cow’s milk protein
allergy. Galactosaemia
Manufacturer
Type of formula
Clinical Indication for use
Additional ACBS
Indications
Nutramigen Lipil 2
400g
First line choice
Mead Johnson
Extensively hydrolysed
protein
Lactose free
Cow’s milk protein allergy, with
or without secondary lactose
intolerance
Galactosaemia
Established lactose and / or
whole protein intolerance
(where MCT not indicated)
Alimentum
400g
Abbott
Extensively hydrolysed
formula (EHF)
Clinically lactose free
Cow’s milk allergy and
conditions requiring an EHF
Aptamil Pepti 2
900g
Cow & Gate
Extensively hydrolysed
Residual lactose
Cow’s milk protein allergy
Established cow’s milk
protein intolerance
Cow & Gate
Extensively hydrolysed
protein, with 50% MCT fat
Lactose free
Cow’s milk protein allergy.
Malabsorption conditions
including fat and disaccharide
intolerance
Lactose / whole protein
intolerance or where amino
acid peptides are indicated
in conjunction with MCT
Extensively hydrolysed formula
Feed
Pepti Junior
450g
37
Appendix E - Guidelines for indications for using specialised infant formula for infants aged over 6 months
Amino acid based formula
Feed
Manufacturer
Type of formula
Clinical Indication for use
Additional ACBS
Indications
Neocate LCP
400g
On advice of
Dietitian or Hospital
Specialist
SHS
Amino acid based
Cow’s milk protein allergy
Severe malabsorption
If EHF not tolerated
Cow’s milk protein allergy
Multiple food protein
intolerance
Conditions requiring an
elemental diet
Nutramigen AA
400g
Please check name
carefully as similar
named products
Mead Johnson
Amino acid based
Cow’s milk protein allergy
Severe malabsorption
Cow’s milk protein allergy
Multiple food protein
intolerance
Conditions requiring an
elemental diet
Colour Code Guide
Green products = can be
prescribed by hospital doctor, GP
or other person with extended
prescribing
Amber Products = Started by Dietitian or hospital Red products =
specialist and continued by Primary Care with Acute Trusts only
request from a Paediatrician or Dietitian for GP to
prescribe.
NB Please remember to write ACBS on prescription. This product list is not exhaustive - see BNF for further information
38
Appendix F – Milk reintroduction for breastfeeding mothers
Milk Reintroduction Details
For Mothers Breastfeeding a child with a Milk Allergy
It is important to reintroduce cow’s milk back into your diet to confirm that the problem
is definitely due to cow’s milk protein allergy and not a coincidence with anything else,
such as an illness. You should only follow a milk free diet if absolutely necessary and
reintroduction is one way to check this.
Reintroducing milk
Start to reintroduce milk containing foods then cow’s milk gradually back into your diet
over a one week period.
If your baby’s symptoms don’t return then he/she doesn’t have cow’s milk protein
allergy and you can continue to have cow’s milk and milk containing products in your
diet.
If your baby’s symptoms return then it is likely that they have cow’s milk protein allergy
and you should remove all cow’s milk and milk containing products from your diet. Talk
to your Health Visitor about the next steps to take for the management of this for you
and your baby.
 Some children may be able to tolerate a certain amount of cow’s milk in their
mother’s diet e.g. mothers are able to include milk in foods, have ordinary
butter/margarine and cheese but their children react if they drink milk. If this is
the case it is sensible to include cow’s milk up to the amounts the baby can
tolerate as long as they remain symptom free. The amount of cow’s milk that
individuals can tolerate varies so you have to find the right amount that suits
you and your child.
 Remember to continue taking your calcium and vitamin D supplement.
Any questions? Give your Health Visitor team a call.
Health Visitor Contact Details ______________________________________
Produced in Partnership with Dorset County Hospital NHS Foundation Trust, Dorset Healthcare
University NHS Foundation Trust & Poole Hospital NHS Foundation Trust March 2014
39
Appendix G(i) – Milk reintroduction for babies under 6 months
Patient Information Sheet
Milk Reintroduction
For Infants under 6 Months of Age
This reintroduction plan is only for babies who have suspected non- IgE Cow’s Milk
Protein Allergy (CMPA), as per the CMPA pathway. Ask your Health Visitor if you are
unsure.
It is important to try and reintroduce cow’s milk into your child’s diet to confirm that the
problem is definitely due to cow’s milk protein allergy and not a coincidence with
anything else, such as an illness. It is important that infants only follow a milk free diet
if it is absolutely necessary and reintroduction is one way to check this.
Follow the steps below
1) Introduce 30mls (1oz) of standard infant formula into one of your baby’s
specialised formula feeds.
