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HOW WE CAN HELP when your thriving baby is irritable and sleepless.
There are several disorders classified under the category of cow's milk protein intolerance (CMPI) also known as milk and soy protein intolerance (MSPI). These can include milk allergy, milk intolerance, lactose intolerance and other rare conditions such colitis (which is not discussed in this article). Many of these terms are often used interchangeably when there's a reaction to milk, but they don't mean the same thing.
It can be difficult to tell these disorders apart because some symptoms can be the same for all these disorders. There are also some obvious and subtle symptoms that are different for each disorder. To further complicate diagnosis, many of these same symptoms can also be present in other conditions that are not related to the milk at all.
Our immune system allows our bodies to fight off many different diseases that could cause us harm. Sometimes our body's defenses go wrong and our immune system fails to recognize milk proteins as being harmless. So when the protein enters our system, our immune system reacts against the protein to destroy it.
Because babies immune systems are immature, milk allergy is more common in infants and children than in adults. Milk allergy affects about 1 in 50 babies. A child is more likely to develop this kind of allergy if blood relatives also experience allergies, such as eczema, asthma or hay fever.
Fortunately, approx 50% of effected children tend to outgrow a milk allergy by 1 to 2 years of age, and approximately 80% of children will have outgrown it by the time they're 3 or 4 years old. So they can then go back to drinking milk and eating dairy foods the same as other children.
Because approximately 50% of children with a cow's milk protein allergy are likely to develop allergies to one or more other foods as well, it's recommended to delay the introduction of solids for these children until around 6 months of age. Once solids are commenced, additional care needs to be taken to avoid high risk foods.
The most common foods that trigger an allergic reaction besides milk are peanuts, eggs, and soy. Foods allergies can also occur with other nuts, fish, shellfish, rye, wheat, oats, berries, tomato, cucumber, white potato and mustard. Highly sensitive children can be allergic to a range of other foods as well.
An allergy to cow's milk usually begins to develop in the first few months of life. A formula fed infant is at greater risk of developing a milk allergy than a breast fed infant because the majority of infant formulas are based on cow's milk. (Goat's and soy based formulas can also cause allergic reactions). Breast fed babies can develop an allergic reaction to proteins contained in cow's milk and foods eaten by the mother and passed through breast milk.
Once an allergy has developed, symptoms often occur immediately or within two hours of coming into contact with the allergen (in this situation the offending cow's milk protein - there a 20 different proteins in cow's milk). Symptoms can involve the skin, nose, throat, lungs and/or gastro-intestinal tract. (See 'Symptoms' below for examples). Fortunately the majority of allergic reactions to milk are not serious. However, a small number of highly sensitive children can suffer extreme and even life threatening symptoms.
If a child has an allergy to milk, symptoms will continue as long as the child is exposed to the allergen. Because a formula fed baby less than 6 months old relies solely on milk for nutrition, a milk allergy will result in failure to gain weight. Dependant on the mother's diet, a breast fed baby with a cow's milk protein allergy is likely to struggle to gain sufficient weight while the mother continues to consume cow's milk protein in any form of dairy food.
Symptoms will disappear when the allergen is excluded from the child's diet. Where the child is formula fed, once her formula has been replaced with one which does not contain the allergen. In the case of a milk protein allergy in a breast fed infant, when all sources of milk products are excluded from the mother's diet.
Diagnosis is usually obvious because of the immediate reaction and can be confirmed if symptoms disappear once the allergen is eliminated from the child's diet. Allergy tests (skin prick tests or RAST blood tests) may also provide assistance in making an accurate diagnosis, as they are almost always positive in these cases.
How and why milk intolerances occur is still not fully understood. One popular theory is that because of an infant's digestive system is not fully matured it doesn't produce enough enzymes to break down all the protein in the milk. This allows poorly digested protein to enter the large intestine, where the normal bacteria present in the bowel, ferment the protein creating stomach and bowel symptoms.
