This factsheet has been written to help you understand and gain some advice on suspected cow’s milk allergy in babies...
- Managing cow’s milk allergy: Cow’s milk allergy is one of the most common food allergies in babies and young children.
- Feeding a child with cow’s milk allergy: The goal of managing cow’s milk allergy is to exclude cow’s milk and foods containing cows’ milk totally for an agreed time frame, with the aim of reintroducing it later.
- Gut health in babies and children: The gut may take many weeks to settle down after a diagnosis of milk allergy.
- The future and allergies: Most children will become tolerant of cow’s milk anywhere from one to five years of age.
- Weaning: Babies at risk of allergy may benefit from earlier introduction of weaning foods but not before 17 weeks.
- Re-introduction of cow’s milk protein: Each baby is different when it comes to re-introducing cow’s milk.
- The milk ladder: Reintroduction of cow’s milk is done gradually, according to something called the ‘milk ladder.
- Outgrowing cow’s milk allergy: Fortunately, sensitivity to cow’s milk decreases with age1 as most children outgrow their allergy.
Milestone 1: Managing cow’s milk allergy
How do I manage my baby’s cow’s milk allergy?
If you and your baby have seen your healthcare professional and have been given a diagnosis of cow’s milk protein allergy, you may be wondering what to do next. These milestones provide you with information to help you proactively manage your baby’s cow’s milk allergy and the possible reintroduction of cow’s milk into their diet.
What is a cow’s milk allergy?
In case you are still wondering what the diagnosis means, here is a short explanation: Cow’s milk allergy (also referred to as CMA) is a reaction to the proteins found in cow’s milk. Generally, symptoms of an allergic reaction to cow’s milk will appear either immediately (within minutes up to one or two hours ) after eating or drinking food containing cow’s milk protein (suggesting an IgE mediated reaction) or the reaction may be delayed – occurring up to 48 hours later (suggesting a non-IgE mediated reaction).2 For some babies the reactions may be mixed, appearing immediately and at times, delayed.1 You will find links to more information at the end of this section.
Nathalie is a mum who knows only too well the journey you go on after your baby is diagnosed with cow’s milk allergy…
When my son was diagnosed I certainly wondered what to do next! I believe that this information will help in providing the support and information you need at this anxious time – Nathalie Newman, Allergy mum and advocate.
What is the difference between immediate and delayed milk allergy?
Immediate Onset: Symptoms appear within one or two hours.
- Symptoms usually develop within minutes up to one to two hours after having cow’s milk. Very occasionally some infants have difficulty in breathing or become floppy with food allergens and need to seek urgent help, this is rare.
- Immediate reactions to milk can occur at any age, but also consider other common culprits including egg or peanut.
- Can occur with cow’s milk, usually when cow’s milk-based formula feeds are used as ‘top-ups’ in a breastfed baby or later when weaning and dairy products (For example, yoghurt) or cow’s milk are given.
- Two ways to confirm: Firstly symptoms, such as skin rash and/or swelling with vomiting and/or wheeze, soon after the baby has had cow’s milk and secondly, by a healthcare professional taking an allergy focused history and if needed allergy tests like skin prick tests or blood tests.
- The correct medical term is IgE mediated cow’s milk allergy.
Delayed Onset: Symptoms appear up to 48 hours later.
- Delayed tummy problems for example reflux, diarrhoea, constipation or skin symptoms including eczema, up to 48 hours after having cow’s milk, which improves or clears up when cow’s milk is stopped and reappears when it’s started again.
- Skin prick tests or blood tests are not recommended for delayed reactions.
- The only reliable test is to take cow’s milk protein out of the baby’s diet or mum’s diet if breastfeeding for two to four weeks and to then reintroduce it by re-challenge.
- The correct medical term is non-IgE mediated cow’s milk allergy.
- Many of the symptoms are also very common in babies who are otherwise well or those with other illnesses, so it is important to get a diagnosis by a healthcare professional.
What does this diagnosis mean for my baby?
The majority of children outgrow milk allergy. Overall, a high percentage of children fully outgrow a milk allergy or gain some tolerance (for example, small amounts of milk protein baked within a biscuit) by the age of five and usually much sooner. Children that persist with a milk allergy past the age of five years old are less common but they may still go on to outgrow this in their teenage years.
