Milk Allergy

Cows' Milk Allergy (CMA) – An introduction
The first months of your baby's life bring much joy. But equally there may be times when you have cause for concern. Even if you have had a baby before, no two infants are the same and it is often difficult to know what is part of an individual baby's development and when there is something amiss.
Because your baby can't tell you when there is a problem, it's right that you trust your instincts. The symptoms of Cows' Milk Allergy can be confused with other conditions but the allergy is more common than you think. In fact, 1 in 20 children under 3 years are allergic to cows' milk. This can make frequently used formula milks unsuitable – and in some cases even breast milk can be an irritant.
CMA can only be confirmed by healthcare professionals. So if you suspect your child's symptoms may be linked to cows' milk, it's important that you make an appointment to ask your doctor's advice.

What is a food allergic reaction?
In short, an allergic reaction to food occurs when the body’s immune system responds inappropriately to something in a particular food. The symptoms caused by this are called 'food allergic reactions'.
What happens in the body?
We all have an immune system to protect us from infections. Our immune system attacks the viruses and bacteria that can make us ill. An allergic reaction is simply an overreaction of that system. With a food allergy, the body’s immune system mistakenly recognises common “proteins” that are present in the foods we eat as potentially harmful. An immune response is set in motion aimed at neutralising the “harmful protein” and is responsible for the symptoms experienced when a child or adult is allergic to a certain food.
What makes diagnosis difficult is that the symptoms don’t always appear straight away. The immune system may respond to a food allergy within minutes of your child eating or drinking. In these cases, there are reliable tests which help doctors make the diagnosis.
Sometimes, the immune system can take longer to react - several hours or even days. This makes it difficult to diagnose through allergy testing.
Which foods are the typical culprits?
Cows' milk
Fish and shellfish
Hens' eggs
Peanuts and tree nuts
Soya beans
Although around a quarter of parents suspect their child has a food allergy, only 1 or 2 in every 20 young children are truly suffering from food allergy.
Food for thought
Food allergies are thought to be occurring more frequently - particularly in developed countries. Most food allergies are acquired in the first years of life and disappear again over time. Children who suffer from one food allergy might be hypersensitive to other foods as well.
Good news! Just because a child is allergic to one food doesn’t mean you have to automatically avoid all the foods which other children are allergic to. Your child’s doctor or dietitian will be able to advise which foods are likely to trigger an allergic reaction in your child.
By getting a correct diagnosis of a food allergy you can eliminate the food that is causing the allergy while ensuring that your child gets the right, nutritionally balanced, diet. Do tell your child’s doctor and/or dietitcian if you suspect symptoms which may be related to food allergies.


Cows’ Milk Allergy in children
When infants and children are fed cows’ milk or any parts of it, this can trigger allergic reactions. By avoiding the ‘proteins’ in cows’ milk completely, the symptoms caused by this reaction can be eliminated.
Cows’ milk – and the proteins it contains - is often one of the first complementary foods to be introduced into the infant’s diet. Cows’ milk is also commonly consumed throughout childhood as part of a balanced diet. Cows’ milk allergy (CMA) is the most common food allergy in infants and young children – up to 1 in 20 of all children may suffer.
The symptoms caused by CMA can be varied and may affect several parts of the body.
How the body is affected:
Skin – including rashes and eczema
Digestion – including vomiting, diarrhoea, colic
Breathing - including wheezing
Excessive crying
Allergic reactions can set in very rapidly (e.g. breathing problems, vomiting), but they can also be delayed or require more of the food (say a bottle of milk) to set them off.

In formula-fed infants and older children, avoiding whole cows’ milk proteins will be necessary to eliminate the symptoms of CMA. This may mean substitutes will need to be included in your child’s diet – your doctor or dietician is best placed to advise what’s best in each case.
If you are breastfeeding - it may be recommended that you avoid milk products – speak with a doctor or dietitian to ensure your diet remains adequate though before avoiding milk or dairy products.
If your baby is being bottle fed - there are alternative formulas containing ‘proteins’ which have been changed so that they are not like cows’ milk protein at all. Your doctor or dietitian will be able to recommend the best CMA management option for your child.