It is believed that for some, these poorly digested proteins then enter the blood steam and create allergy-type symptoms related to skin, nose, throat and lungs. (These symptoms are referred to as 'allergy-type symptoms' when present day allergy tests provide negative test results).
It's now believed that milk protein intolerance is more complex than it first appeared and for those with allergy-type symptoms, it may involve the immune system after all. Many milk (and food) intolerances are likely to be reclassified as allergies in the future, when the underlying immune mechanisms are fully understood and the development of diagnostic tools to test for these become available.
Because of the difficulty in diagnosing cow's milk protein intolerance, accurate figures are unavailable. However, it's suspected that up to 8% of infants could experience some degree of milk intolerance in the early months. Some specialists believe the figures could be even higher than this. The figure decreasing as children grow and their digestive system matures.
Foods that can commonly cause reactions associated with intolerance, in sensitive people include milk, cheese and yogurt, chocolate, egg, flavor enhancers, food additives and natural salicylates found in strawberries, citrus fruits and tomatoes.
Symptoms of milk intolerance mostly involve only the stomach and bowel (see 'Symptoms' below for examples). However, symptoms involving the skin, nose, throat or lungs that mimic those of milk allergy, can also occur.
The onset of symptoms related to milk intolerance is often more delayed than that of an allergic reaction and is rarely as life threatening. Symptoms are often 'dose related', with a little not causing a problem but a lot producing symptoms.
Present day tests used to diagnose allergies are of little benefit in diagnosing milk intolerance. A combination of detailed history and a process of elimination are often used to determine if milk protein intolerance exists.
Cow's milk protein intolerance is often confused with lactose intolerance, which is intolerance to lactose contained in milk. This confusion is probably due to the fact that cow's milk protein and lactose are both found in the same foods. To further add to this confusion milk allergy or intolerance to milk protein can cause changes to the lining of the small intestines which can then result in secondary lactose intolerance.
Because many of the symptoms that indicate a cow's milk protein intolerance and lactose intolerance can be the same, it can sometimes be difficult to tell them apart. (See our article on lactose intolerance for more information)
Severe reactions which may result in floppiness in infants or anaphylaxis (shock) are rarely caused by milk allergy.
- Immediate rash around the mouth.
- Swelling of lips, mouth, tongue, face or throat.
- Generalized eczema on the trunk.
- Eczema behind ears and in body creases, such as neck and elbows.
- Scaly skin on cheeks, cradle cap.
- Dry skin or skin cracks e.g. bottom of the ear lobe, corner of the eye.
- Persistent diaper rash.
- Hives.
- Itchy red rash.
- Allergic "Shiners" (black eyes).
- Watery or itchy eyes.
- Runny nose (clear, watery).
- Stuffy or blocked nose, causing difficulty with feeding (breast or bottle).
- Sneezing.
- Itchy nose.
- Persistent cough.
- Wheezing or shortness of breath.
- Abdominal pain and bloating.
- Cramps.
- Vomiting.
- Excessive gassiness, passing wind.
- Diarrhea (loose runny stools), mucous or blood in motions.
- Failure to gain weight or weight loss.
- Pulling away from or refusing the breast or formula.
- Irritability or unsettled behavior.
- Poor sleep patterns.
Symptoms relating to the skin, nose, throat and lungs are not only restricted to people suffering from milk or food allergies. Many people show these symptoms to basically any other immune reaction. This could be from a bee sting, medications e.g. penicillin, pollens, house dust, animal hair or moulds.
Many stomach and bowel symptoms often associated with cow's milk protein intolerance can also be due to other conditions, gastro-intestinal infections or possibly feeding management. Where eliminating milk from the diet does not relieve these symptoms, further exploration may be necessary.
Behavioral symptoms on their own are not diagnostic of an allergy or intolerance and are likely to be due to a number of other possible causes not related to milk or food.
Reactions can occur immediately or up to several days after exposure to cow's milk proteins. The timing of symptoms can help to tell the difference between a milk allergy and intolerance.
