If you are wondering if your child may be allergic to cow’s milk, the most common category of dairy products, then the following summary may offer some indication, and inform your consultation with your GP, midwife or health visitor. It may take a while to formally diagnose, but is then quite manageable, not least because it is now such a prevalent infant condition.
People are often surprised at how common cow’s milk allergy is among infants. It is thought to affect between 1.8 per cent and 7.5 per cent of babies. Symptoms commonly appear before six months of age (1) and so begins what can often be, for parents and caregivers, frustrating and repeated trips to their GP, midwife or health visitor, before a formal diagnosis is given. So how can you begin to identify cow’s milk allergy in your baby at home, and what care and support should you expect if your suspicions are confirmed?
Symptoms
Symptoms will depend on which type of milk allergy the baby or child has. There are two distinct types: IgE and non-IgE mediated.
Babies and children with IgE mediated cow’s milk allergy will have one or more of the following every time they have milk or dairy:
- Hives or nettle rash (urticaria)
- Lip, face or eyelid swelling
- Vomiting
In the most extreme cases –
- Breathing difficulty, floppiness, or collapse (anaphylaxis)
There might be symptoms on skin contact with milk as well. In most cases, breastfed babies will not get any symptoms when their mother has cow’s milk or dairy in her diet.
If there are anaphylaxis symptoms parents/carers should call 999 immediately.
Families of babies with non-IgE mediated cow’s milk allergy will have one or more of the following within one hour to several hours after they consume milk or dairy:
- Itchy skin and eczema that is not getting better with treatments (such as steroid skin creams and moisturisers)
- Signs of tummy ache
- Diarrhoea
- Blood or mucous in the poo
- Constipation
- Refusing feeds
- Slow growth
- Vomiting
- Being very fussy and unsettled, generally
Symptoms can also happen in breastfed babies when their mother has dairy or milk in her diet.
Diagnosis
Whichever type of cow’s milk allergy it is, the first port of call is the GP or health visitor. An allergy focused history will be taken to help decide if milk allergy is likely.
The National Institute for Clinical Excellence (NICE) has published guidance on milk allergy (link) which may help families understand the process followed by GPs and clinics.
In most cases babies/ children with IgE mediated milk allergy will need a referral to an allergy clinic where a doctor or specialist nurse will listen to the story of reactions and symptoms.
They may carry out skin prick testing (link) to confirm a diagnosis, usually during the same appointment.
They may also do a blood test in some cases; results will then take longer to come back.
Most non-IgE mediated allergy can be diagnosed and managed without a referral to the hospital2 and there are no “allergy tests” recommended.
The diagnosis is made by cutting cow’s milk out of the baby’s diet completely. In breastfed babies this may mean the mother cutting all dairy out of her diet as well.
Bottle fed babies will be switched to an extensively hydrolysed milk formula, where the milk has been broken down to safer proteins. If this isn’t tolerated or is refused, baby may be switched to an amino acid formula.
If symptoms settle, then cow’s milk should be carefully put back into the diet at some stage to see if symptoms return.
In rare cases non-IgE mediated milk allergy can be more severe. Food Protein Induced Enteropathy or FPIES for short (Non-IgE-mediated food allergy – BSACI) causes symptoms between one and four hours after the food. The reaction can sometimes be confused with sepsis (severe infection). The symptoms of FPIES are:
- Severe vomiting
- Becoming very pale, sleepy or floppy
- Loss of consciousness
This severe reaction may need treating as an emergency in hospital. All cow’s milk and dairy must be strictly avoided. These babies need to be seen in an allergy or general paediatric clinic.
Fortunately, most cases of FPIES are outgrown before the school years begin, and but the first trial, putting milk back into the diet, is usually done in hospital, for safety.
Management
Once diagnosed with IgE mediated allergy it is usually recommended to strictly avoid all cow’s milk and dairy.
In most breastfed, babies there will be no need for mothers to stop milk or dairy in their diet (3) as not enough milk protein enters the breast milk to cause reactions. Avoidance of milk might be suggested in Mums if eczema remains difficult to manage, despite treatment.
If some dairy is already being tolerated or tests show low sensitivity, parents may be advised to start introducing milk straight away or at around one year of age using the baked milk ladder.
If a baby has non-IgE mediated allergy the family will be advised to avoid cow’s milk and dairy. This might include breastfeeding, with mothers stopping milk and dairy in their diet if this causes symptoms.
If some dairy is being tolerated, families may be advised to continue the baked milk ladder straight away. In most cases introducing milk via the baked milk ladder will be suggested from around one year of age.
What is the baked milk ladder?
The milk ladder is a step-by-step approach to reintroducing cow’s milk into the diet, but it is not something parents and caregivers are advised to do in cases of an IgE mediated cow’s milk allergy without the advice and recommendation of their specialist allergy team.
The first step begins literally with baked milk where the cow’s milk protein has been extensively heated and mixed with a carbohydrate, e.g.wheat flour (such as in a biscuit), for approximately 20-30 minutes in an oven. This changes the cow’s milk protein to reduce the likelihood of an allergic reaction. The ladder then progresses through stages to cooked milk, where the protein is cooked for less time, and then lastly to uncooked milk.
Dietitian’s Role
In both types of cow’s milk protein allergy, it is particularly important that families are supported with insight from a dietitian who can offer advice about appropriate formula milks, calcium intake and weaning dairy free. They can also support families with the baked milk ladder. Dairy avoiding breastfeeding mothers may also need support from a dietitian.
Babies with IgE mediated allergy and/or with eczema are more at risk of other food allergies. Introducing other allergenic foods early and giving them often is vital in avoiding more food allergy (link to BSACI weaning advice).
For those with IgE mediated allergy if the baked milk ladder is not yet recommended this is usually reviewed every 6-12 months. When ready, the baked milk ladder may often be started and continue entirely at home. In some cases, a hospital challenge will be arranged (testing for a reaction). This will depend on levels of sensitivity and how severe symptoms were.
For non-IgE mediated allergy the baked milk ladder is likely to be suggested after one year of age. In most cases the baked milk ladder will be started and continued at home, with a dietitian’s support.
If the milk allergy does last into adulthood, there are techniques to manage it and dietary provisions and we will cover those in All About Allergy soon.
References
1. BSACI guideline for the diagnosis and management of cow’s milk allergy D. Luyt1 , H. Ball1 , N. Makwana2, M.R. Green1 , K. Bravin1 , S. M. Nasser3 and A. T. Clark3 Clinical & Experimental Allergy, 44 : 642–672, 2014.
2. National Institute for Health & Clinical Excellence (NICE).
3. McWilliam V, Netting MJ, Volders E, Palmer DJ; WAO DRACMA Guideline Group. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow’s Milk Allergy (DRACMA) guidelines update – X – Breastfeeding a baby with cow’s milk allergy. World Allergy Organ J. 2023 Nov 3;16(11):100830. doi: 10.1016/j.waojou.2023.100830. PMID: 38020284; PMCID: PMC10656250.
Lisa Clarke
Lead Clinical Nurse Specialist for Paediatric Allergy at Nottingham University Hospitals NHS Trust.
Lisa has over 18 years of experience as an allergy nurse specialist, spanning adult and paediatric allergy services. Lisa is also mother to 23-year-old Aeron, who is allergic to all dairy products, eggs, and most nuts and 27-year-old Jevan allergic to legumes.
