What are the treatment options for my child's cows milk protein allergy?

Cow milk protein allergy occurs when someone has an immune response to proteins present in cow's milk because their body mistakenly thinks of the proteins as a threat.

Cow's milk protein allergy is an allergy that typically presents before children turn one and has a prevalence of between 1.8%-7.5% (1<yrs old) in England. Interestingly, about 80% of children will be able to introduce cows’ milk back into their diet at around 3-5 years, in other words, they grow out of the allergy.

Types of CMPA & their symptoms

There are 2 main types of CMPA that present with different reaction times and symptoms;

1. IgE mediated CMPA - immediate reaction

An IgE refers to an ‘immunoglobulin’, a specific type of protein that is produced by the immune system in response to proteins in cow’s milk. The reaction is often immediate (and up to 2 hours after of ingestion the milk) and may result in the following symptoms;

· itchy skin rashes (redness or hives)

· swelling of the face, eyes or lips

· runny nose, itchy eyes

· eczema

· coughing

· vomiting

· swallowing or breathing difficulties (rare)

2. Non-IgE mediated CMPA – delayed onset reaction

Non-IgE mediated refers to a different immune response which does not involve IgE’s - it involves other cells in the immune system including T cells and white blood cells. The reactions to this type of CMPA range from a minimum of 2 hours - 72hrs after the ingestion of the cow’s milk - the reaction is therefore often less obvious and may include symptoms such as;

· diarrhoea - often with a sore bottom (nappy rash)

· constipation – often associated with excessive straining

· gastro-oesophageal reflux disease

· profuse vomiting

· abdominal pain, bloating or distension

· mucous and/or blood in the stools

· nausea

· painful wind, excess gas

· eczema

· food refusal/faltering growth

Diagnosis & Treatment

Due to the difference in nature of the IgE and non-IgE- mediated CMPA’s their diagnosis and treatment differ;

IgE mediated

· IgE blood tests - by looking at the levels of this immune protein in the body a diagnosis can be made.

· Skin Prick Tests - a process whereby the milk is exposed to the child’s skin and the severity of the reaction (i.e size of the red circle) can be a useful indicator of allergy diagnosis.

Non-IgE

The treatment for delayed onset CMPA is termed ‘exclusion and reintroduction’. This is a somewhat complicated, time-consuming process which should always be led by a dietitian or registered nutritionist (check out our sessions here). In summary, cow’s milk is excluded from the diet and then after, roughly 3 weeks (to ensure that any traces of the milk are removed from the body) the milk is reintroduced. At this point, if symptoms are present a diagnosis can be made.

Understanding the background of the allergy, known as the allergic history, is another crucial element of diagnosis and something which the dietitian will talk you through.

Positive Diagnosis and Treatment

· Often, initially, all dairy and diary-containing products from both the child and mother’s diet are removed

· breast-feeding mothers are always encouraged to breastfeed where possible - breast milk has been scientifically proven to be the best source of nutrients for babies up to the age of 6 months

· milk substitutions

Several replacements exist for cow’s milk during this time and your dietitian will help you decide on these, as they differ in composition.

Typically children are placed on

a) extensively hydrolysed formulas (eHFs)

b) amino-acid-based formulas (AAF).

· occasionally dietary supplements e.g. calcium and vitamin D

· gradual reintroduction via the ‘milk ladder’

NB: Severe reactions such as lack of breathing are considered a medical emergency and 999 must be contacted immediately.

Our team here at Nutrition and Co will take you to the next steps, whichever they may be from the list above. It is very important that this allergy is followed up as milk is an integral part of a child’s diet, particularly when it comes to nutrients for growth, and should not be excluded unnecessarily.

Remember most children grow out of this type of allergy - without repeated exposure, their tendency to no longer react may not be picked up on

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Want support & keen to know more?

Book a 1-1 express nutrition consultation with our expert allergy dietitian.

Here you will find out ;

- the exact protocol for your child (Evidence based)

- all the resources you need

- a nutrition summary report that has been individualised to your child

- an abundance of dairy free recipes for your child

& much more!

References

Allergy UK ‘What is a food allergy?’ Available from: https://www.allergyuk.org/about-allergy/what-is-an-allergy/ (Accessed July 2022).

BDA. Milk allergy: Food Fact Sheet. 2022. Available from: https://www.bda.uk.com/resource/milk-allergy.html (Accessed July 2022).

Food Allergy Specialist Group (FASG) of The British Dietetic Association. Cow’s Milk Free Diet for Infants and Children. 2020. Available from: https://patientwebinars.co.uk/wp-content/uploads/2020/03/Diet-Sheet-Milk-Free-Diet-Children-20.03.20.pdf (Accessed July 2022).

Motala & Fiocchi. 2012. Cow’s milk allergy in children. World Allergy Organisation. Available from: https://www.worldallergy.org/education-and-programs/education/allergic-disease-resource-center/professionals/cows-milk-allergy-in-children (Accessed July 2022).

NHS. Pathway for the diagnosis and treatment of Cow’s Milk Allergy in Children. 2017. Available from: https://www.herefordshireccg.nhs.uk/your-services/medicines-optimisation/prescribing-guidelines/nutrition/specialist-infant-formulae-for-cma-cow-s-milk-protein-allergy/769-hccg-cow-s-milk-allergy-pathway/file (Accessed July 2022).

NICE. Cow's milk allergy in children. August 2021. Available from: https://cks.nice.org.uk/topics/cows-milk-allergy-in-children/background-information/definition/ (Accessed July 2022).