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Why does CMA occur?
It is not clearly understood why some children’s immune systems try to ‘fight’ certain foods or the ‘proteins’ they contain. In general, infants and young children are much more sensitive as their immune systems are still quite immature. Children coming from a family with an extensive history of allergy have a greater risk of developing food allergy than those with allergy-free relatives. However, even infants and children having no family history of allergy at all can have allergic symptoms.
What are common food allergy symptoms?
It’s not always easy to spot the symptoms of food allergies – even for doctors. That’s because the signs of food allergy can be mistaken for other common conditions seen in babies and infants.
The following may be clues to a food allergy, especially if accompanied by restless sleep or excessive crying:
• Eczema
• Diarrhoea
• Colic
• Constipation
• Wheezing
• Vomiting/Reflux
Sometimes the allergy in question can be to cows’ milk. Cows’ milk allergy (CMA) typically develops in the first year of life.
CMA or lactose intolerance?
Although Cows' Milk Allergy (CMA) and lactose intolerance can cause similar symptoms, they are two completely different conditions and affect the body in different ways. It is quite easy to confuse them, but the following information should help to explain the difference.
The main difference is that CMA is a food allergy, which means that the immune system overreacts to one or more “proteins” contained in cows' milk. To avoid a food allergic reaction, it is important to avoid the intake of the protein.
Lactose intolerance is the inability to digest the milk sugar which is called lactose. It is a food intolerance which means that the body cannot deal with this nutrient. The immune system is not involved so no allergic reaction takes place. Symptoms such as bloating, abdominal pain, flatulence, or diarrhoea can be signs of lactose intolerance. The skin and breathing are not usually affected. However like CMA, the symptoms of lactose intolerance can only be managed by avoiding certain foods. In this instance, any foods containing lactose – which means all sorts of milk and dairy products. Fortunately, lactose-free milk and dairy products are available in most shops and can be a good alternative.
Please go and see your child’s doctor or dietitian if you are worried or not sure about your child’s symptoms.
How is CMA diagnosed?
How can you find out for sure if your child is allergic to cows' milk? What will your child's doctor do to confirm the diagnosis?
What might happen at the doctor’s?
Diagnosing CMA can mean a bit more than a single test at the doctor’s.Your child’s symptoms, medical history and overall assessment will be taken into account along with any test results when deciding if your child has a food allergy.
Here are some questions your child’s doctor may ask:
How old was your child when you first noticed the symptoms?
How quickly do symptoms develop?
How severe are the symptoms?
How long do they last?
How often do they happen?
Where do symptoms usually appear? (For example at home, or at school?)
Do the same symptoms happen each time your child eats a particular food?
Do you suspect a specific food is involved – if so, how much of the suspected food does your child need to eat for symptoms to appear?
How you can best prepare for your doctor’s appointment:
When it comes to diagnosing allergies, the child’s medical history may be as important as any diagnostic test results. So do make a note of any information about your family’s medical history as well as the medical history of your child before visiting the doctor.
Identifying the symptoms is the first step in providing relief for your baby. So the more you tell your doctor, the better.
Why not keep a diary to see how different foods affect your baby?
There is a lot to cover at the doctor’s appointment so it’s a good idea to make a note of any questions you might like to ask your doctor so you don’t forget. Questions parents often ask include:
Could my child’s symptoms be caused by food allergy?
Is it possible to confirm if my child has a food allergy?
Which tests will have to be performed?
Do I need to see a specialist?
What will be the next steps?
Which tests might your doctor want to do to diagnose food allergy:

Your child’s doctor will use all of the information you provide to help decide whether allergy tests are called for. Allergy testing can involve:
Skin tests

Diets to aid a diagnosis

Elimination diet


Skin Prick Tests



Food challenges
Can it happen in breast-fed babies?
Very rarely, babies who only receive breast milk can react to cows’ milk proteins. These proteins can be passed on through their mother’s milk if she has been consuming dairy products. In this situation, healthcare professionals recommend that breast-feeding is continued due to its benefits and the mother tries to eliminate cows’ milk protein from her diet.
Breastfeeding and CMA
The first few months of a baby’s life are a crucial period for its growth and development. The World Health Organization (WHO) recommends breastfeeding exclusively for the first six months as breast milk contains antibodies which will help your baby’s immune system develop and protect against certain infections. Normally babies will not develop allergic symptoms while being exclusively breastfed.
If my baby has CMA do I have to stop breastfeeding?
Although breastfeeding is best for most children, very sensitive babies can have allergic reactions. This does not mean that they are allergic to breast milk itself. What happens is that they react to the small amounts of cows’ milk proteins (from milk or dairy products you have eaten) that pass from mother to baby in the breast milk. Should this happen, you may be advised to eliminate cows’ milk, dairy products, and all products containing cows’ milk from your diet. Please talk to a dietitian when eliminating any foods from your diet in order to be sure you – and your baby - are getting all the vital nutrients to stay healthy.
If your child shows allergic symptoms while being exclusively breast-fed, the ideal solution is to avoid foods containing cows’ milk proteins but still carry on breastfeeding. If you have any questions or concerns it is important that you ask your healthcare professiona

