by Dr Marie-Therese (Terri) Lovis, General Practitioner
The new MAP guidelines were published in 2019 and are now hosted on GPIFN here.
Cows’ Milk Allergy- Diagnosis and Management for the GP
Cows’ Milk Allergy (CMA) is an allergy to cows’ milk protein or to the carbohydrate (galactose-alpha-1-3-galactose). The prevalence of CMA has been reported as ranging from 1.9 – 4.9% in young children1 and it is the leading cause of food allergy in infants and children younger than 3 years2. In recent years the diagnosis and prescribing of specialist milk for CMA has increased in primary care. One of the suggested reasons for this is ‘greater research focus on allergy, leading to greater, but sometimes misdiagnosed, identification of cows’ milk allergy’3. Milk allergy can present in exclusively breastfed infants but is much more rare than in formula fed infants (One study found the prevalence to be 0.5% amongst a cohort of 1974 patients which was just 9 infants)4. Many of the symptoms of delayed allergy can represent normal physiology and it is important not to over diagnose CMA in a healthy infant due to the negative consequences of an unnecessary exclusion diet for mother and infant.
Up to 90% of children will grow out of their allergy by age 31. When this happens depends on various factors including how young they are when they develop the allergy, whether it is delayed or immediate, the severity of the symptoms and other allergies present.
CMA should not be confused with lactose intolerance, which is an intolerance to the sugar lactose, usually due to a temporary lack of the enzyme lactase which breaks down lactose. Lactase may be temporarily reduced due to changes in the gut lining after gastroenteritis. Lactose is present in both cows’ milk and breastmilk, however lactose intolerance is due to an enzyme deficiency rather than an allergic reaction as with CMA.
There are two main types of CMA:
An IgE-mediated (immediate) allergy with symptoms starting within minutes to 2 hours of eating dairy. Symptoms might include urticaria, swollen eyes, lips, wheezing and/or vomiting.
A Non-IgE-mediated (delayed) allergy may cause eczema, respiratory symptoms, reflux, diarrhoea, cramps, constipation and sometimes blood in the stool.
Diagnosis of CMA
It is important to note that babies cry for many reasons and that some of the symptoms associated with a diagnosis of CMA may be caused by an alternative diagnosis, or may even fall within the range of normal infant behaviour.
The MAP guidelines & NICE CKS: Cows’ Milk Protein Allergy in Children- Diagnosis includes detailed information on symptoms, taking an allergy focused history and examination. An allergy focused history is essential and will include asking about the presence of a family history of asthma, hayfever, eczema and food allergies, as well as the presence of the symptoms listed above.
- It is physiologically normal for babies to posset regularly; reflux can be physiological and does not always require treatment, nor is it usually due to allergy. Parents may simply need reassurance. It is hard and exhausting caring for young babies, especially if they cry frequently. Parents may need more support with their baby. The website http://purplecrying.info/ is a great resource to signpost to parents to support those struggling with an infant that cries frequently.
- Breastfed babies who have difficulties latching or other issues within the breastfeeding dyad may cry more, be unsettled and present with ‘colic‘ symptoms. It is important therefore to ensure that as part of the clinical history and management, specialist support for breastfeeding including latch and tongue-tie assessment is addressed at an early stage.
- If an infant is bottle fed breastmilk or formula, ensure that parents are practicing responsive bottle feeding. Babies made to ‘finish the bottle’ may be overfed and their vomiting may be due to excessive intake. The guidance on formula packs may not align with current best practice guidance on frequency and volume of feeds for babies at different stages5.
- It is also important to be aware that the majority of infant eczema is not caused by CMA, although one should certainly consider it in eczema that is resistant to treatment.
Children with IgE-mediated allergy presentations should be referred to paediatrics and they may have specific IgE testing +/- skin prick testing.
Children with Non-IgE-mediated allergy can be diagnosed when all dairy products are removed from the diet of the baby and the breastfeeding mother for 2-4 weeks6, 7 to see if the symptoms improve, followed by a trial of reintroduction of dairy, confirming the diagnosis if symptoms recur. This is an important step that should only be missed out in extreme cases.
Breastfeeding should continue for as long as the mother wishes and continuation of breastfeeding is particularly important for atopic children. The GP should aim to support the mother to continue breastfeeding by ensuring she has the guidance needed to commence a varied dairy free diet. If CMA is confirmed by the recurrence of symptoms following reintroduction of dairy, referral to a dietitian for advice for her diet as well as for the infant once complimentary foods are introduced. You may find the BDA Food Fact Sheet: Milk Allergy useful for dietary pointers.
