November 02, 2020

Cow's Milk Protein Allergy

Cow's milk protein allergy is one of the most common food allergies seen in children. It is most commonly seen during the first year of life. Many children who have been allergic to cow's milk protein become tolerant to it by the time they are 5 years old.

In this article:
What is cow's milk protein allergy?
Allergic reactions to milk
Milk alternatives

What is cow's milk protein allergy?

Cow's milk protein allergy is an allergic condition which is triggered by drinking cow's milk or by drinking or eating products made from cow's milk. See the separate article, What You Need To Know About Allergic Reactions, for more details.

It can cause:
  • Skin symptoms, such as rashes and eczema
  • Gut (digestive tract) symptoms, such as feeling sick (nausea), being sick (vomiting) and abdominal (tummy) pain
  • Breathing (respiratory) symptoms, such as a runny nose and wheezing. See the separate article, Breathlessness and Difficult Breathing, for more details.
The symptoms of cow milk protein allergy are often vague and sometimes it is very difficult for a definite diagnosis to be made.

Cow's milk protein allergy occurs in about 7% of babies who have formula milk, but in only about 0.5% of exclusively breast-fed babies, who also usually have milder reactions. Exclusive breast-feeding may also protect babies from developing an allergy to cow's milk protein after they are weaned. See also the separate articles, Infant and Young Child Feeding; and also see The Dos and Donts Of Breastfeeding, for more details.

Cow's milk protein allergy is more likely in children who have other allergic (or atopic) conditions such as asthma, eczema or hay fever, or if close family members have those conditions.

Allergic reactions to milk

There are two different processes which cause allergic reactions in the body; cow's milk can trigger either of these in some people. Some people develop symptoms of both types of reaction.

Non-immunoglobulin E-mediated reactions (non-IgE-mediated allergy)

These are slow reactions which can occur hours, or more usually days, after consuming milk. There can be a skin reaction such as eczema, tummy (abdominal) symptoms such as pain, reflux or colic or breathing (respiratory) symptoms.

The best way to find out if the child has this kind of allergy is to exclude cow's milk from their diet. Milk needs to be excluded for at least two weeks, as the symptoms caused by slow reactions also take quite a long time to settle. If the symptoms settle when milk is removed from the diet, a challenge test can be done in which the child has a small amount of milk. If the milk causes the same reaction as before, the diagnosis can be confirmed. It may take several days for the reaction to show. A challenge test can be repeated every few months, as the child is likely to grow out of this allergy with time.

For babies who are bottle-fed, there is special formula milk available on prescription. This has the proteins broken down so that they do not cause the allergic reaction.

Mothers who are breastfeeding need to exclude milk and milk-containing foods from their own diet. They should be prescribed a supplement of calcium and vitamin D, so that they don't become deficient in these nutrients.

Older babies and children who are on a cow's milk-free diet for confirmed allergy should see a specialist children's (paediatric) dietician who can make sure the diet is balanced and contains enough calcium.

It is important to read the labels on food that you buy. Some milk products which are used as ingredients may have names such as casein, whey or curd. More familiar dairy products such as butter, yoghurt and cheese are also found in many packaged foods.

Most children with this kind of allergy grow out of it by the time they are 3 years old.

Immunoglobulin E-mediated reactions (IgE-mediated allergy)

These are usually fast reactions which can cause skin rashes and vomiting. They occur within two hours of the milk being consumed. They are triggered by the body releasing a chemical called histamine, so antihistamine medicine can be used to treat the symptoms. It is extremely rare that cow's milk causes a life-threatening anaphylactic reaction. See the separate article, Anaphylaxis: Causes, Symptoms, Testing, Treatment and Prognosis, for more details.

This type of allergy can be diagnosed with a skin prick test or a blood test. If this type of allergy is suspected, the child would usually be referred to a children's doctor (paediatrician) who would arrange for the test to be done in hospital.