Your GP or allergy specialist will work with you, usually with the help of a dietitian,5 to actively manage your child’s CMA which will give them the best chance to outgrow their allergy. Read more about this in Milestone 2. Whilst many babies may have immediate relief after removing cow’s milk from their diet, for other babies, it can take longer than the two-to-four-week recommended time frame for symptoms to resolve, especially if they have more severe symptoms. It’s important to get support during this time. After symptoms have cleared, your healthcare professional may discuss carefully introducing cow’s milk protein back into your baby’s diet, either through your breast milk, formula choice or baked milk.
It’s not unusual to feel anxious or stressed after receiving the diagnosis. Please seek help if you feel overwhelmed by this stress.
How can I cope with anxiety about my child’s allergy?
Managing your child’s allergies can be worrying, but remember that you are not alone. It is very common to feel anxious after this diagnosis but it is possible for you and your baby to lead a normal happy life alongside a food allergy. Your healthcare support team, family, other parents and friends are important supporters in your journey. Planning ahead, especially before going out, can also help to alleviate your concerns. Allergy UK have many resources to help you.
What should I do if my baby still has symptoms?
If you are concerned after diagnosis that your baby is still experiencing symptoms, even though you have removed milk from their diet, you should talk to your healthcare professional about your baby’s ongoing care. Your healthcare professional may refer you and your baby to a dietitian if your baby’s symptoms are mild to moderate. However, if symptoms are severe you may be referred to a children’s specialist allergy service.
It‘s also helpful to record your baby’s symptoms in a food allergy and symptoms diary. Your healthcare support team will use this information to understand the relationship between your baby’s symptoms and the food they’ve had. Recording symptoms will also help your healthcare professional decide if any tests are required and help them to distinguish allergic reactions from other causes and confirm whether it is delayed or immediate onset cow’s milk allergy.
Cow’s milk allergy is one of the most common food allergies in babies and young children.
Milestone 2: Feeding a child with a cow’s milk allergy
Why change my baby’s feeding?
You will have been advised to avoid feeding your baby anything that contains cow’s milk protein. However, you are probably aware that many of the foods we consume daily contain cow’s milk, which provides an important source of energy, protein, vitamins and minerals both for you and your growing baby. But the fact is that it also contains the protein that causes allergy in some people. So, it’s important to understand that avoiding cow’s milk is not a long-term solution. The aim is to reintroduce milk protein when possible and this Roadmap is designed to help guide you through that process.
The goal of managing cow’s milk allergy is to exclude cow’s milk and foods containing cows’ milk totally for an agreed time frame, with the aim of reintroducing it later. Often milk products can begin to be introduced from 12 months of age, although this does vary.
When your child is at the stage where their tolerance to cow’s milk protein can be assessed, then cow’s milk may be carefully reintroduced, step by step, into your baby’s diet under the supervision of your healthcare professional. The way in which this is done is different depending on whether your child has an immediate or delayed reaction to milk, you will find more about this in Milestones 6 and 7.
Should I continue breastfeeding?
While it is rare, some babies can have an allergic reaction to cow’s milk protein consumed by Mum and passed to her baby through her breastmilk. If you have been able to successfully breastfeed then we encourage you to continue because of the many benefits for both you and your baby. Breastfeeding provides all the nourishment that a young baby needs, as well as many other benefits, such as antibodies. The nutrients in breast milk are easily digested and absorbed and your milk continually changes to meet your baby’s needs. If you are breastfeeding and your baby has allergic symptoms (for example diarrhoea and/or eczema), discuss a cow’s milk-free diet with a dietitian because it is important that breastfeeding mums have a healthy balanced diet.
It is recommended that you take Vitamin D (10 mcg) and calcium (1000 mg) supplements until you are able to speak to a dietitian. Vitamin D aids the absorption of calcium and helps to
keep teeth and bones healthy. In the UK all breastfed babies from birth to one year of age should be given a daily supplement of 8.5-10mcg of vitamin D.
It is really important for you to know that you can feed your child successfully whether you are breast or bottle feeding. This Milestone is intended to take some of the worry out of feeding your child. Working with a dietitian can also help to provide support and confidence especially when it comes to weaning – Nathalie Newman, Allergy mum and advocate.
What if I’m breast and/or formula feeding?