Symptoms can begin to develop within 45 minutes of exposure to cow's milk proteins. The reaction is either a measles-like rash or hives, facial swelling. The respiratory system can be affected in this group, causing wheezing or sneezing or itchy, red eyes. This reaction usually occurs after small volumes of cow's milk. Allergy tests (skin prick tests or RAST blood tests) will often provide positive test results for this group.
Symptoms can begin to develop between 45 minutes and 20 hours after exposure to cow's milk proteins. Moderate amounts of milk are required to trigger this reaction. Allergy tests (skin prick tests or RAST blood tests) are only positive in about 1 in 3 children in this group.
Symptoms can begin to develop up to 20 hours after exposure to cow's milk proteins. Large volumes of milk are required to trigger this reaction. Only 1 in 5 children with delayed reactions show a positive skin prick test.
If your child has any of the symptoms above or if you suspect your child may have a milk or food allergy, see your child's doctor. Diagnosis is a difficult enough process even for an expert. Trying to work it out the best method of dealing with a cow's milk protein allergy or intolerance on your own would be virtually impossible.
An allergic response after drinking of milk generally occurs within the first 2 hours. In nearly 60% of young children milk reactions occur after that time, meaning they are more likely to be milk protein intolerant rather than allergic to the milk protein. Because milk intolerance does not involve an IgE (Immunoglobulin E) immune response, these children are unlikely to have positive results to present day allergy tests.
A thorough history of the specific symptoms, severity and time symptoms develop in relation to ingestion of the offending food can help to make a clinical diagnosis of an allergy or intolerance. In making a diagnoses a doctor will generally recommend a process of elimination, which if successful will make diagnostic testing unnecessary. Tests are normally only necessary where food other than milk is suspected.
This is an allergy test where a special "patch" of test material is placed upon the skin and the allergy response tested.
This is an allergy test where an allergen is placed and pricked onto the skin and any allergy response measured. This test can be carried out safely and reliably in children as young as three months of age.
CAP/RAST blood tests measure antibodies to proteins called IgE (Immunoglobulin E). It also tests for milk proteins as whole or individual fractions of milk (casein, whey, and beta-lactoglobulin).
Milk allergy and intolerance can also be diagnosed by removing milk (and milk products) from the diet for a period of time then reintroducing it for one feed to see if it causes symptoms.
For a proper investigation, a detailed understanding of food composition is needed, such as that of an experienced dietician. Simple advice to avoid foods, such as dairy products can be misleading as many foods contain milk. If the full range of intolerances is not identified, symptoms may return at some stage when the child eats a food containing the problem substance.
IMPORTANT: Elimination and re-introduction of milk and its products should only be undertaken with medical advice, particularly in cases with severe symptoms.
Babies can develop cow's milk protein allergy or intolerance even while they are exclusively breastfed, because cow's milk proteins can pass through breast milk. Breast feeding is often the safest, least irritant and most nutritious diet for sensitive babies and continued breast feeding should be encouraged where possible.
Milk and food intolerance in a breast fed infant is one of the most complex conditions to accurately diagnose. Present day diagnostic tests are limited in their capacity to diagnose all incidences of milk (or food) intolerance. To complicate diagnosis further, 50% of babies with a cow's milk protein intolerance will also develop allergies or intolerance to one or a number of other foods the mother may eat.
Management of a cow's milk protein intolerance in infants requires much more than simplistic advice to "eliminate all dairy foods". Because milk is a basic ingredient of many prepared foods, milk proteins are hidden in so many other foods.
For many breast feed babies, a diagnosis of cow's milk allergy in a thriving infant is often made by well meaning friends, family and health professionals, based on vague symptoms such as eczema, irritability, sleeplessness or gastric discomfort. Although, these can be symptoms of a cow's milk protein allergy or intolerance, they can also be due to numerous other more common (and easily corrected) reasons.
Sadly, like many other breast feeding mothers who can be mistakenly lead to believe their baby has an allergy to something they have eaten, if symptoms fail to settle, as often occurs, you may feel compelled to make further more restrictive food eliminations and this could potentially compromise both yours and your baby's health and can reduce your chances of successful breast feeding.
