Patient’s Story (Role-Player Brief)

You are Chloe Bishop, the mother of 6-month-old Leo. You sound tired, anxious, and a bit tearful. You’ve booked this call because Leo’s eczema is “worse than ever” and he’s “constantly grizzly and unsettled.”

Presenting Complaint:

• Eczema: It’s all over his torso and in his arm and leg creases. It’s red, dry, and he’s always scratching. The hydrocortisone “doesn’t seem to touch it.”
• Feeding/Reflux: He’s very fussy after his bottles. He possets (brings up milk) frequently, sometimes an hour or more after a feed. It doesn’t seem to be large amounts, but it’s constant.
• General State: He’s grizzly, cries a lot, and his sleep is very disturbed (and so is yours).
• Bowel Movements: If asked, you’ll say his poos are “slimy” and he seems to strain a lot, but the poo itself is soft. Sometimes you’ve seen “little streaks of blood” but you weren’t sure and thought it might be from a small tear from straining.

Key Information (Only reveal if asked):

• Feeding History: You exclusively breastfed for the first 4 months. The eczema and fussiness started around that time, just after you introduced combination feeding with a standard cow’s milk-based formula (e.g., Aptamil 1). His symptoms have gotten progressively worse since then. You are now only doing one breastfeed at night and the rest is formula.
• HV Visit: You are very worried about his weight. The Health Visitor seemed concerned two weeks ago when she said he had “dropped a centile” (he’s dropped from 25th to 9th).

ICE (Ideas, Concerns, Expectations):

• Ideas: “I think it’s just really bad eczema like his dad had, and he’s got his dad’s reflux too. I’m probably just being an over-anxious first-time mum.”
• Concerns: “My biggest worry is his weight. The Health Visitor looked so concerned, and I feel like I’m failing him. And honestly, I’m exhausted… I’m not coping.”
• Expectations: “I was hoping you could prescribe a stronger steroid cream for his skin and maybe some Gaviscon or a special reflux milk to help him keep his feeds down.”
  • (Your sister mentioned asking for a “special formula for allergies,” but you are hesitant about this. It seems like a lot of hassle, and you don’t want to seem like a “fussy mum.”)

Role-Play Instructions:

• Start the call sounding tired and worried.
• Focus on the eczema and reflux first.
• If the doctor only offers treatment for the skin/reflux, you must ask, “But what about his weight? I’m so worried he’s not growing properly.”
• Initially, resist the idea of changing his formula, saying things like, “Are you sure? It seems like such a big change. What if he hates it?”
• You will agree to the plan if the doctor explains the link between all the symptoms (skin, tummy, growth) clearly and empathetically.

Marking Scheme

Data Gathering & Diagnosis

Phase 1: Open the Consultation & Explore Presenting Complaints Rationale: To build rapport and gain a deep, patient-centred understanding of the primary issues (eczema, reflux, irritability) before narrowing down.

• Key Questions:
  • “I understand you’re calling about Leo. Tell me what’s been concerning you.”
  • Eczema: “Can you describe the eczema for me? Where is it? What does it look like? How often are you using the creams?”
  • Reflux: “You mentioned he’s unsettled after feeds. Tell me more about that. What happens? Is he vomiting? How much?”
  • Irritability/Sleep: “How is he in himself? How is his sleep, and just as importantly, how is your sleep?”

Phase 2: Broaden the Differential & Screen for Red Flags Rationale: To actively rule out ‘cannot miss’ diagnoses (e.g., severe IgE allergy, infection, surgical causes) and gather specific evidence for non-IgE allergy.

