Cow’s milk allergy – does my child have this?

There seems to be a lot of confusion on this topic so I have been meaning to write a blog entry for some time on cow’s milk allergy. I have finally found some time to write this on a flight back from Athens after a Gastroenterology Congress.

Although many parents believe their child has a cow’s milk allergy, only about 2-4% have a real allergy – meaning that the cow’s milk allergy was proven through a double blind challenge where the child received milk without the parents or the medical staff knowing and developed symptoms. I am actually not surprised that there is such a difference between believing a child has a cow’s milk allergy and real cow’s milk allergy because some of the symptoms of this allergy overlap with normal childhood tummy complaints like colic, loose/harder stools and spitting up of milk which usually settles with time as the tummy becomes more mature. So, it is not always an easy diagnosis to pick up even for us as healthcare professionals.

First some basics and unfortunately this is a bit technical but essential to help you understand. You get two types of cow’s milk allergy: Immunoglobulin E (IgE) mediated, which is the immediate type allergy, where a baby consumes the milk/milk products and usually within 2 hours has symptoms that include skin rashes, hives, acute vomiting and in severe but rare, cases swelling and closing of the throat, and compromised breathing called anaphylaxis.  This usually is an easier allergy to identify. The other type of allergy is a non-IgE mediated cow’s milk allergy which is a delayed type allergy and the symptoms typically occur after 2 hours and can take up to a couple of days to occur after the consumption of cow’s milk/cow’s milk products. The delayed type cow’s milk allergy usually affect the stomach and bowels and you can get diarrhoea (with or without blood), severe constipation, abdominal pain, vomiting and/or eczema. This allergy is really hard to diagnose as it relies on symptoms only!

Its important to familiarise yourself with the terminology, in particular there seems confusion about the delayed type cow’s milk allergy, which often is inappropriately called a “lactose intolerance” or a “cow’s milk protein intolerance”.  A food allergy means the reaction is mediated by the immune system, whereas with a food intolerance this is not the case. This is important as the treatment is different between for example lactose intolerance and cow’s milk protein allergy. A non-IgE mediated cow’s milk allergy is treated with a total elimination diet of cow’s milk in all forms due to an allergy to the protein, whereas lactose intolerance is just an intolerance to lactose the carbohydrate in cow’s milk and is treated with a low lactose diet and a lactose free milk, where only the carbohydrate “lactose” is removed. However all lactose free milks, yoghurts, cheese still contain the cow’s milk protein, so is not suitable for a child with a cow’s milk protein allergy.

The diagnosis of an IgE-mediated cow’s milk allergy is based on an allergy focused history that your doctor/dietitian takes and tests including skin prick tests and specific IgE blood tests help with confirming this diagnosis. Unfortunately, with the delayed type non-IgE mediated cow’s milk allergy there is no reliable blood test or skin test to help with the diagnosis. The diagnosis is reliant on following an elimination diet of cow’s milk for about 4 weeks with subsequent symptom improvement followed up by a reintroduction with the reappearance of symptoms.  Do not be fooled by any alternative tests on the market for “intolerances” (i.e. Vega testing, York test or IgG4 testing and lots more).

It is really important that the diagnosis of cow’s milk allergy is made by a healthcare professional that understands allergy and that you do not just cut out cow’s milk out of your child’s diet as this is a nutrient that is essential for growth. There are many guidelines available to help with the diagnosis In the UK we have the NICE guidelines and also MAP guidelines, which are really good.  I will post a blog of specialists feeds next week.

Should a toddler be on a low fat high fibre diet?

This question does come up every now and again in my practice and I do often see young children on low fat yogurts, skimmed milk, very lean meat, only whole grain products and looking very skinny and often iron deficient. Firstly, I want to say that the suggestions I am making today, are for children that grow normally and where overweight and obesity is not a problem.