2) After 2-3 days introduce 30mls (1oz) of standard infant formula into each of
your baby’s specialised formula feeds.
3) After 2-3 days increase the volume of standard infant formula by 30mls (1oz) in
every feed.
4) Continue increasing the proportion of standard infant formula by 30mls (1oz) in
every feed every 2-3 days until all the milk is standard formula. This may take a
few weeks.
 If at any point your child’s symptoms return, this confirms the diagnosis of cow’s
milk protein allergy. Stop the test and resume a milk free diet. Try reintroducing milk again at around 12 months of age as many children grow out of
cow’s milk allergy. Ask your Health Visitor for advice on how to do this.
Any questions? Give your Health Visitor team a call.
Health Visitor Contact Details ______________________________________
Produced in Partnership with Dorset County Hospital NHS Foundation Trust, Dorset Healthcare
University NHS Foundation Trust & Poole Hospital NHS Foundation Trust. March 2014
40
Appendix G(ii) – Milk reintroduction for babies over 6 months
Patient Information
Introducing Milk Back Into Your Child’s Diet
The Milk Ladder
Parent Information:
Name:
Date:
An assessment of your child’s allergy, medical history and/or results indicate that it is time to
see if they have outgrown their food allergy. This can be done by adding milk into the diet
gradually at home. Milk is introduced into the diet by following a ‘milk ladder’ where each food
contains increasing levels of milk protein. It is important to start with well-cooked/processed
milk first before progressing to ‘raw’ dairy products. The milk ladder introduces milk back into
your child’s diet in a gradual way – try not to skip a step, it is better to take things slowly during
the reintroduction process than to rush.
Before you start you should check:
1) Is your child well?



Your child should be in good health, free of cold/coughs or any other illness. If
they are unwell, wait until they are better to do the challenge
If your child has asthma or eczema make sure their symptoms are well under
control
If in doubt, wait until you are sure your child is well
2) Is it the right time?
 If you are due to go on holiday or have another special event looming then you
should delay the challenge. This challenge is likely to take a minimum of 2-3
weeks
3) Does your child take antihistamines?
 Antihistamines (e.g. Piriton, Cetirizine) can mask reaction symptoms so your
child
should not be taking them during the challenge. If they use antihistamines, do
the challenge at a time of the year when they are least affected by seasonal
allergies
41
Appendix G(ii) – Milk reintroduction for babies over 6 months
If your child is well, the time is right and they are not taking routine antihistamines then you
can progress with the challenge.
Throughout the challenge it is useful to keep a record of the foods tried/the amounts eaten
and any reaction (including how long after the food was eaten did the reaction occur).
Milk Ladder Details
1) Start the challenge by testing some cow’s milk on your child’s skin (cheek or where
eczema may flare up). Wait a couple of hours, if no reaction (e.g. rash/itchy skin)
occurs progress to 2).
2) Now gradually start to introduce products that may have traces of milk in them into your
child’s diet. Each of the foods listed contain progressively more milk protein in them.
Try each food for a few days (up to a week) before moving onto the next food.
Start with 1 malted milk biscuit. Look out for a biscuit that contains milk powder rather
than whey powder. Then progress to ½ a digestive or garibaldi biscuit that contains
milk. After a few more days try a mini muffin or cupcake (30g) before moving onto one
scotch pancake. The scotch pancake should contain milk protein rather than whey
powder. (Scotch pancakes contain less milk than muffins/cupcakes but are cooked for
a much shorter time).
3) The next stage of the ladder is to try baked dishes such as shepherds pie or lasagne
(mash/white sauce made using cow’s milk – but no cheese). Try ½ a portion (100g) Try
this a few times before moving onto 4).
4) If your child continues to be symptom free then you can try the next few stages as
below, for each stage try for a few days over the course of a week before moving on.
Firstly introduce pizza that has a milk free base – check the ingredients or make your
own. You can use a milk free pitta bread or corn tortilla as a base. This introduces
cooked cheese. Start with ½ a mini pizza (or equivalent size) and progress up to one
mini pizza before moving onto stage 5).
An alternative to a mini pizza is to add 15g of grated hard cheese to a suitable dish
(shepherd’s pie, pasta dish – previously tolerated) and grill/bake for at least 10
minutes.
5) Now try a portion of 10g milk chocolate – this can be increased up to 35g before trying
stage 6).
6) If your child remains symptom free now try 1 pot of yoghurt (125ml).
7) This stage will test if your child can tolerate cheese that isn’t cooked. Introduce a
portion of cheese - 25g. Most hard cheeses contain 20-25% protein and can be used at
this point. Try cheddar as a first choice.