In the case of non-IgE-mediated allergy, it can take 2-4 weeks on an exclusion diet to see an improvement but parents might notice a change after a few days. A symptom diary can help to objectively identify if there has been an improvement during the exclusion period.
- If there is no improvement during the exclusion period, dairy can be reintroduced to the diet of mother and baby and an alternative diagnosis sought.
- If an improvement is seen then it is important to reintroduce dairy while continuing the symptom diary. If symptoms return when back on dairy the diagnosis has been confirmed. Following this a referral to a paediatric dietitian should be made.
Studies estimate that over 10% of children with CMA will also be allergic to soya8, 9. In cases of severe eczema or gut symptoms you may wish to discuss with a specialist with regards to also excluding soya +/- egg. Any reintroduction would need to include a gradual reintroduction of one item at a time to confirm the allergy. Excluding these three foods can significantly impact the diet of a breastfeeding mother or infant and must not be done lightly.
NICE CKS: Cows’ Milk Protein Allergy in Children- Suspected Cows’ Milk Protein Allergy Details the diagnostic procedure for immediate and delayed CMA.
After a Diagnosis of CMA
According to the NICE guidelines10, non-IgE-mediated CMA can be managed in primary care if the GP feels competent but the mother and baby should be referred to a paediatric dietitian for guidance on introducing solid foods and to support breastfeeding mothers with their own dietary exclusions.
You should refer to a paediatric allergy clinic when:
- The baby has faltering growth
- There is a question about the diagnosis with ongoing symptoms
- There has been an immediate (IgE-mediated) allergic reaction
- There has been one or more severe delayed (non-IgE-mediated) reactions
- There is more than one food allergy
- If there is severe ongoing eczema where there is a risk of other allergies
If the baby has symptoms of CMA (especially IgE-mediated) then the parents need to ensure that all those looking after the child are aware of the allergy and check all food given to the child. If child-care is used they should ask to see the child-care setting’s policy on food allergies especially regarding avoidance of cross-contamination from other children’s plates and training in the management of allergy.
If the child has an IgE-mediated CMA, parents should be given guidance on managing anaphylaxis and immediate allergy (which will be supported by the paediatric allergy clinic). If the child has a history of a severe IgE allergy or mild plus a history of asthma s/he should be prescribed an adrenaline pen . Parents should be given an Allergy Action Plan, to be used in childcare and school settings.
Ongoing Cows’ Milk Exclusion for the Infant
Breastfeeding a Baby with CMA Information to support breastfeeding mothers with a dairy exclusion diet.
Formula Feeding a Baby with CMA Information to support the appropriate use of hydrolysed or amino acid formula if a baby with CMA is formula fed.
Introducing Solids (Family Foods) when Dairy Free
WHO guidance is for babies to be exclusively breastfed until 6 months. Complementary solid foods can be introduced from 6 months and there is significant evidence for benefits to mother and baby from continued breastfeeding until at least 2 years of age11.
When the family see the paediatric dietitian they will get more ideas on being dairy free and help with ideas for when it’s time to introduce solid food for the baby. The baby will need high calorie snacks to replace the fat and calories that they would get from dairy products normally. Homemade dairy free flapjacks, sugar free carrot muffins, pieces of chicken, houmous and cucumber, peanut butter oat balls, rice pudding with coconut cream are all ideas.
- High sugar options should be avoided.
- Once solids are introduced, dairy free milks can be used in food preparation:
- Milks fortified with at least 120mg/100ml of calcium should be used.
- These may include soya (if soya is tolerated) eg. Alpro Soya Junior 1+, oat milk and almond milk.
- Rice milk should not be used until 4.5 years of age due to high levels of naturally occurring arsenic12.
When making meals for the baby they can make porridge/rice pudding with dairy free milks and creams (expressed breast milk; alternative milks including: oat, soya (if tolerated), coconut, almond, dairy free formula etc.).
Be mindful that cows’ milk allergy can co-exist with soya allergy (see above) and starting soya may also cause symptoms.
Dairy Free Milk Drinks Beyond Infancy
Breastfeeding is recommended until 2 years of age and beyond11. If the infant receives formula feeds s/he can be switched from dairy free formula under the guidance of a paediatric dietitian at 1 year of age if:
- A varied diet is followed,
- The baby can tolerate soya and
- The baby is growing well.
At this stage the baby can have non-dairy calcium fortified milk eg. Alpro Soya Junior 1+ (This is found in the UHT aisle in the supermarket and is different to normal soya milk as it is specially designed for children over 12 months).
