cow's milk allergy

Cow’s milk is one of the most common causes of food allergy in infants, affecting about one in 50 children. Most children eventually outgrow their allergy and although symptoms can persist into adulthood, it is rare. Many infants are allergic to other foods as well, such as eggs and peanuts.

Reactions to cow’s milk can include swelling of the lips, face or eyes, hives or welts, tingling of the mouth or wheezing. In some children, gastrointestinal symptoms can include diarrhoea, reflux/vomiting or poor weight gain. Reactions can also include eczema.

The majority of children with cow’s milk allergy have mild symptoms, but a small percentage experience severe reactions called anaphylaxis. Anaphylaxis is the most severe form of allergic reaction and involves several parts of the body, including either the respiratory system and/or cardiovascular system. If your child, or you, is at risk of anaphylaxis, you will be prescribed an adrenaline autoinjector (e.g. EpiPen). In severe cases, even trace amounts can trigger symptoms.

Milk allergy occurs when the immune system reacts to the protein in milk. If your child is diagnosed with a milk allergy, you need to completely eliminate milk, dairy products and any foods with milk-containing ingredients from their diet.

Anyone who is worried that they, or their child, may have a milk allergy should seek their GP’s advice, and see a specialist if necessary. Your GP or specialist will make a diagnosis based on the history of previous reactions. The allergy can be confirmed by skin prick tests and/or blood tests to measure the allergy antibody.

Most children tend to outgrow their milk allergy when they get older; almost half by the time they are eight years old, and about 80 per cent by the time they are 16 years old. It is very important to have a reliable diagnosis by a specialist before reintroducing milk, and to seek the advice of a registered dietitian.

In rare cases, usually in infants and toddlers, allergy to cow’s milk can be associated with allergy to beef and other cow-based products such as gelatine. Although this is uncommon, you should discuss any concerns with your specialist or dietitian.

Avoiding cow’s milk

Treatment of cow’s milk protein allergy involves excluding all forms of milk, dairy products and all foods with milk-containing ingredients.

Milk is an important source of many nutrients including energy, protein, fat, calcium, Vitamins B12, B2 (Riboflavin) and Vitamin A. These are all important for growth and health. Calcium is especially important for developing and maintaining strong bones in children and adults.

Avoiding cow’s milk can be difficult and should be done in consultation with a registered dietitan. Information about label reading, alternative foods and milks is needed to ensure nutrient needs are provided for growth of the infant and child, for the breastfeeding mother and adults. Advice on calcium supplements may also be required.

Breastfeeding

Some infants may develop symptoms of cow’s milk allergy while breastfeeding, as the cow’s milk proteins can be passed into mother’s breastmilk. It may be necessary to avoid milk in the mother’s diet to help improve symptoms in the infant; this should only be done with appropriate medical and dietetic advice. A calcium supplement for the breastfeeding mother is usually required

Replacements for Cow’s Milk

Specialised infant formula - hypoallergenic formula

In some cases, it may be necessary to consider a specialised infant formula.

Extensively hydrolysed formula (EHF): The cow’s milk proteins have been broken down by enzymes into very small particles called peptides e.g. Pepti-Junior (SHS Nutricia). Some infants who are very sensitive to the cow’s milk protein may still react to Pepti-Junior and require an amino acid formula.

Amino acid formula (AAF): Amino acids are the simplest form of protein and very easy for the body to digest. Amino acids form the building blocks for protein e.g. Neocate (SHS Nutricia).

An allergy specialist or paediatrician can apply for a Special Authority Number for these hypoallergenic formulae. The formula can then be obtained on prescription with a partial subsidy; a small part charge payment is required by the family (and is similar to the cost of ordinary infant formula).

Soy milk formula: Soy-based formula is not generally recommended for infants under six months of age with cow’s milk allergy as there is a risk they may become sensitised to soy or will react to the soy protein. Soy formula may be considered for infants over six months of age who are not sensitised to soy and who have refused the hypoallergenic formula.

Partially hydrolysed formula (PHF): Partially hydrolysed formula is not suitable for the treatment of cow’s milk allergy as the cow’s milk protein has been only partially broken down, e.g. Karicare HA, Nan HA Gold Protect.