8) 100mls sterilised cow’s milk or infant formula (in tetra packs/cartons). This milk is ultra
heat treated for 30 minutes so is often tolerated at this point in the ladder
9) The final stage is to introduce 100mls pasteurised cow’s milk or infant formula
(powder).
42
Appendix G(ii) – Milk reintroduction for babies over 6 months
*Some children may be able to tolerate a certain amount of cow’s milk in their diet e.g. include
milk in foods, have ordinary butter/margarine and cheese but are unable to tolerate drinks of
milk. If they have more than the particular amount that they are able to tolerate then they may
develop symptoms (up to 48 hours later). If this is the case it is sensible to include cow’s milk
up to the certain amounts they can tolerate and remain symptom free.
* If at any time your child has a reaction then you should STOP THE TEST but re-try in 6
months.
Symptoms of a reaction are usually similar to the reaction your child first presented with.
These include:







Tingling, itching in mouth
Developing rash
Dry/red patches of skin appearing
Nausea/vomiting
Abdominal pain
Diarrhoea
Wheezing (give inhaler if available)
If any of these occur, give your child some antihistamine and monitor their condition.
Your child may feel quite nervous about trying this milk challenge, this is quite normal but you
can help them by allowing adequate time and doing the challenge at home under your
supervision in a calm environment.
They may also find cow’s milk products have a different taste/smell to the foods they are used
to. Give your child time to accept the new tastes and flavours during the challenge period.
Any questions? Give your Health Visitor team a call.
Health Visitor Contact Details ______________________________________
Produced in Partnership with Dorset County Hospital NHS Foundation Trust, Dorset Healthcare
University NHS Foundation Trust & Poole Hospital NHS Foundation Trust.
43
Appendix G(ii) – Milk reintroduction for babies over 6 months
Patient Information Sheet
Following a Milk and Soya Free Diet
when you are Breastfeeding
Name: ____________________________________________
Date: __________
Breastfeeding provides the best source of nutrition for babies. It is suitable for most
babies with cow’s milk protein allergy. Occasionally breast fed babies can react to
cow’s milk proteins and soya proteins that transfer in breast milk from the mother’s diet
– if that is the case you may be advised to avoid milk and soya products whilst you are
breastfeeding. This may only be for a short period of time or may be for a few months.
Breastfeeding technique should be checked first with your Health Visitor or
Breastfeeding Counsellor as sometimes a change in positioning can improve feeding
and reduce some symptoms.
What Should You Exclude?
Cow’s milk and cow's milk products including dried milk. The diet should be free of
cow’s milk protein (casein and whey) and milk sugar (lactose).
Goat's, sheep and other mammalian milks are not recommended either as they
contain a protein very similar to that found in cow's milk.
In addition you need to avoid all sources of soya/soya protein
Suitable Milk Substitutes
Milk is an important source of nutrition for breastfeeding mothers. When milk is
excluded from the diet, it is vital to replace it with a nutritionally complete alternative.
Milk alternatives which could be suitable include those made from:
 Almonds
 Coconut
 Hazelnut s
 Hemp
 Oats
 Pea and other pea products
Always choose a milk alternative that is fortified or enriched with calcium – they
should provide at least 120mg of calcium /100mls. Organic versions do not
usually have calcium added.
44
Appendix G(ii) – Milk reintroduction for babies over 6 months
Which Foods should you avoid?
Some of the foods you need to avoid in your diet are obvious, such as milk, cheese,
cream, yoghurt, butter and soya. However, many other foods contain cow's milk and
soya - these should be avoided too. Look for the list of ingredients printed on the
package and avoid foods that contain the following -.
Cow's milk protein may be labelled as:
all types of milk, including fresh, dried, UHT, condensed and evaporated
cheese
cream/artificial cream, ice cream
yoghurt, fromage frais
butter/margarine/ghee
buttermilk
lactose/milk sugar
milk powder/skimmed milk powder/non fat milk solids
milk protein/milk solids
whey/whey syrup sweetener
shortening containing whey
casein/caseinate/hydrolysed casein
lactalbumin/lactoglobulin
Soya may be labelled as:
soya beans/soya bean curd/soya protein/soya albumin
soya milk/soya yogurt/soya ice cream
soy sauce
soya flour/soya starch/soya gum
tofu and tofu protein
textured vegetable protein
hydrolysed vegetable protein
soya oil
soya lecithin (E322)
tempeh
miso
edamame (fresh soya beans)
If any of these names are listed in the ingredient list of the food then you should avoid
that food.
The table on the following pages gives you a guide as to which foods should be milk
and soya free and those foods which you may need to avoid.