If the baby cannot tolerate soya the dietitian might recommend a dairy free milk or may recommend to continue on a dairy free formula depending on the above factors. This is usually only recommended by a paediatrician or paediatric dietitian rather than being started by the GP.
Once the child is 2 years old s/he can move to a dairy free milk12 that is fortified with at least 120mg/100ml of calcium eg. Oat milk. Before the age of 2 these milks are considered too low in protein and fat compared to dairy free formula or soya.
Reintroduction of Cows’ Milk
The dietitian will discuss when it is safe to reintroduce cows’ milk. In the case of non-IgE-mediated cows’ milk allergy they will discuss the ‘Milk Ladder’ so this can be done slowly and safely step by step. NICE recommends implementing a strict cows’ milk elimination diet until the child is 9–12 months old and for at least 6 months after confirmation of diagnosis7. Please see the full iMAP page for resources to support the family when reintroducing cows’ milk.
Individuals should be reassessed at 6-12 monthly intervals from 12 months of age to assess for suitability of re-introduction8.
NICE CKS: Cows’ Milk Protein Allergy in Children Revised June 2015
Local Infant Feeding Information Board (LIFIB) Multidisciplinary group of healthcare professionals based in the northwest of England who critically appraise information and research on infant feeding issues, producing factual evidence-based summaries for healthcare professionals.
First Steps Nutrition Trust: Specialised Infant Milks in the UK- Infants 0-6 Months Information for Health Professionals September 2019- scroll down to the purple report. See sections 3.12 and 3.13 which cover extensively hydrolysed peptide-based infant milks suitable from birth and amino-acid based infant milks for non-metabolic disorders, suitable from birth.
CMA Resources for Parents
British Dietetic Association (BDA) Food Fact Sheet: Milk Allergy Lists foods to avoid if dairy free.
First Steps Nutrition Trust Independent evidence based guidance on eating healthily including leaflets on special diets and guidance on recipes and portion sizes.
First Steps Nutrition Trust: Eating Well- Vegan Infants and Under 5s Recipes are suitable for a dairy-free diet. Scroll down the page to reach this guide.
The NHS Website: Children’s Teeth Guidance on dental health for children, particularly important for those given dairy free formula.
The NHS Website: Vitamin D Guidance on vitamin D supplements for babies and children.
Food Maestro Website and smart phone App. You can enter your allergies then scan products to check if they are safe (Co-developed by Guys and St Thomas’ Hospital).
Dilan and Me: Has useful tips on thriving as a breastfeeding mother or an infant with CMA including a handy list of dairy and soya free treats.
- Venter C, Broen T, Shah N, Walsh J, Fox A. Diagnosis and management of non-IgE-mediated cow’s milk allergy in infancy – a UK primary care practical guide. Clinical and Translational Allergy. 2013;3(1):23
- Koletzko S, Niggemann B, Arato A, Dias J, Heuschkel R, Husby S et al. Diagnostic Approach and Management of Cow’s-Milk Protein Allergy in Infants and Children: ESPGHAN GI Committee Practical Guidelines. Journal of Pediatric Gastroenterology and Nutrition. 2012;55(2):221-229
- First Steps Nutrition Trust: Specialised Infant Milks in the UK (Infants 0-6 months) Information for Health Professionals September 2019. Scroll down to the purple report.
- Host A, Husby S, Osterballe O. A prospective study of cow’s milk allergy in exclusively breast-fed infants. Incidence, pathogenetic role of early inadvertent exposure to cow’s milk formula, and characterization of bovine milk protein in human milk. Acta Paediatr Scand. 1988;77(5):663-70.
- First Steps Nutrition Trust: Infant Milks in the UK- A Practical Guide for Healthcare Professionals June 2019. Scroll to the green report.
- Surrey CCGs Prescribing Advisory Database (PAD)
- NICE CKS: Cows’ Milk Protein Allergy in Children Revised June 2015
- Luyt D, Ball H, Makwana N, Green M, Bravin K, Nasser S et al. BSACI guideline for the diagnosis and management of cow’s milk allergy. Clinical & Experimental Allergy. 2014;4:642-672
- Kattan J, Cocco R, Järvinen K. Milk and Soy Allergy. Pediatric Clinics of North America. 2011;58(2):407-426.
- NICE Guideline CG116: Food allergy in under 19s: assessment and diagnosis February 2011
- WHO: Infant and Young Child Feeding Factsheet Updated February 2018
- British Dietetic Association (BDA) Food Fact Sheet: Milks for Children with Cows’ Milk Allergy