• Key Questions:
  • IgE Allergy (Immediate): “Has Leo ever had an immediate reaction after a feed? For example, a sudden rash like nettle stings (hives), swelling of his lips or face, sudden coughing, wheezing, or any breathing problems?”
    • Rationale: To rule out an acute IgE-mediated allergy, which is a medical emergency.
  • Non-IgE Symptoms (Delayed):
    • GI: “Tell me about his nappies. What are his poos like? Are they very loose (diarrhoea), or hard (constipation)? You mentioned straining? Any mucus or blood?”
      • Rationale: To screen for key non-IgE symptoms (blood/mucus in stool, constipation, diarrhoea).
    • GORD: “You mentioned him bringing milk up. Does he seem in pain with it? Does he arch his back?”
      • Rationale: To assess the severity of the GORD, a common non-IgE symptom.
  • Severity & Complications:
    • “You mentioned the Health Visitor was concerned about his weight. Can you tell me more about that? Do you know what his weight was?”
      • Rationale: To confirm faltering growth, a key complication and indication for referral.
    • “How bad is the eczema? Is he scratching a lot? Is the skin broken or weeping?”
      • Rationale: To assess severity. Severe/treatment-resistant eczema is a symptom of non-IgE allergy.
  • Important Differentials:
    • “Has he had any fever? Does he seem generally unwell, hot, or lethargic?”
      • Rationale: To rule out an underlying infection (e.g., gastroenteritis, UTI) causing irritability and poor feeding.
    • “When he brings milk up, is it very forceful? Does it fly across the room (projectile vomiting)?”
      • Rationale: To rule out surgical causes like pyloric stenosis (though age is at the upper limit).

Phase 3: Build the Clinical Context Rationale: To identify the crucial diagnostic link (feeding history) and risk factors (atopy).

• Key Questions:
  • Feeding History: “This is a really important question: When did these symptoms start?“
  • “What was he being fed before the symptoms started? Was he exclusively breastfed?”
  • “When did you introduce formula? Which one is he on?”
  • “Is he taking any breast milk at all now? If so, how much?”
    • Rationale: This sequence is vital. Symptoms starting after the introduction of cow’s milk formula is the key diagnostic clue.
  • Treatment History: “How often are you using the Dermol and Hydrocortisone? Do you feel they are helping at all?”
    • Rationale: To establish that the eczema is treatment-resistant.
  • PMH/FMH: “You mentioned his dad had reflux. Is there any family history of allergies, eczema, asthma, or hay fever?”
    • Rationale: To check for atopy, a major risk factor.

Phase 4: Understand the Patient’s Perspective & Impact Rationale: To conduct a holistic, patient-centred consultation to understand the person behind the symptoms, which is crucial for shared decision-making.

• Key Questions:
  • ICE: “What are your own thoughts on what might be causing all this?”
  • “What is your single biggest worry right now?” (Links to ‘Concerns’ – his weight, her coping).
  • “What were you hoping we could do for you and Leo today?” (Links to ‘Expectations’ – stronger steroids, Gaviscon).
  • Impact: “How is all of this affecting you? You sound exhausted.”
    • Rationale: To identify and acknowledge the parental/carer stress

Working Diagnosis:

• Likely: Non-IgE-mediated Cow’s Milk Allergy (CMA). The constellation of symptoms (treatment-resistant eczema, GORD, GI upset) starting after the introduction of formula, combined with faltering growth, makes this the strongest diagnosis.
• Differentials: Severe GORD (primary), Lactose Intolerance (unlikely to cause eczema/blood in stool), Eosinophilic Oesophagitis.

Diagnosis & Explanation:

“Chloe, thank you for explaining all that so clearly. I know how worrying and utterly exhausting this must be, especially when you’re doing everything right.

“Based on everything you’ve described – the severe eczema that isn’t getting better, the reflux, the slimy poos, and especially the concern about his weight – I don’t think these are all separate problems. I strongly suspect they are all linked to one single cause: a non-IgE-mediated cow’s milk allergy.

“This is a type of delayed allergic response to the protein in his regular formula. It’s not a severe, immediate allergy, but it causes inflammation, which is showing up on his skin (the eczema), in his tummy (the reflux and nappies), and is affecting his growth.

“The good news is, this is very manageable, and we have a clear plan to confirm it and get him feeling better. How does that sound to you?”