Please remember to always check the ingredient lists on products.
45
Appendix G(ii) – Milk reintroduction for babies over 6 months
Milk and Soya Free Foods
Foods to avoid or check the
ingredients
Butter, ordinary margarine, low
fat spread, soya spread, soya
oil
Fats
Milk and soya free margarines
e.g. Pure, Dairy free Tomor,
Vitalite. Pure vegetable fats
such as vegetable oil, sunflower
oil and olive oil, lard, cocoa
butter. Supermarkets own
brand vegetable based
margarines
Eggs and
Dairy Products
Eggs
Milk substitute. Oat cream e.g.
Oatly. Coconut cream
Meat &
Alternatives
All fresh and frozen beef, lamb,
pork, ham, bacon, veal, rabbit.
Offal: liver, kidney
Poultry: chicken, turkey
Check the ingredients of
sausage, burgers, tinned meats,
meat pies and other processed
meats. Tofu , TVP
Fresh and frozen fish without
coating or sauce
Avoid fish in white sauces and
fish fingers in batter. Check the
ingredients of tinned fish
Cereals
Wheat, rye, barley, oats, rice,
maize, flour, macaroni,
spaghetti, dried pasta
Tinned spaghetti containing
cheese, macaroni cheese.
Check ingredients of fresh filled
pasta
Breakfast
Cereals
Rice Krispies, Shredded Wheat, Avoid Special K and Swiss type
Shreddies, All Bran, Weetabix,
cereals. Check ingredients of
Ready Brek, Porridge made
muesli and other cereals
with milk substitute or water,
Branflakes, Frosties
Fish
Cheese, including vegetarian
and soya based cheese
alternatives, yoghurt, fromage
frais, crème fraiche, cream.
Soya desserts and custards
Bakery Products Home made bread, cakes,
biscuits and pastry made with
milk alternative and soya free
margarine
Many types of bread contain soya
flour, check labels carefully. Milk
breads, cakes, biscuits, pastries.
Puddings
Tinned milk puddings, Instant
Whip, Angel Delight, Yoghurts,
Ice-cream, including non-dairy
fat types. Ready made custard,
instant custard. Soya based ice
Rice, semolina, sago, tapioca
and custard made using custard
powder and a suitable milk
substitute. Ice lollies, sorbet,
jelly, oat based dairy free ice
46
Appendix G(ii) – Milk reintroduction for babies over 6 months
cream
cream.
Fruit &
All types of fruit, fresh, dried,
Vegetables &Potatoes tinned in juice or syrup. All
vegetables, fresh, tinned or
frozen without added ingredients
Avoid potato mashed with milk
or butter. Check ingredients of
vegetable and potato salad,
instant potato, crisps
and other savoury snacks.
Edamame beans/soya beans.
Tofu/TVP
Drinks
Tea, coffee, cocoa, , fruit juices,
fruit squash, fizzy drinks, Bovril,
Marmite
Avoid Horlicks, Ovaltine,
drinking chocolate, Milo and
instant hot chocolate drinks.
Check soups and
avoid cream soups
Confectionery
Boiled sweets, fruit gums,
pastilles, marshmallows
Avoid fudge, toffee, milk
chocolate.
Check ingredients of plain
chocolate
Other Products
Sugar, jam, honey, syrup, Bisto,
Oxo, salt, pepper, herbs, spices,
essences, salad cream,
mayonnaise, gravy, tomato
ketchup
Avoid sugar substitutes
containing lactose e.g. Sweet 'n'
Low, Canderel, monosodium
glutamate powder.
Please note this is not an exhaustive list and as ingredients can change, always
check the label.
If you are eating out ask the restaurant before you order if you are unsure if meals will
be milk and soya free. Phone ahead and check before you visit to make sure there are
suitable dishes available for you.
Check with your pharmacist about tablets or medicines which may contain lactose
Adapting Recipes?
Many ordinary recipes can be adapted by using your milk alternative. Use a milk and
soya free margarine instead of butter and a milk and soya alternative in place of cow's
milk. Ask for the leaflet ‘Adapting recipes’ for further information.
What About Calcium?
47
Appendix G(ii) – Milk reintroduction for babies over 6 months
Calcium is needed for strong teeth and bones. Lack of calcium can increase risk of
osteoporosis (fragile bones) and fractures later in life. Requirements while
breastfeeding are 1250mg per day.
1 pint of calcium fortified/enriched milk alternative will provide around 700mg per day.
Even though you can include other calcium rich non-milk/soya free sources of foods in
your diet, most breastfeeding women on a milk free diet will need a calcium
supplement. You can use the ‘Sources of Calcium’ table to help you choose calcium
rich foods.
