What do I need to do if I suspect my child has a cow’s milk allergy?

Last week I wrote a blog on cow’s milk allergy, which I had quite a bit of response on. I thought it is useful to follow this up as promised with a blog entry on what to do if you suspect your child has cow’s milk allergy. First of all, please do NOT remove cow’s milk out of your child’s diet without consulting with your doctor to establish whether there are other causes for the symptoms that your child is exhibiting. If a cow’s milk allergy is suspected an elimination diet of cow’s milk may be recommend to see if the symptoms improve.  This should ideally be done under the supervision of a dietitian. I know that I often get complaints that some of you do not have dietitians in your areas or that there is a long waiting list to see one. It is worth the wait as cow’s milk provides a lot of essential nutrient especially if in the young. The British Dietetic Association has some Fact Sheets that have been put together by the Food Allergy Specialist Group, that provide information, but they do not replace an individualised dietetic appointment.

I wanted to broadly discuss general treatment models for cow’s milk allergy. If you are breastfeeding your baby, please continue breastfeeding and get advice on how to optimally take out cow’s milk out of your diet without compromising your nutritional status and reducing breast milk quality. It is highly likely that a calcium and vitamin D supplement will be required. In some cases your doctor/dietitian may recommend that you remove not only cow’s milk but soya and other food allergens. Again, this should NOT occur unsupervised.

If your child is not on breast milk, but on formula milk you will be recommended a hypoallergenic formula. You get two types, an extensively hydrolysed formula and an amino acid formula. The majority of children with have full symptom improvement on an extensively hydrolysed formula, which is made from short chain peptide (cow’s milk protein chopped up in smaller building blocks) that your child’s body will not recognise as an allergen. In a small number of children an amino acid formula is required. These are formulas that contain amino acids only, the smallest building blocks of protein.

Its important to note that these formulas taste different, smell different and yes, will lead to your child’s stools to look different – dark green in the majority of cases. If they spit up, the smell of this will also be different and it will have a different texture. This is absolutely normal and related to the fact that these milks have smaller pieces of protein or amino acids.

Whilst writing on hypoallergenic formulas, its crucial that parents also understand that any milk from animals on 4 legs (goat, sheep, buffalo, donkey) should be avoided as the protein is very similar and over the counter milks like for example oat, quinoa and coconut milk should only be offered after 1 year of age and ideally after a review by a dietitian. You can though use them in cooking from 6 months of age.

I would like to finish off this blog entry by saying that what I have written above does not replace professional advice cow’s milk allergy and nutritional management. Advice is ideally tailored for the individual.

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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.