How are CMA symptoms managed?
CMA symptoms can be managed by eliminating cows’ milk protein from your child's diet. There are several substitutes available - including formulas containing cows’ milk proteins which have been changed or broken down (these are called ‘hydrolysed formulas’)and formulas that contain no cows’ milk protein at all (these are sometimes called ‘amino acid-based formulas’).
Because all children need proteins for growth and development, proteins can’t be completely removed from your child’s diet. So milk proteins must be replaced by alternatives. However, the majority of infant milk formulas you may be familiar with contain ‘intact or whole’ milk proteins and protein fragments (in other words, cows’ milk proteins which haven’t been changed or broken down). So many baby milk formulas aren’t suitable either.
What are the types of infant formula?​
Standard infant formulas that you can buy in a supermarket or local shop
These are not suitable for babies allergic to certain proteins. This is because they are made with cows’ milk powder which has been modified to provide what is needed in a baby’s diet but still contain whole cows’ milk proteins. These proteins can cause allergic reactions in babies with CMA.
Extensively hydrolysed formulas (eHF)
These are formulas considered ‘foods for special medical purposes’ and are prescribed by a doctor for the management of CMA. Here the cows’ milk protein has been broken down into small fragments. However, depending on the type of milk allergy (immediate or delayed), eHFs may cause allergic symptoms in some children with severe cows’ milk allergy.
Amino acid-based formulas (AAF)
These formulas are also prescribed by the doctor for infants with CMA. They are similar to most other infant milks except for one important difference. Instead of being based on whole or broken down cows’ milk protein, they are based on amino acids, sometimes known as the building blocks of protein. These individual amino acids are so small that they are not recognised by the immune system and so are very unlikely to provoke any allergic reaction in children with cows’ milk allergy.
Soya milk
Soya formula used to be the only product that could be given to infants and children with CMA. Nowadays, formulas based on amino acids or hydrolysed proteins are widely available and are generally deemed to be more appropriate.
Soya infant formulas contain soya protein derived from soya flour, and a mixture of carbohydrates in the form of sucrose and corn syrup. Medical guidelines in the UK and the USA do not recommend soya products for infants under the age of 6 months and so should only be used in specified circumstances. If your child is over 6 months and your child’s doctor suggests a soya formula because of CMA, tolerance to soya protein may well need to be checked first.
Other milks
In some countries, milk from other mammals such as goats and sheep, have traditionally been used for feeding infants with CMA. Such milks are not always tolerated by babies allergic to cows’ milk as the proteins are very similar in structure to cows’ milk protein. Cereal milks could be another option, but if these milks are not fortified, some vitamins and minerals may be missing, and there could be inadequate amounts of essential nutrients your baby needs. Equally, it is recommended by the UK's Food Standard Agency that children under the age of 4.5 years do not consume rice milk.
Check with your child’s doctor or dietitian before feeding your child any of the alternatives above to make sure they can tolerate them and whether they meet your baby’sdietary requirements.
What can I do to relieve the symptoms?
Usually, symptoms will disappear once the allergic food has been identified and eliminated from the baby’s diet. Until this happens, here are some tips to help you and your baby:
What can I do if my baby has skin reactions?
Use a daily skin care routine regularly applying moisturising creams to prevent flares and further skin damage. Ask your pharmacist for suitable creams which won’t irritate the skin further. Try and prevent scratching or rubbing whenever possible. It will also help to keep rooms at a cool, stable temperature and consistent humidity levels. Try not to expose your baby’s skin to general irritants, such as
wool or synthetic fibres
soaps and detergents
perfumes and cosmetics
dust
sand
cigarette smoke
other chemicals such as chlorine, mineral oil, or solvents
What can I do if my baby has colic or cramps?
Baby colic usually improves on its own at around three to four months of age. In the meantime, prevent your baby swallowing air by sitting him or her as upright as possible during feeding. Remember also to let your baby burp often, sitting him upright or holding him upright on your shoulder, while supporting his neck and head. Gently rub his back and tummy until he burps. It is quite normal if he or she brings up a small amount of milk when you do this. Also, when bottle feeding, don’t let your baby drink too quickly.
What can I do if my baby has reflux?
Reflux is when liquid comes back up after being swallowed and is a natural mechanism that affects all babies, some more often than others. Here are some general feeding guidelines which should limit reflux to a minimum:
feed your baby in an upright position in a calm environment
feed smaller portions more often rather than larger meals
after feeding avoid jiggling your baby and allow time to burp
You can also try to adjust your baby’s sleeping position by raising the head of the cot. Tight clothing and pressure on the baby’s tummy e.g. in car seats should be avoided. Dummies can also help to neutralise some acidity in the reflux.
When should all the symptoms have disappeared?
If your child has been correctly diagnosed with CMA and is successfully eliminating cows' milk protein from it's diet then you are already half-way there!
After adjusting your child to a suitable formula, it may take a little while for their body to get back to normal – rather like waiting for a cut to heal. Of course, if you stop feeding the formula that suits your baby when the symptoms have disappeared or consume cows’ milk protein as part of your own diet while breastfeeding – symptoms could come back in a flash. Your child's doctor will be able to advise you on how long to avoid cows’ milk.
Some formulas prescribed by doctors (known as 'eHF') can still cause allergies in some children with CMA
If your infant is prescribed an extensively hydrolysed formula (eHF) and symptoms do not improve after two to four weeks, your doctor might consider switching to an amino-based formula (AAF). If symptoms do not disappear on an AAF, it may be time for another look at the diagnosis.
• What are eHFs?
Cows' milk-based formula treated with enzymes in order to break down most of the proteins that cause symptoms in allergic infants.
• What are AAFs?
Infant formula based on synthetic amino acids. It is suitable for the dietary management of children allergic to cows' milk or with multiple food protein intolerance.
When should my child’s condition be reviewed?
All children with CMA should be regularly checked by doctors for their general health, improvement in symptoms and, eventually, to find out if they have grown out of their allergy.
What is the doctor checking for?
Your child’s doctor will be looking out for:
Growth
Height
Ongoing signs and symptoms
Objective measures of food allergy
Check-ups should occur periodically so that the condition and the clearing of symptoms can be monitored appropriately.
Will my child grow out of cow’s milk allergy?
Many, but not all, children outgrow their food allergies. This depends on the individual child and can vary by type of foods.
Good news! The majority of children who are allergic to milk will grow out of their allergy by the age of 3 - 5 years.
Your doctor will re-evaluate your child to check. This process may include several tests, such as skin testing, blood tests, and/or oral food challenges depending on the type of the allergic reaction.
Types of allergic reactions