Vitamin D is needed by the body to absorb calcium and the best source is from the
action of sunlight on the skin. The Department of Health recommends that all
breastfeeding women should take a vitamin D supplement.
Speak to your local pharmacist about which supplements are suitable. Calcium and
Vitamin D supplements are available to purchase in pharmacies and supermarkets.
Sources of Calcium
Remember to always check labels to confirm these products are milk and soya free.
Foods providing 250mg of Calcium
Sardines canned (including bones)
Calcium-enriched milk alternative
Calcium fortified orange juice
e.g. Tropicana Essentials - Calcium
Foods providing 150mg of Calcium
Curly Kale/spring greens
Tahini paste (sesame seed paste)
Pilchards
Fortified breakfast cereal
Foods providing 100mg of Calcium
Tinned salmon
Broccoli
Baked beans/kidney beans
Foods providing 50mg of Calcium
White bread
White flour products
e.g. milk/soya free hot cross bun
Cabbage
Dried figs
Sesame seeds (1 tbsp)
Foods providing 25mg of Calcium
Dried apricots
Nuts e.g. brazil, almonds, walnuts
Chapatti x 1
Egg
Portion Size
60g or half a tin
200mls
200mls
Portion Size
90g
20g (1 tsp)
60g or half a tin
35g
Portion Size
115g or half a tin
90g
200g or half a tin
Portion Size
60g (2 slices)
1
90g
20g or 1 dried
10g
Portion Size
50g or small handful
30g or small handful
55g
1 medium
48
Appendix G(ii) – Milk reintroduction for babies over 6 months
Fish fingers x 2
Hummus
Dried fruit e.g. sultanas
Sunflower seeds (2 tbsp)
White fish poached in water
Wholemeal bread (2 x slices)
56g
50g
50g or 2 tablespoons
25g
170g
60g
Contact Details
Dietitian__________________________________________________
Health Visitor _____________________________________________
Produced in Partnership with Dorset County Hospital NHS Foundation Trust, Dorset Healthcare
University NHS Foundation Trust & Poole Hospital NHS Foundation Trust. March 201
49
Appendix H – Weaning onto a milk and soya free diet
Patient Information Sheet
Weaning onto a
Milk and Soya Free Diet
Name: ___________________________________________ Date: _____________
Why A Milk and Soya Free Diet?
Around 3% of children develop cow’s milk protein allergy. In most cases a strict cow’s
milk free diet is needed to treat the allergy. This information will help you avoid milk
whilst making sure your child gets all the nutrition they need to grow and develop well.
Cow’s milk protein allergy may cause a variety of symptoms. Some children who are
allergic to cow's milk protein are also allergic to soya protein so this may need to be
excluded from the diet too. It can take longer for children to recover, but many ‘grow
out’ of cow’s milk and soya protein allergy. Reviews with your health care professional
can guide you on how long you need to continue avoiding cow’s milk and soya in the
diet.
Which Products Should You Exclude?
Cow's milk including dried milk. The diet should be free of cow’s milk protein (casein
and whey) and milk sugar (lactose).
Goat's, sheep and other mammalian milks are not recommended as they contain
lactose and a protein very similar to that found in cow's milk.
In addition all sources of soya/soya protein should be avoided.
Replacing Cow's Milk
Milk is an important source of nutrition for babies and children. If infants are
breastfeeding they can continue to do so alongside weaning onto cow’s milk and soya
free solids. If a child is not breastfeeding and taking an infant formula it is vital to
replace it with a nutritionally complete alternative.
Prescribed Milk Alternatives
Your child may have been prescribed an Extensively Hydrolysed Formula such as
Nutramigen Lipil, Alimentum, Pepti-Junior, Aptamil Pepti or Neocate LCP. They
should continue on this until advised otherwise by your Dietitian, Health Visitor or
Doctor.
Most babies under 1 year need approximately 600ml (20oz) each day to ensure they
are meeting their nutritional needs. Over 1 year of age this amount reduces to around
350ml (12oz). These amounts do vary according to the child and their diet. Check
with your Doctor, Health Visitor team or Dietitian if you have concerns about their
50
Appendix H – Weaning onto a milk and soya free diet
calcium needs.
Cow's Milk and Soya Milk Alternatives
Please check with your Dietitian or Health Visitor before using any milk alternatives as
some may not be suitable for other allergies and some may be low in calories, protein,
calcium and/or other nutrients. Rice milk should NOT be given to children under 5.
The following milk alternatives should not be used as a child's main milk drink under
the age of 1 but they can be useful in home cooking and can be included in the
weaning diet after the age of 6 months.
