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Yesterday I was contacted by several people about a blog post, written by a GP, on diagnosis of Cow’s Milk Protein Allergy (CMPA) and industry involvement. They wanted my opinion. Well, here it is:

While the start of the post is possibly written in a way that will get peoples backs up, I actually think Jonny makes some reasonable points, however, I would like to expand on those too.

Dear Jonny

I’m the first to have a moan to my colleagues when I see a patient whose allergy has been repeatedly missed by other health Care Professionals (HCP), but I actually think GP’s have it tough. 

Food allergy is a relatively new field, with more information on symptoms, diagnosis and management coming out all the time. When I qualified 20 years ago, you’d occasionally come across the odd child with CMPA, with classic symptoms of vomitting, diarrhoea, poor weight gain etc, but if a mum tried to tell you her child was allergic to rice, she’d be met with disbelief as rice was one of the few foods (along with pears and lamb) that were thought to be pretty well hypoallergenic!

How things have changed...

With so many clinical conditions to keep up to date with and ever stretched resources, how do GP’s prioritise their training? With new NICE Guidance coming into Dr’s in-trays on a regular basis, many get missed. Yes, the MAP Guidelines were sponsored, but at least, thanks to a marketing budget government organisations don’t have, many more GP’s are aware of them then were of the NICE Guidelines on Allergy when they came out.

The important fact isn’t that MAP says ‘one or more...’, it’s the ‘consider...’ written before that statement. You’re exactly right Jonny, randomly basing a diagnosis just on one of the symptoms on this list would be madness. Which is precisely why you should then be thinking about an allergy focussed clinical history, as recommended by BSACI and RCPCH.

I’m not going to discuss all the symptoms as I have things to do this morning, but consider the following...

Yes, colic can be a normal part of infancy, but needs further questioning. Screaming excessively for 20 hours a day or colic continuing for 9 months is not normal.

Possets and small vomits can occur as a result of poor muscle tone in the lower oesophageal sphincter and usually improve as infant grows. I’ve also seen it when a bottle fed baby is being overfed (always check feed volumes before just telling parents to give less though to ensure they are still meeting requirements). Your job is to question what’s normal and what’s not...

Food refusal or aversion around the neophobic phase or a toddler testing boundries can be normal. An infant pulling away from the breast or bottle shortly after every feed has started, seemingly distressed and uncomfortable, then refusing anymore is not. Thanks to development of impedance studies, we now know this can be as a result of direct mast cell stimulation (triggering pain) as milk is traveling down the oesophagus, not acid coming back up from the stomach. If ignored this can delay diagnosis, lead to distress for infant and family and ultimately lead to severe food aversion as the infant soon associates feeding with pain. 

In addition, I’ve seen too many mum’s being wrongly told it’s because they are not producing enough breast milk and baby is just hungry, being encouraged to give top-ups with formula or give up breast feeding completely. By the time this has made symptoms worse, it’s usually too late for mum to go back to breast feeding and try an exclusion diet. I recently saw a mum who was encouraged to stop breast feeding and give standard infant formula, despite her telling me that there would still be milk dripping from her nipples when the baby pulled away. She did not have a problem with supply.

As for marketing, first we need to clarify what you mean by ‘formula’ for the public. Hospitals (and I assume primary care establishments), as part of the baby friendly initiative DO NOT have baby milk companies coming in to the wards promoting standard infant formulas. We promote breast milk where possible. Reps for Specialised Infant Formulas (for allergy/metabolic disorders) are allowed to talk to the dietitians and Dr’s, but again do not go onto wards and talk to parents.

The Reps job primarily is to promote their product, and get you to remember their products name. As a health care professional, your job is to make an informed decision based on the specific properties of the feed and what is best for the clinical situation. 

The MAP guidelines direct GP’s as to whether an exclusion diet for a breast feeding mum, an extensively hydrolysed formula (EHF), or and amino acid (AA) formula is the best choice for a particular situation. It does NOT tell you which specific feed to give. If a Dr is swayed by a new pen or a pack of post-it notes, or the advert on the back (that we’ve all been so cynical about, that we ignore anyway) more fool them. 

If you are not sure what to use, ask your local dietitian to come and talk to the GP’s to give an unbiased comparison of the different feeds available and in what situations they should be used.

Advertising on a piece of literature is irrelevant at the moment anyway as many GP’s are restricted to only being able to prescribe a specific EHF or AA formula based on medicines management guidance from the CCG. Not sure what it’s like where you live Jonny, but round here the choice is purely based on cost (which I feel is also completely inappropriate). We have had to change the specialist formulas we use in our hospital as a result of this, as it lead to prescription issues on discharge and unnecessary swapping of feeds. I don’t like making decisions based on cost.

Like you, I object to too much involvement from feed companies. I have a huge problem with a particular company who encourage the use of two week trial of their AA formula as a diagnostic tool! It then becomes very difficult to get a mum to change onto an EHF (if appropriate) after they have seen improvement in symptoms.

Increase in parents knowledge of symptoms and special formulas, either as a result of direct marketing, or social media, is exactly why GP’s need to have a better understanding of allergy. Either so you can reassure parents whose infant’s symptoms are ‘normal’ or really listen to them so you can spot true allergy symptoms before the average 7 visits to the GP it currently takes. 

I applaud the feed companies providing free training. Otherwise many HCP, GP’s included, wouldn’t get any. I for one, have to carefully consider any training I go on. Since coming back from maternity leave, I have had to self pay, or find funding, for every course I have been on. A GP, without a massive interest in allergy, is much more likely to consider attending an allergy update if it isn’t going to cost anything. These courses are taught by qualified experts, they discuss recognition of symptoms, management, case studies, latest research etc. They DO NOT recommend specific formula’s made by the sponsoring feed company (although they usually have a stand at refreshment time...).

What we need is HCP's (not just GP’s), with a better understanding of allergy so diagnosis is not delayed longer than necessary. This will also lead to more appropriate prescribing and treatment, as well as reducing reliance on expensive AA formulas, when not necessary. But ultimately, it will also be better for the patient. 

We also need easier, more timely access to dietitians for appropriate support as well as follow-up, not only to ensure the patient is receiving an age appropriate, nutritionally balanced diet, but also to help with challenges and reintroduction so restricted diets (and special formulas) are not continued for longer than necessary. 

I understand where you were coming from with this article, but you have to understand many allergy parents have faced a long battle to get a diagnosis and are naturally defensive when Dr’s come across as seemingly dismissive. Believe you me, we would not chose to go on dietary restriction while breast feeding, or change to expensive unpleasant smelling formulas, or to have our children on restricted diets if we didn’t need to. 

Kind regards