Skin prick testing for allergies
A person receiving a skin prick test (SPT). An SPT is performed by using a needle to place a tiny amount of liquid allergen just under the skin of the forearm. SPTs are safe and the results, a raised bump with redness around it (called a wheal and flare), usually appear within 30 minutes. A number of allergens can be tested with an SPT, including ragweed, house dust mite, cat, grass, egg, milk, and peanut. Credit: National Institute of Allergy and Infectious Diseases (NIAID) / National Institutes of Health (NIH).
Most children with this kind of allergy grow out of it by the time they are 5 years old. If the reaction has been severe, it may be safest to carry out a challenge test in hospital.

A referral to a paediatrician should be made for either type of reaction if:
  • The child is not growing well.
  • There have been any severe reactions.
  • Multiple food allergy is suspected.

Mixed IgE- and non-IgE-mediated allergy

Sometimes there can be a mixture of the two types of allergic reaction. This causes a combination of the two types of allergic responses.

Milk alternatives

If cow's milk protein allergy is suspected then your doctor can prescribe formula milk suitable for your baby. There are several different types of milk available.

Extensively hydrolysed milk is usually tried first. The protein in hydrolysed milk is broken down (hydrolysed) into smaller pieces so that it does not trigger a reaction. Examples of hydrolysed milks are Similac Alimentum®, Nutramigen Lipil® 1 and 2 and Pepti® 1, 2 and Junior.

If a baby is still having symptoms on a hydrolysed formula then they can try an amino acid (AA) formula. This is sometimes tried first if the allergy is severe or if there are multiple allergies. The protein in AA formula is completely broken down into its smallest units, called amino acids. This should prevent any cow's milk protein reaction occurring. Examples of amino acid formulas are Neocate® and Nutramigen® AA.

Under the age of 6 months, babies should have either breast milk or specially developed infant formula milk. This should remain their main drink up to the age of 1 year. See the separate articles, Infant and Young Child Feeding; and also see Breastfeeding Dos' and Donts' You Need to Know, for more details.

Some people give their children goat's milk or other types of milk which are believed to be more easily digestible than cow's milk. In fact, the proteins in other available mammal milks are very similar to those in cow's milk. Therefore, changing to goat's milk rarely causes improvement in confirmed cow's milk protein allergy.

Using milk which is low in a sugar called lactose and found in milk will not be helpful. This is because it is the protein and not the lactose in cow's milk which is causing the problem.

Soya milk is not generally recommended for children who are allergic to cow's milk. Soya is another common cause of childhood food allergies and those who have one allergy are more likely to develop others. It should not be used as a main drink for babies aged under 6 months. However, it may be recommended by a healthcare professional after that time if the child is not allergic to it.

What is lactose intolerance?

Lactose intolerance is a different condition from cow's milk protein allergy. It occurs because the body cannot digest a sugar called lactose found in milk, rather than a protein. It is very common worldwide but tends to develop in later childhood or in adulthood.

Reference(s):
1). British Society for Allergy and Clinical Immunology (2014): Guideline for the diagnosis and management of cow's milk allergy. Available Online.
2). NICE Clinical Guideline (February 2011): Food allergy in under 19s: assessment and diagnosis. Available Online.
3). NICE CKS, Updated December 2019: Cow's milk protein allergy in children. Available Online.
4). Allergy UK: Cow's milk allergy. Available Online.
5). Sian Ludman, Neil Shah, Adam T Fox; Managing cows’ milk allergy in children. BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5424 (Published 16 September 2013). Available Online.
6). Koletzko S, Niggemann B, Arato A, et al; Diagnostic approach and management of cow's-milk protein allergy in infants and children: ESPGHAN GI Committee practical guidelines. J Pediatr Gastroenterol Nutr. 2012 Aug55(2):221-9. doi: 10.1097/MPG.0b013e31825c9482. Available Online.
7). Turnbull JL, Adams HN, Gorard DA; Review article: the diagnosis and management of food allergy and food intolerances. Aliment Pharmacol Ther. 2015 Jan41(1):3-25. doi: 10.1111/apt.12984. Epub 2014 Oct 14. Available Online.

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