Milk alternatives which could be suitable include those made from:
 Almonds
 Coconut
 Hazelnut s
 Hemp
 Oats
 Pea and other pea products
Always choose a milk alternative that is fortified or enriched with calcium – they
should provide at least 120mg of calcium /100mls. Organic versions do not
usually have calcium added.
Which Foods Should You Avoid
Some of these foods are obvious, such as milk, cheese, cream, yoghurt and butter.
However, many other foods contain cow’s milk and these should be avoided too. Look
for the list of ingredients printed on the package and avoid foods which contain the
following –
.
Cow's milk protein may be labelled as:
milk, including fresh, dried, UHT, condensed and evaporated
cheese
crea, ice cream
yoghurt, fromage frais
butter/margarine/ghee
buttermilk
lactose/milk sugar
milk powder/skimmed milk powder/non fat milk solids
milk protein/milk solids
whey/whey syrup sweetener
shortening containing whey
casein/caseinate/hydrolysed casein
lactalbumin/lactoglobulin
On labels soya can be called:
soya/soy/soyabean/soya albumin/soya protein
soya milk
soya flour/soya starch/soya gum
51
Appendix H – Weaning onto a milk and soya free diet
textured vegetable protein (TVP)
soya oil
soya lecithin (E322)
tempeh
tofu/soya bean curd
miso
edamame (frsh soya beans)
Milk and Soya free foods
Foods to check or avoid
Fats
Milk and soya free margarines
e.g.; Pure, Tomor, Granose,
Vitaquell. Pure vegetable fats,
vegetable oil, lard, coca butter.
Supermarket own brand
vegetable based margarines.
Butter, ordinary margarine,
soya spread
Eggs and
Milk Products
Eggs,
Milk alternative.
Oat cream e.g. Oatly, coconut
cream
Milk, cheese, including
vegetarian cheese, yoghurt,
fromage frais, crème fraiche,
soya cheese, soya yoghurt,
cream
Meat
& Alternatives
All fresh and frozen beef, lamb,
pork, ham, bacon, veal, rabbit.
Offal: liver kidney. Poultry:
chicken, turkey
Check the ingredients of
sausage, burgers, tinned
meats, meat pies and other
processed meats. Tofu, TVP
Fish
Fresh and frozen fish without
coating or sauce
Avoid fish in white sauces &
fish fingers in batter. Check
the ingredients of tinned fish
Cereals
Wheat, rye, barley, oats, rice,
maize, flour, macaroni, spaghetti,
dried pasta
Tinned spaghetti containing
cheese, macaroni cheese.
Check ingredients of fresh
pasta
Breakfast
Cereals
Rice Krispies, Shredded Wheat,
Shreddies, All Bran, Weetabix,
Ready Brek, Porridge made with
water, Branflakes, Frosties
Avoid Special K and Swiss
type cereals. Check
ingredients of muesli and
other cereals
Bakery Products Home made bread. Home-made
cakes, biscuits and pastry made
with milk free margarine
52
Many breads contain soya and
milk, check labels carefully.
Milk breads, Procea, Cakes,
biscuits, pastries. Check labels
- some biscuits are milk/soya
free
Appendix H – Weaning onto a milk and soya free diet
Puddings
Tinned milk puddings,
Instant Whip, Angel Delight,
Yoghurts, Ice-cream,
including non-dairy fat types.
Ready made custard.
Soya yoghurt, soya desserts,
and soya frozen desserts
Avoid potato mashed with
Fruit and Vegetables All types of fruit, fresh, dried,
milk or butter. Check
&Potatoes
tinned in juice or syrup. All
ingredients of vegetable and
vegetables, fresh, tinned or frozen potato salad, instant potato,
without added ingredients
crisps and other savoury
snacks.
Drinks
Rice, semolina, sago, tapioca and
custard made with a suitable milk
alternative, ice lollies, jelly. Oat
based dairy free ice cream
Avoid Horlicks, Ovaltine,
Drinking chocolate, fruit juices, fruit Bournvita, Milo and instant
squash, fizzy drinks, Bovril,
hot chocolate drinks. Check
Marmite
ingredients of soups and
avoid cream soups
Other
Products
Sugar, jam, honey, syrup, Bisto,
Oxo, salt, pepper, herbs, spices,
essences, salad cream,
mayonnaise, gravy, tomato
ketchup
Baby Foods
Check labels of baby rice and
rusks
Avoid sugar alternatives
containing lactose e.g.
Sweet 'n' Low, Canderel,
monosodium glutamate
powder.
Check ingredients of baby
foods as many contain milk and
soya
Please note this is not an exhaustive list and as ingredients can change, always check
the label.