If you are not breastfeeding or are mixed feeding, your healthcare professional will advise you on the most suitable ‘hypoallergenic’ formula milk for an infant with a cow’s milk allergy.
If your baby did not show any allergic symptoms on breast milk alone and the symptoms appeared only when cow’s milk-based ‘top-up’ feeds were given, you should continue breastfeeding and continue to consume cow’s milk in your diet. You may wish to return to breastfeeding only. However, if this is not possible, and ‘top-up’ feeds are needed, your healthcare professional may advise you to replace cow’s milk-based formula with hypoallergenic infant formula.
It is worth noting any baby who has less than 500ml formula per day should also be given a vitamin D supplement of 8.5- 10mcg per day.
What is a “hypoallergenic formula”?
The word “hypoallergenic” means low allergy. The two recommended formulas for babies under six months with cow’s milk allergy are:
- Extensively Hydrolysed Formula (eHF)
- Amino Acid Formula (AAF)
Soya is unsuitable under six months of age due to natural phyto oestrogens, but fresh soya milk can be tried in cooking from six months of age (for example, in family meals such as white sauce for lasagne) and as the main drink from the age of one year. Soya infant formula is available to buy from the age of six months old. Some infants may also react to soya, so exclude if you see symptoms similar to cow’s milk allergy returning (this is less likely in the immediate type allergy). Milk alternatives such as almond, oat or coconut milk have poor nutritional value compared with cow’s milk and are not suitable for infants. However, they may be used when cooking meals for the family. Rice milk should not be used for children under four and a half years of age.
What is an extensively hydrolysed formula (eHF)?
eHFs contain proteins that have been broken down into smaller segments so they are less likely to cause an allergic reaction and are therefore suitable for 90% of babies with cow’s milk allergy. They are either whey or casein-based, which are different types of milk proteins, and it’s important to discuss the best option with your healthcare professional. Some eHF’s contain pre- and probiotics that promote the growth of good bacteria in the gut and some eHFs with specific probiotics may also help to speed up the process of returning to cow’s milk.
For adults it may seem that eHFs have an unpleasant taste, but remember that babies experience taste differently from an adult and therefore they are more likely to accept an eHF. There are allergy formulas available that are halal and kosher certified, please ask your healthcare provider.
What is an amino acid formula (AAF)?
AAFs are based on the individual building blocks (amino acids) that make up a protein. Amino acid formulas are recommended on the rare occasion that a baby continues to have symptoms of cow’s milk allergy on an extensively hydrolysed formula (eHF) after two to four weeks, or when it is not an appropriate first choice for a baby with severe allergic reactions. It should be noted there are halal and kosher certified allergy formulas available, please speak to your prescriber.
Your healthcare professional will advise you on the most suitable ‘hypoallergenic’ formula milk.
What if my baby is older?
Hypoallergenic formulas are available for different age groups of babies with cow’s milk allergy, from birth up to young children, it is recommended to be prescribed up to the age of two years old. You can also use alternative milks such as soya, almond, hemp, oat or coconut once your child is two years old, or sooner if advised by your healthcare professional and rice milk once your child is over fourand- a-half years old. Many alternative milks have adequate calcium as long as you do not buy organic versions, but they are often lower in energy and protein than cow’s milk. Make sure you keep track of your child’s growth in their
Are there special preparation instructions for hypoallergenic formulas?
- Preparation instructions of some hypoallergenic formulas are different from those of routine formulas. Always follow the preparation instructions provided with the formula or on the packaging.
- All equipment used to feed babies must be sterilised, hands thoroughly washed and surface cleaned before preparing the formula.
- Once prepared, the formula can spoil quickly. Feed immediately after preparation. To reduce the risk of infection, it’s best to make up feeds one at a time, as your baby needs them.
- Do not freeze prepared formula and do not use if un-refrigerated for more than two hours.
- Use the formula that has been in contact with the infant’s mouth within one hour and do not refrigerate. Throw away prepared formula left in the bottle and clean utensils.
- Do not use a microwave to warm the formula.
- Take care when preparing formula containing probiotics, since heat may deactivate the probiotics. When preparing a formula containing probiotics it is advised that you make individual fresh feeds for immediate use and use boiled water cooled to room temperature.
For further information on how to prepare infant formula, refer to the manufacturer’s website, your healthcare professional, dietitian or NHS Choices.