Management (For Suspected Non-IgE CMA Case)

1. Address ICE & Agree on Goals:

• “I know you were thinking about stronger creams and reflux medicine, and your sister had mentioned a special formula. Your sister is absolutely on the right track. While creams just treat the skin, we need to address the root cause of this inflammation, which we think is the formula. By doing this, we should be able to help his skin, his tummy, and his growth all at the same time. Does that make sense?”

2. Immediate Assessment:

• “Because the health visitor was worried about his weight and his eczema is significant, I would like to see Leo face-to-face in the clinic today or tomorrow, if you can make it. This will let me properly check his weight, examine his skin from head to toe, and listen to his chest and tummy to make sure there’s nothing else going on. We can also check his heart rate and breathing.”

3. Investigations & Initial Treatment (The Trial):

• “The main way we diagnose this is with a special diet. I am going to prescribe a 2 to 4-week trial of a hypoallergenic formula.
• “Because his symptoms are moderate-to-severe (with the eczema and faltering growth), we will use one called an extensively hydrolysed formula (eHF). This means the milk proteins are already broken down so his body shouldn’t react to them.”
• “You must stop his current formula completely and use this one for all his formula feeds.”
• “I see you’re still doing one breastfeed. That’s fantastic, and you can absolutely continue. However, for the trial to work, you will also need to strictly eliminate all cow’s milk and dairy products from your own diet. This is very important as the protein can pass into your breast milk. This is tough, but it’s only for a short trial.”

4. Referrals (Specialist Input):

• “This isn’t something I want you to manage alone. I am making two referrals today:
  1. An urgent referral to a Paediatric Dietitian. This is a specialist in children’s nutrition. They are essential for monitoring Leo’s growth and will give you full support on managing the milk-free diet for yourself. They will also create the plan for reintroducing milk later to confirm the allergy.
  2. A referral to the specialist Paediatric Allergy Clinic. We are doing this because Leo has both faltering growth and significant atopic eczema with this suspected allergy. This is a clinic with specialist doctors and nurses who can do further tests if needed (like skin prick tests to rule out any IgE allergy) and provide a long-term management plan.”

5. Health Promotion & Self-Care:

• “While we wait for the new diet to work (it can take 2-4 weeks to see a full improvement), please continue with his skin care. Use the Dermol 500 as his soap substitute and moisturise him frequently. You can continue using the 1% hydrocortisone on any red, inflamed patches as you have been.”
• “For your own diet, the dietitian will give you detailed advice, but you will need to start checking all food labels for milk, butter, cheese, yoghurt, etc. They will also advise you on taking a calcium and vitamin D supplement for yourself.”

6. Explicit Safety Netting & Contingency Planning:

• “It is very important that you seek urgent help if Leo develops any new or sudden symptoms after a feed, especially lip or face swelling, a sudden blotchy rash (hives), or any difficulty breathing – in that case, you must call 999.”
• “Also, please call us back or contact 111 if his vomiting or diarrhoea gets much worse, if he seems very sleepy or floppy, or if you are worried he is becoming dehydrated – for example, if he has very few wet nappies or sunken eyes.”

7. Summarise, Check Understanding & Agree on Follow-Up:

• “So, just to recap: I’ll see you in the clinic this week to check Leo over. I’m prescribing the new formula for you both to start a strict 2-4 week trial. I’m also referring you to the dietitian and the allergy clinic for expert support.”
• “I will book a telephone review with you in 2 weeks to see how he is getting on with the new formula. How does that whole plan sound to you? Do you have any questions about starting the new diet?”

8. Further Management & Escalation (Contingency for Failed Trial):

• “When we speak in 2 weeks, if there has been no clear improvement at all, we have a clear next step.
• “If we still strongly suspect the allergy, the next step would be to offer a trial of a different kind of hypoallergenic formula, called an amino-acid formula (AAF). This one is broken down even further and is for babies who don’t get better on the first (eHF) one. We would do this while we wait for your specialist appointment.
• “If, on the other hand, we feel it’s not the allergy after all, we would stop the trial, you could go back to your normal diet and his regular formula, and we would refer him to a general children’s clinic (paediatrics) for a different type of investigation.
• “The key thing is that we have a plan B, and we won’t stop until we get his growth and comfort sorted.”

