Introduction

Human breast milk is the best for a baby.

The majority of infant formulae are made using modified cow’s milk and contain cow’s milk protein.

Cow’s milk protein allergy prevalence varies from 2-7.5%.  Resolution can be expected in between 75 and 90% of cases before 5-6 years of age, though lower rates may be seen in referred or highly selected groups of patients.

Symptoms of cow’s milk allergy can vary to include:

  • Pruritus
  • Urticaria
  • Angio-oedema
  • Vomiting
  • Diarrhoea
  • Abdominal cramps
  • Respiratory difficulty
  • Wheezing
  • Hypotension
  • Syncope
  • Gastro oesophagel reflux
  • Shock

Cow’s milk allergy symptoms can be less specific than the symptoms caused by other food allergens, so a higher clinical suspicion is needed.

An allergy focused clinical history can usually distinguish the 2 main types of cow’s milk allergy: either IgE mediated (usually associated with rapid onset of urticaria, swelling, and airway symptoms) or non IgE mediated (more associated with delayed gastrointestinal and skin symptoms).

It’s very important to decide early what type of cow’s milk allergy is concerned as the natural history is different and the management has to be tailored. A decision must be made at diagnosis about the length of time for milk exclusion which will vary depending on the type of cow’s milk allergy. Reintroduction of milk following exclusion is required to confirm diagnosis or resolution.

Skin prick testing and serum specific IgE testing are only helpful in IgE mediated allergy.

Most children present before 6-7 months of age where milk is the major or sole food therefore other food allergies usually do not need to be considered.

All children on a milk exclusion diet should be reviewed by a Paediatric or Community Dietitian. Removal of cow’s milk from a child’s diet is a major decision. It has significant nutritional and family consequences. It must be replaced with a nutritional equivalent.

Exclusively breast fed infants with cow’s milk allergy may respond to a time defined complete maternal exclusion of cow’s milk. This should be supervised by a Dietitian.

Where infant formula is in use, those with extensively hydrolysed protein or amino acids as their protein base are proven to be hypoallergenic. The latter is more likely to be indicated in those who present younger and show signs of severe and persistent allergy.

There is no place for lactose free formula.
The use of other mammalian milk (e.g. goat, sheep, camel, donkey, horse) and/or plant based milk (e.g. soy, rice, oat, almond, coconut) is not indicated. Some are not nutritionally complete, some cross react with cow’s milk and cause reactions.