Don’t worry if your child still shows ‘positive’ reactions in skin or blood tests! It may be that a food challenge under the direction of a paediatric specialist may be necessary to prove that CMA has finally gone away.
TIP – Arrange regular check-ups of your child by their doctor. Ideally after the age of 12 months and not before 6 - 12 months after you noticed the last allergic reactions.
Why is weaning so important?

Weaning is an important time for families as it provides the ideal opportunity to introduce the infant to a variety of new tastes and textures. These early experiences have a strong effect on later eating habits as infants who miss important flavour and texture milestones may become faddy or difficult feeders in childhood and this may persist into adulthood. This means that obtaining a varied and balanced nutritional intake will be more difficult.
Why do parents of cows’ milk allergic infants find weaning so difficult?

Introduction of solid foods can be daunting for most, but for parents dealing with a cows’ milk allergic infant, this is potentially an even more challenging experience. Traditionally, mothers start weaning with baby rice, fruit and vegetables, followed shortly by fromage frais and yogurt. Finger foods such as bread sticks or toast fingers served with soft cheese are also popular weaning foods. Many of these foods , as well as other favourites such as broccoli in a cheese sauce cannot be given to cows’ milk allergic infants and should be avoided.
The most difficult question that remains however is at what point other foods that commonly cause allergies, such as egg, fish, soya, wheat, peanuts and tree nuts, can be safely introduced. Parents are understandably cautious when it comes to feeding their baby these foods.
Weaning is further complicated by additional restrictions on the use of soya milk (shouldn’t be used until 6 months of age) and rice milk (shouldn’t be used until 4.5 years) based products for all infants in the UK.
How can a dietitian help?