Goat’s milk, sheep’s milk, mare’s milk

These animal milks are not suitable for children or adults with cow’s milk allergy as the proteins are very similar to those in cow’s milk and most people will react to these too.

Milk replacements over one year of age

Some children may require continuation of a hypoallergenic formula, e.g. those allergic to both cow’s milk and soy milk. Review with a registered dietitan is important to assess nutrient and, particularly, calcium requirements.

Soy milk

Look for a soy milk that is fortified with calcium, vitamins B12 and B2 (Riboflavin), as these replace the nutrients found in cow’ milk. The fat and energy (calorie) content of soy milks vary. Some older children and adults may prefer lower fat milks.

Rice milk, oat milk, nut milk/ beverages

Rice milk / beverages are lower in energy, protein and fat, some may be fortified with calcium and B vitamins. Rice milks are not recommended for children under five years of age as the sole milk replacement.

Oat milk, nut milk /beverages have differing amounts of energy, protein, fat, added calcium and vitamins. These milks can be an alternative for adults; however a calcium supplement may be required.

MILK LABELLING GUIDE

Note: Milk may be found in foods that are not listed here, so always read the ingredients label.

Avoid foods that contain milk or any of these ingredients which contain milk:

• anhydrous milk fat
• artificial butter flavour
• beverage whitener
• butter
• butter fat
• butter oil
• buttermilk
• casein
• caseinates (in all forms)
• cheese
• chocolate
• cream
• cottage cheese
• cream cheese
• curds
• dairy
• dairy protein
• dairy whitener
• fromage frais
• ghee
• hydrolysates - casein, milk protein, whey
• ice cream
• lactalbumin
• lactalbumin phosphate
• lactoglobulin
• lactoferrin
• lactose
• lactulose
• mascarpone
• milk in all forms including derivative, powder, protein, solids, malted, condensed, evaporated, dry, whole, low-fat, non-fat, skimmed, goat’s milk, ewe’s and sheep’s milk and milk from other animals.
• milk chocolate
• milk protein isolate
• nisin
• non-fat milk, non-fat milk solids
• nougat
• quarg
• quark
• skim milk powder
• sour cream
• sour milk
• super glossy (glazing agent)
• whey (in all forms)
• yoghurt.

Some examples of where milk protein may be present:

• bread
• bread crumbs
• carob
• chips
• chocolate
• coconut milk powder
• confectionery
• custard
• cakes
• pudding
• desserts
• dressings, e.g. salad dressing
• flavourings
• lactic acid starter culture
• margarine
• muesli
• non-dairy products
• nougat
• pesto
• popcorn
• processed meats e.g. sausages, luncheon etc
• processed foods
• wines clarified with milk protein

What is lactose intolerance?

Milk allergy is sometimes confused with lactose intolerance. These are different conditions and treatment is not the same. It is important when a diagnosis is given that a clear distinction is made between these conditions, so that the appropriate treatment can be undertaken.

Lactose is the milk sugar found in every kind of milk - cow's milk, goat's milk, sheep's milk and human breast milk, as well as in some dairy products made from milk. Lactose intolerance is due to a lack of or insufficient production of an enzyme in the gut - lactase. As a result, when drinking milk or eating dairy products, the lactose is not digested and can cause unpleasant symptoms, such as flatulence, bloating, abdominal pain, diarrhoea, and nausea. Symptoms are dose-related, which usually means small amounts of lactose may be tolerated with no ill effects. Different people can tolerate varying levels of lactose depending on their particular degree of lactase deficiency. Lactose intolerant people can tolerate hard cheese as the lactose is removed in production.

---

This fact sheet is based on information available at the time of going to print but may be subject to change. It is important to remember that we are all different and individual cases require individual medical attention. Please be guided by your GP or specialist.

Acknowledgments: We would like to thank Dr Jan Sinclair, Paediatric Immunologist,
and Jenny Heyward, Paediatric Dietitian, of Starship Children’s Health for their
assistance in writing this information. This fact sheet is also based on information 
provided by the Australasian Society of Clinical Immunology and Allergy.

October 2008