If you are eating out ask the restaurant before you order if you are unsure if meals will
be milk and soya free. Phone ahead and check before you visit to make sure there are
suitable dishes available for you.
Check with your pharmacist about tablets or medicines which may contain lactose
Weaning
Weaning a baby who has cow’s milk and soya allergy should be the same as weaning
a non-allergic baby, except that you must not give any foods that contain cow’s milk or
dairy products or soya based products. You should aim to start giving solid foods at
around six months but not before four months (17 weeks).
Begin weaning with low allergenic foods such as pureed rice, potatoes, root and green
vegetables and fruit. Use a little of your baby’s usual milk (breast or hypoallergenic
formula) to mix the food to the desired consistency. Introduce new allergenic foods
such as egg and fish one at a time. Allergenic foods should be given for 3 days to
53
Appendix H – Weaning onto a milk and soya free diet
ensure adequate exposure and leave a couple of days between new foods to be able
to ascertain if there is any reaction. Keeping a food diary can be useful.
First foods include:
 soft fruits and cooked vegetables (e.g. cooked apple or pear, avocado, banana,
carrot, parsnip, sweet potato or yam

milk and soya free baby cereals made with your child’s milk alternative (e.g. baby
rice, baby porridge. Please note some of these products may contain milk/soya so
carefully check the ingredients list on the label)

pureed or mashed up meat, chicken or lentils

As your baby moves through weaning, food can become more ‘chopped’ in texture
until your baby is managing family meals and finger foods.
As your baby moves through weaning, food can become more ‘chopped’ in texture.
Stage Two is mashed with soft lumps and soft finger foods. Stage Three is minced or
chopped family foods and hard finger foods. Eventually your baby will be managing
family meals.
Breakfast


milk and soya free breakfast cereal or porridge with milk alternative
fruit puree or mashed banana
toast *fingers with milk and soya free margarine (see list
Snacks and Finger foods





small pieces of soft, ripe fruit (e.g. banana, peach, mango, melon)
dried apricots or raisins
raw vegetable sticks (e.g. cucumber sticks, peppers)
lightly cooked vegetable pieces (e.g. broccoli & cauliflower florets, carrot, parsnip &
courgette sticks, green beans)
bread sticks* or rice cakes* with hummus, mashed avocado or milk and soya free
spread
sandwiches with ham/chicken/tuna/egg mayonnaise*, cucumber slices and milk
and soya free margarine
toast* with baked beans* and well-cooked scrambled egg (made with milk
alternative) and milk and soya free margarine
Main Meals


minced or finely chopped meat or flaked fish served with;
pasta in a roasted vegetable and tomato based sauce or a milk and soya free white
sauce (see recipe).
or meat, fish served with mashed potatoes/chopped roast or new potatoes,
mashed/chopped vegetables
54
Appendix H – Weaning onto a milk and soya free diet

flaked fish poached in a milk alternative, mashed potato and vegetables
mashed, cooked lentils/dhal, chickpeas or other pulses with well-cooked boiled rice

55
Appendix H – Weaning onto a milk and soya free diet
Puddings





soft ripe or dried fruit
home made milk and soya free custard with fruit
rice pudding, semolina or custard made with milk alternative
milk jelly or egg custard made with milk alternative
fruit crumble made with milk free margarine
*may contain milk and/or soya, please check the label
Adapting Recipes?
Many ordinary recipes can be adapted by using your milk alternatives. Use a milk
and soya free margarine instead of butter and milk alternatives in place of milk in
recipes. Try making up batches of milk and soya free meals/puddings and freezing
them in ice-cube trays to allow you to serve small portions with less waste. Ask for
‘Adapting recipes’ leaflet for further ideas.
What About Calcium?
Calcium is needed for strong teeth and bones. Lack of calcium can increase risk of
osteoporosis (fragile bones) and fractures later in life. Calcium requirements for
infants under 1 year old is 525mg/day and for 1-3 year olds is 350mg/day.
Most babies under 1 year need approximately 600ml (20oz) of milk alternative each
day to ensure they are meeting their nutritional needs. Over 1 year of age this amount
reduces to around 350ml (12oz). These amounts do vary according to the child and
their diet. Check with your Doctor, Health Visitor or Dietitian if you have concerns
about their calcium needs.
Use the ‘Sources of Calcium’ table to help you choose calcium rich weaning foods.
Please note the portion sizes listed in the table are based on adult portions, so you
will need to adapt the portion size accordingly.