Fat is the most energy dense source of nutrition in our toddlers’s diets and does not only play an essential role in the development of the cell membranes of the organs (i.e. retina) and the central nervous system, but with a small stomach capacity plays an important role in achieving energy requirements. Do you remember expressing breast milk and being surprised at the thick fat layer when the breast milk separates out?  Well, almost half of the energy from breast milk comes from fat.  The World Health Organization recommends that breast feeding ideally should continue until 2 years of age, meaning also that they have requirements for higher fat until this age.

Of course there is fat, fat and fat. So breast milk is high in essential fatty acids and therefore an ideal source of fat. We also do not want young children to have a diet high in saturated fat (i.e. animal fat), but rather a mixture of different fats – olive oil, rapeseed oil, coconut oil, avocado oil and yes they can have real butter (remember that butter can be high in salt, so check this) as well. Its best though to provide a variety of fat as each type of fat has a different role.

When it comes to protein that often contributes to fat intake – ideally one should aim for 2 portions of oily fish per week, the rest white meat, white fish and pulses and limit red meat to twice per week. When it comes to milk products, in a child that grows normally the recommendation is to have full fat milk and products until 2 year of age and then you can consider changing this to semi-skimmed milk and lower fat milk products. Remember, that fat does not only contribute energy but some of the fat sources contain fat soluble vitamins like vitamin D, E and A and omega-3-fatty acids.

Now what about fibre content of foods. Should you give whole grain rice/pasta and bread from the time you start weaning? The exact amount of fibre young infants require is unclear, but we do know that excessive fibre leads to rapid gut transit time, meaning that the food moves faster through the gut and can reduce the time for absorption. In addition, too much fibre can bind essential vitamins and minerals and reduce the availability for absorption. It is therefore better to have a balanced approach as your toddler should already have 5 portions of fruit/vegetables per day which provides plenty of fibre. I usually suggest providing whole grain (not granary) bread from when they are able to finger feed and they can have Weetabix or other whole grain breakfast cereal from 7-8 months of age (make sure low in salt and sugar), but to wait for whole grain rice/pasta and other similar products until they are one year of age.

It has become a big fashion to add ground up flaxseed and other seeds to toddler meals, but remember flaxseed for example is very very high in fibre, so your child does not get the time to absorb the omega-3-fatty acids, so rather use the oil than the seeds themselves if you want to increase the omega-3-fatty acid intake.


Baby Led Weaning (BLW) – When to use?

There is almost not a week going by without parents asking me about the BLW approach. For those of you that do not know this approach it was developed by Jill Rapley, a UK qualified health visitor that suggested starting with soft pieces of food from 6 months of age – meaning you jump the whole puree phase and babies just start by feeding themselves. She has published several books and has a website as well.

Initially it was seen as a craze from us as healthcare professionals, but since then this method of weaning has been studied by a couple eminent researchers. The studies have found that the majority of babies can feed themselves from 6 months of age using this approach and thrive, they learn how to regulate their own appetite better, have a preference for healthier foods and have a lower BMI  (Body Mass Index) when they are older . There are however babies where this approach may not be appropriate, in particular those children with developmental delay, with faltering growth and other medical problems where food needs manipulation due to a medical reason. In these cases it is better to consult a dietitian or if you are in the UK your health visitor to establish if this method is safe and would sustain growth and development.

Key to using BLW is to start it only at 6 months of age and really to follow your baby with introductions. It is amazing how quickly they learn to eat soft fruit and vegetables and I have plenty of babies who eat meat happily without any teeth. You will find plenty of You Tube videos if you are a “non-believer” of babies from 6 months of age chomping on chicken legs and other more complex foods.

The advantage for me in using this approach for children with no underlying medical conditions is that you get less feeding difficulties as the baby has to regulate their own appetite and will therefore eat what they want to eat, instead of you as parents feeling they need to eat a specific portion. Although this method is pretty new, it is possibly also that we may have less obesity using an approach where babies control their own appetite. Of course you still need to offer a balanced meal and for this I suggest that you look at my previous blog entries to help you out. Happy feeding !