Alternative Scenario Management: “Confirmed non-IgE CMA”

Note: The following management plan is not for the main case (“Dropping Centiles and a Stubborn Rash”). This is a distinct, alternative scenario for a follow-up consultation after a child has already successfully completed a milk-free trial and a positive home reintroduction, confirming non-IgE CMA allergy.

1. Offer and Explain Investigations & Referrals:

• “Now that we’ve confirmed the allergy, the most important thing is getting you the right long-term support. I will ensure an urgent referral to a Paediatric Dietitian is in place if it hasn’t been already.”
• “The dietitian is a specialist in children’s nutrition. They are essential for this next phase. They will monitor Leo’s growth very carefully and give you expert advice on all the milk-free foods he can have as he weans. They will also advise you on vitamin and calcium supplements to make sure he’s not missing out on anything.”
• “We also need to check if a referral to the specialist allergy clinic is needed. We would do this if he starts to develop severe symptoms, or if he has multiple food allergies.”

2. Collaborative Treatment Planning (Medication & Lifestyle):

• “The main plan now is to continue the strict cow’s milk-free diet. This means continuing with his hypoallergenic formula and, for you, keeping all dairy out of your diet while you are breastfeeding. We’d typically recommend this until he is 9 to 12 months old, and for at least 6 months.”
• “The good news is that most children outgrow this. So, after that time, the next step will be to test if his body has learned to tolerate milk. This is not something to do right now, but it’s the long-term goal.”
• “The dietitian will create a plan for you to do this safely at home using something called a ‘Milk Ladder’. This is a brilliant, step-by-step way to reintroduce milk. You start with foods containing very small amounts of well-baked milk (like a tiny piece of a specific biscuit or muffin) and, if he’s okay, you very gradually move up the ladder over weeks or months towards fresh milk.”
• “When you do eventually start that ladder, we’d recommend you have a non-drowsy, age-appropriate antihistamine available at home, just in case he has a mild skin reaction. We can prescribe this nearer the time.”

3. Explicit Safety Netting & Contingency Planning:

• “This is a very important point: before you ever start the milk ladder, we must check him. If he has any active, red eczema at that time, or if he has ever had an immediate-onset reaction (like hives, swelling, or wheezing), we must not do the reintroduction at home. If that’s the case, you must let us know, and we will refer him to the allergy specialist for a supervised challenge in the hospital.”
• “If you do start the milk ladder and any of his old symptoms return – for example, his eczema flares up, his reflux comes back, or he gets an upset tummy – you must stop the reintroduction immediately. Go back to the strict milk-free diet and contact us or the dietitian for advice. We would then wait another 6 to 12 months before trying again.”
• “And as always, if he ever has a severe, immediate reaction (any lip/face swelling, widespread hives, vomiting, wheezing, or difficulty breathing), that is an emergency, and you must call 999.”

4. Summarise, Check Understanding & Agree on Follow-Up:

• “So, just to recap our long-term plan: we will keep him on his strict milk-free diet, with full support from the dietitian, until he’s about 9-12 months old. At that point, as long as he has no new symptoms and his skin is calm, we will make a plan for you to try the ‘Milk Ladder’ at home to see if he’s outgrown the allergy.”
• “We will arrange a routine follow-up with you and the dietitian in the next few months to check his growth and support you with weaning. How does that long-term plan feel to you?”

Important Disclaimer

This MedDigest consultation is a fictional case, created for educational and revision purposes only. It should not be used for clinical decision-making or as a substitute for your own clinical judgment.

This content is an independent educational resource designed by MedDigest to illustrate clinical principles. It has not been produced, reviewed, or endorsed by NICE or the Royal College of General Practitioners.

Medicine is constantly evolving. For definitive recommendations, always refer to the latest official guidelines and your local clinical protocols.

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