Where a child is highly sensitive to a particular food the mother has eaten, she will display obvious symptoms which can include skin rashes, respiratory difficulties or she will struggle to gain enough weight (or possibly lose weight).
An accurate diagnosis of milk or food intolerance often relies on a complicated process of elimination and challenge. Diagnosis is best left your child's pediatrician and any food avoidance should ONLY be done with medical or dietetic advice so that the mother's nutrition and consequently baby's nutrition is not compromised.
Parents often become concerned about milk or food intolerance simply because their child is irritable and sleepless. Restrictions to the maternal diet are rarely indicated, and are of questionable value, where a baby is thriving and symptoms are generally behavioral. Strict food restrictions in this situation is likely to cause more harm than good, as it can result in less than adequate maternal nutrition and reduced milk production (further adding to your baby's distress).
Gastric symptoms of gas and diarrhea in thriving healthy breast fed infants are often associated with a lactose overload. As this condition is often mistaken for lactose intolerance, we include more about this in our article on Lactose Intolerance. Even spitting up is more likely due to be to large feeds and a small tummy. (Also see our article on Reflux.)
Where your breast fed baby is thriving and symptoms are mostly behavioral or linked to stomach ache, gas or loose stools, we suggest you seek support from an experienced health professional to explore the many more common reason for these behaviors and symptoms to occur BEFORE going down the path of what could turn out to be unnecessary and unhelpful food restrictions.
Many babies who are allergic to cow's milk proteins will also be allergic to the protein contained in goat's milk and soy beans. As all infant formulas readily available on the market are based on cow's milk, goat's milk or soy beans, switching from one brand of formula to another rarely helps. For the cow's milk protein intolerant child a specialized formula may be necessary. Specialized formulas are only available on a doctor's prescription.
Some babies with who are sensitive to cow's milk can tolerate goat's milk formula. However, babies with a true cow's milk allergy are frequently unable to tolerate goat's milk as well.
Around 50% of babies who are allergic to cow's milk can tolerate soy-based formula.
Partially hydrolyzed formulas are available without a doctor's prescription and may prove useful where a child is 'at risk' of developing an allergy (e.g. where family members have allergies) However, partially hydrolyzed formula are NOT RECOMMENDED for cow's milk allergic children, once symptoms have developed.
Hydrolyzed formula can be used for babies with cow's milk allergy, when breastfeeding isn't possible and if soy formula is poorly tolerated. These are cow's milk-based formula that has been processed by breaking down the protein into smaller parts that are less likely to cause allergy. These specialized formulas require a doctor's prescription.
"Neocate" is not based on cow's milk. It's a totally non-allergenic extensively hydrolyzed formula that is completely broken down into amino acids. It can be helpful for the 10% of cow's milk allergic children, who continue to display allergic symptoms while on an extensively hydrolyzed formula (which can contain residual fragments of cow' milk proteins). Neocate is only available on a doctor's prescription.
Unfortunately there may be no way of totally avoiding the development of an allergy where a child has a tendency. The chances of a child developing an allergic reaction to cow's milk proteins is increased if blood relatives suffer with allergies such as eczema, asthma or hay fever.
There's no conclusive evidence that avoiding particular foods during pregnancy is beneficial. Severe restrictions may affect the nutrition of the developing baby. Exposure to allergens while in the womb may help promote immune tolerance.
- There's some evidence that exclusive breast feeding during the first 4-6 months appears to protect against the development of allergy and helps to enhance immune activity. If you are breast feeding your need for calcium provided in dairy products is particularly great during this time, so it's not a good idea to restrict milk and dairy foods as a preventative measure.
- Restrict exposure to cigarette smoke, house dust, mould and animal hair.
- Delay starting solids until as close as possible to 6 months, when a child's digestive system has had time to mature a little. Delay the introduction of egg white until at least 12 months and nuts and seafood until at least 24 months or longer.
HOW WE CAN HELP when your thriving baby is irritable and sleepless.
See also:
Lactose intolerance
Reflux
Lactose overload
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