A dietitian can help to make weaning a less stressful event and will be able to advise parents on how to wean their infant confidently.
The dietitian can advise parents on:
When to wean
Each infant should be managed individually and developmental signs of readiness for solid food in the infant and parental opinions should be taken into consideration when advising on the ideal age to begin weaning.
Signs of developmental readiness:
Can sit up unsupported
Shows interest in other people’s eating
Chewing fists
Waking during the night when previously had slept through
Crying between feeds
What to do with the other foods commonly causing allergic reactions on infancy?
Some parents may ask if their cows’ milk allergic infant should be tested for other possible food allergies prior to introducing new foods. Unfortunately there is no clear guidance for health care professionals about whether to test or not, and practices may vary across the UK and indeed across the world.
It is however known that up to 50% of infants with CMA can also develop allergies to other foods.
The following is therefore recommended:
Introduce only one new food at a time and start with single ingredients
Your dietitian can provide you with a list of foods to introduce and start with small amounts, ideally cooked, of each food first and increase the amount of food if no reaction occurs.
Try to introduce new foods earlier during the day, so that you can observe any possible reactions and get advice if necessary.
Discuss clear steps with your doctor to follow in case of an allergic reaction to a food, particularly what to do if your child’s breathing is affected.
What if CMA continues beyond the first birthday?
Although many children will grow out of their cows’ milk allergy, for others it will continue, and for some, it may persist into their teenage years. During this time, children will be regularly reviewed, and possibly undergo further allergy tests and dietary challenges to see when they have outgrown CMA.
When CMA does persist beyond the early years, this can be particularly challenging because;
Energy requirements and the need for certain nutrients change as children grow
By this time, the child is developing his or her own taste preferences and can increasingly choose for themselves what they do and don’t eat
Food shopping for a child with CMA can be tricky because milk proteins are present in a wide range of products that are not always clearly labelled on the packaging
It is important to continue to exclude all cows’ milk protein from the diet whilst offering a healthy balanced diet in terms of calories, protein, calcium and vitamin content. Nutritional needs will vary between children and change as the child grows.
Even if CMA persists beyond the early years, you don’t need to manage alone. The advice of a dietitian can be invaluable in tailoring the diet to meet the child’s specific nutritional needs.
What diet should be followed as a child with CMA grows?
Growing children need calcium and other nutrients which are found in milk. Fortunately this can be obtained from a growing range of products that can be substituted in place of cows’ milk in a child’s diet.
These products vary in terms of taste, appearance and nutritional content and it will be important to tailor the choice of product to the dietary needs and preferences of the child.
It is important that parents and children think carefully before introducing any milk proteins. For instance, CMA reactions are often worse if the child is unwell, so it’s worth being extra careful with diet if they have a cold or other illness. If you are in any doubt, discuss these decisions with your healthcare professional.
Thinking ahead
It’s difficult to predict when children will grow out of CMA. You and your healthcare professional will want your child reviewed periodically to see if they still react to cows milk, however it is important to be prepared in case CMA persists into the school years. There are a wide range of modified products and milk protein alternatives available, and your healthcare professional is there to guide and support you, no matter how long CMA persists.
Allergies: Living with a soya allergy
Soya beans are legumes. Other foods in the legume family include kidney beans, string beans, black beans, pinto beans, chickpeas, lentils, carob, liquorice and peanuts. Many people are allergic to more than one legume. If your doctor is unable to identify which soya product is causing your allergy, you may be advised to avoid them all.
It is not always easy to avoid these foods since many surprising products may contain soya.
Who is allergic to soya?
Soya allergy is more common in infants. The average age at which the allergy manifests is three months but the majority of infants outgrow it by the age of two. Although adults do suffer from soya allergy, it is rare.
What are the symptoms?
There are many symptoms of soya allergy, including:
• Skin conditions, such as eczema
• Swelling
• Nasal congestion
• Anaphylaxis
• Asthma
• Mouth ulcers
• Colitis and other gastrointestinal problems, including diarrhoea
• Conjunctivitis
• Shortness of breath
• Fever, fatigue, weakness and nausea
• Low blood pressure
• Itching
• Hives
How do I avoid exposure?
Always check the ingredients on the label before you use a product. In addition, check the label each time you use a product. Manufacturers occasionally change recipes and a trigger food may be added to the new recipe.
Soya products include:
• Soya flour
• Soya nuts
• Soya milk
• Soya sprouts
• Soya bean granules or curds
• Tofu
Soya-containing ingredients include:
• Soya protein
• Textured vegetable protein (TPV)
• Hydrolysed plant protein
• Hydrolysed soya protein
• Hydrolysed vegetable protein
• Natural and artificial flavouring (may be soya based)
• Vegetable gum
• Vegetable starch
Soya-containing food includes:
• Miso
• Soy sauce
• Worcestershire sauce
• Tamari
• Tempeh
• Vegetable broth
• Some cereals
• Some infant formula
• Baked goods
http://www.webmd.boots.com/allergies/guide/allergies-living-with-soya-allergy
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