The South East London Non-IgE Cow's Milk Allergy Rapid Access Clinic (SEL Non-IgE CMA RAC) is a clinic for patients with suspected non-IgE cow's milk allergy (CMA), and was launched in November 2021. The clinic was designed to support patients with appropriate diagnosis and prescription of hypoallergenic formula (HF).
Cow's Milk Allergy typically presents in the first year of life, affecting 2-3% of infants. Diagnosis of non IgE CMA can be challenging as symptoms may overlap with other common childhood conditions. The iMAP Home Challenge is the gold-standard tool to confirm or exclude the diagnosis of non-IgE CMA.
This project was developed following identification of a high spend on HF across SEL; combined with low rate of confirmation of diagnosis of non-IgE CMA via iMAP Home Challenge, and low levels of dietetic input. Around £1.5 million was spent on HF in SEL in the 2021/2022 financial year which is twice maximum the expected amount. SEL audit data has shown that only 20% of babies with suspected cow's milk allergy on HF had completed the iMAP home challenge to confirm or exclude the diagnosis of non-IgE CMA in 2020/21.
Lack of standard care and diagnosis for patients with suspected non-IgE cow's milk allergy can lead to inappropriate prescription of HF and elevate NHS spend. In addition, delays to assessing patients with suspected cow's milk allergy can negatively impact on breastfeeding rates and lead to unnecessary dietary restrictions.
Whilst the iMAP Home Challenge is the gold-standard for diagnosis, audit data from 2021 showed that most patients in SEL did complete this after starting on HF. Patients referred to secondary care often need to wait for long period of time before being seen by a dietitian for further management of CMA and dietary support (e.g. dairy free diet). Consequently, it has been identified in preliminary SEL audit data that a high number of patients have continued on HF beyond 12 months of age, although most children can safely transition to a calcium-enriched plant-based milk alternative.
The SEL Non-IgE CMA RAC was therefore designed to contribute to early diagnosis and management of non-IgE CMA, improving patient care pathways and reducing unnecessary spend on HF. Patients are seen within 2-4 weeks from referral and they receive information about the iMAP Home Challenge. If Non-IgE CMA is confirmed, patients are booked into a virtual group session to learn about dairy free diet, how to gradually re-introduce cow's milk closer to 12 months via the iMAP milk ladder and appropriate transition onto an alternative drink after 1 year of age. In addition, patients who require further support regarding growth and multiple food allergies are appropriately referred to secondary care.
The benefits of this service include promoting equity of service provision and a standardised approach to care and management of non-IgE CMA across SEL, promoting prescribing efficiency through prevention of inappropriate HF prescriptions, promote cost-savings to the NHS, improving patient access to dietetic care, and supporting collaborative working with local dietetic teams and services across the ICS.
To summarise, the Non-IgE CMA RAC is a project which aims to improve care for patients with suspected CMA and ensure cost and effective prescription of hypoallergenic formulas across SEL.
