Listing of Pharmaceutical Benefits (NHL) - Schedule 4 part 1

Cows' milk protein enteropathy

Initial treatment for up to 6 months

Must be treated by a specialist allergist, clinical immunologist or specialist paediatric gastroenterologist and hepatologist, or in consultation with a specialist allergist, clinical immunologist or specialist paediatric gastroenterologist and hepatologist; AND

The condition must not be isolated infant colic or reflux; AND

Patient must be intolerant to both soy protein and protein hydrolysate formulae, as demonstrated when the child has failed to respond to a strict cows' milk protein free and strict soy protein free diet with a protein hydrolysate (with or without medium chain triglycerides) as the principal formula; AND

Patient must be up to the age of 24 months.

The name of the specialist and the date of birth of the patient must be included in the authority application.

Listing of Pharmaceutical Benefits (NHL) - Schedule 4 part 1

Severe cows' milk protein enteropathy with failure to thrive

Initial treatment for up to 6 months

Must be treated by a specialist allergist, clinical immunologist or specialist paediatric gastroenterologist and hepatologist, or in consultation with a specialist allergist, clinical immunologist or specialist paediatric gastroenterologist and hepatologist; AND

The condition must not be isolated infant colic or reflux; AND

Patient must be up to the age of 24 months.

The name of the specialist and the date of birth of the patient must be included in the authority application.

Listing of Pharmaceutical Benefits (NHL) - Schedule 4 part 1

Combined intolerance to cows' milk protein, soy protein and protein hydrolysate formulae

Initial treatment for up to 6 months

Must be treated by a specialist allergist, clinical immunologist or specialist paediatric gastroenterologist and hepatologist; AND

The condition must not be isolated infant colic or reflux; AND

Patient must be older than 24 months of age.

The name of the specialist and the date of birth of the patient must be included in the authority application.

Listing of Pharmaceutical Benefits (NHL) - Schedule 4 part 1

Proven combined immunoglobulin E (IgE) mediated allergy to cows' milk protein and soy protein

Initial treatment for up to 6 months

Must be treated by a specialist allergist, clinical immunologist or specialist paediatric gastroenterologist and hepatologist, or in consultation with a specialist allergist, clinical immunologist or specialist paediatric gastroenterologist and hepatologist; AND

Patient must have failed a trial of protein hydrolysate formulae (with or without medium chain triglycerides); AND

Patient must be up to the age of 24 months.

The name of the specialist and the date of birth of the patient must be included in the authority application.

Listing of Pharmaceutical Benefits (NHL) - Schedule 4 part 1

Eosinophilic oesophagitis

Initial treatment for up to 3 months

Must be treated by a clinical immunologist, suitably qualified allergist or gastroenterologist; AND

Patient must require an amino acid based formula as a component of a dietary elimination program; AND

Patient must be 18 years of age or less.

Treatment with oral steroids should not be commenced during the period of initial treatment.

Eosinophilic oesophagitis is demonstrated by the following criteria:

(i) Chronic symptoms of reflux that persisted despite a 2-month trial of a proton pump inhibitor or chronic dysphagia; and

(ii) A lack of demonstrable anatomic abnormality with the exception of stricture, which can be attributable to eosinophilic oesophagitis; and

(iii) Eosinophilic infiltration of the oesophagus, demonstrated by oesophageal biopsy specimens obtained by endoscopy and where the most densely involved oesophageal biopsy had 20 or more eosinophils in any single 400 x high powered field, along with normal antral and duodenal biopsies.

The date of birth of the patient must be included in the authority application.