The Department of Health also recommend that a supplement containing vitamin A, C
and D should be given to all children aged six months to five years. This is a
precaution because growing children may not get enough of these vitamins,
especially those not eating a varied diet, such as fussy eaters.
Supplements are available to purchase in pharmacies and supermarkets, or may be
available on prescription. Ask your Health Visitor for advice.
Sources of Calcium
Remember to check the ingredients lists to make sure these products are milk and
soya free.
Foods providing 250mg of Calcium
Sardines canned (including bones)
Calcium fortified milk alternative
Calcium fortified orange juice
56
Portion Size
60g or half a tin
200mls
200mls
Appendix H – Weaning onto a milk and soya free diet
e.g. Tropicana Essentials - Calcium
Foods providing 150mg of Calcium
Curly Kale/spring greens/spinach
Tahini paste (sesame seed paste)
Pilchards
Fortified breakfast cereal
Foods providing 100mg of Calcium
Tinned salmon
Broccoli
Baked beans/kidney beans
Foods providing 50mg of Calcium
White bread
White flour products
e.g. milk/soya free hot cross bun
Cabbage
Dried figs
Foods providing 25mg of Calcium
Dried apricots
Chapatti x 1
Egg
Fish fingers x 2
Hummus
Dried fruit e.g. sultanas
White fish poached in water
Portion Size
90g
20g (1 tsp)
60g or half a tin
35g
Portion Size
115g or half a tin
90g
200g or half a tin
Portion Size
60g (2 slices)
1
90g
20g or 1 dried
Portion Size
50g or small handful
55g
1 medium
56g
50g
50g or 2 tablespoons
170g
Contact Details
Dietitian__________________________________________________
Health Visitor _____________________________________________
Produced in Partnership with Dorset County Hospital NHS Foundation Trust, Dorset Healthcare
University NHS Foundation Trust & Poole Hospital NHS Foundation Trust. March 2
57
Appendix I – Equality Impact Assessment Form
What are the intended outcomes of this work? Include outline of objectives and
function aims
The main purpose of the guidelines is to support professionals and staff working with
families with milk allergy or suspected milk allergy to ensure correct diagnosis and
management
Who will be affected?
Staff and patients/families with children with possible allergy
Evidence
What evidence have you considered?
Disability Consider and detail (including the source of any evidence) on atittudinal,
physical and social barriers.
No Impact
Sex Consider and detail (including the source of any evidence) on men and women
(potential to link to carers below)
No Impact
Race Consider and detail (including the source of any evidence) on difference ethnic
groups, nationalities, Roma gypsies, Irish travellers, language barriers
No Impact
Age Consider and detail (including the source of any evidence) across age ranges on old
and younger people. This can include safeguarding, consent and child welfare.
Guidelines are for children under 2 years to advise on ensuring consistent approach and
avoid unnecessary dietary restrictions.
Gender reassignment (including transgender) Consider and detail (including the source
of any evidence) on transgender and transsexual people. This can include issues such as
privacy of data and harassment.
No Impact - Guidelines are for infants.
Sexual orientation Consider and detail (including the source of any evidence) on
heterosexual people as well as lesbian, gay and bi-sexual people
No Impact
Religion or belief Consider and detail (including the source of any evidence) on people
with different religions, beliefs or no belief.
No Impact
Pregnancy and maternity Consider and detail (including the source of any evidence) on
working arrangements, part-time working, infant caring responsibilities
No Impact
58
Carers Consider and detail (including the source of any evidence) on part-time working,
shift-patterns, general caring responsibilities
No Impact
Other identified groups Consider and detail and include the source of any evidence on
different socio-economic groups, area inequality, income, resident status (migrants) and
other groups experiencing disadvantage and barriers to access.
Different incidence of milk allergy in differing races. Common guidelines will ensure
consistency of approach
What is the overall impact? Consider whether there are different levels of access
experienced, needs or experiences, whether there are barriers to engagement, are there
regional variations and what is the combined impact?
None
Addressing the impact on equalities Please give an outline of what broad action
you or any other bodies are taking to address any inequalities identified through the
evidence.
The guidelines will provide a consistent approach to the diagnosis and management of
milk allergy. By providing evidence case and an agreed formulary there will be consistent
prescribing of milk allergy infant formula feeds.
This should reduce different patterns on prescribing in primary care and consistent
approach from secondary care regarding milk prescription requests.
This should reduce/eliminate requests for prescriptions from parents where a specialist
formula use cannot be justified but soya formula may be being prescribed due to cost
implication to the family.
Name of person who carried out this assessment:
Katherine Gough, Head of Medicines Management
Date assessment completed:
25/2/2016
Name of responsible Director:
Sally Shead
Date assessment was signed:
10/03/2016
59