What can i eat if i have a milk protein allergy

Alternative milks

Soya formulas own been prescribed in the past for CMPA but soya is also a common allergen, so this is no longer routinely advised. About 10-15% of children allergic to cow’s milk will also react to soya. Soya milk also contains isoflavones which own a feeble oestrogenic activity.

Other milks, such as pea, oat or coconut, may be used after the age of 2 years, depending on the child’s nutritional status and any other allergies they may own.

A brand fortified with calcium should be used if available. Rice milk is not recommended for children aged under 4.5 years.

If the symptoms of CMPA persist into older childhood or beyond then patients need to continue to avoid milk and milk products. The proteins in goat’s milk and other mammal milks which may be available are almost identical to those found in cow’s milk, so those are not suitable substitutes. It is significant to maintain an adequate calcium intake.

Children who are avoiding cow’s milk for allergy reasons should be referred to a paediatric dietician for specialist advice.

Challenge test

The prognosis of CMPA is excellent with a remission rate of approximately 45-50% at 1 year, 60-75% at 2 years and 85-90% at 3 years[15].Children can own a challenge test every 6-12 months to see if they are capable to tolerate milk.

What can i eat if i own a milk protein allergy

It may take several days for the reaction to show, particularly for non-IgE allergy.

The challenge test can be carried out in stages, according to the ‘Milk Ladder’[16]. This is a hierarchy of milk-containing foods, beginning with those least likely to cause a reaction and gradually moving towards being capable to drink a glass of milk. In baked form, such as muffins, cakes or malted milk biscuits, cow’s milk is less allergenic and may be tolerated sooner than unbaked milk.

There is some evidence that including cooked milk in the diet may hasten the resolution of allergy to non-cooked milk[17, 18].

If the kid has had IgE type reactions, particularly if they own been severe, then a challenge test should be carried out under shut supervision.

Allergen avoidance

The management of CMPA generally consists of avoidance of the allergen. If CMPA is the cause of the symptoms then they should resolve within two weeks of stopping cow’s milk.

If the kid is formula-fed, they can be given extensively hydrolysed milk formula such as Nutramigen®, Aptamil Pepti® or Pepti Junior®.

These are based on cow’s milk but the proteins are broken below into smaller peptides that are less likely to trigger an allergic reaction.

Babies who own CMPA may own their growth and development impaired by the disorder; however, hydrolysed formula is shown to provide balanced nutrition and to restore normal growth and development[12, 13].

If the symptoms persist on hydrolysed formula but a suspicion of CMPA remains, then attempt an amino acid formula.

These include Nutramigen AA® and Neocate LCP®. Hydrolysed milks are cheaper and are also generally better tolerated, although the flavour and tolerability varies[14].

If the kid is breast-fed and the mom wishes to continue breast-feeding, she must eliminate milk and milk products from her diet. This will include checking ingredients for anything derived from milk, such as casein, whey and lactose. The mom should make certain she is still getting adequate calcium in her diet. It is recommended that she be offered calcium and vitamin D tablets; however, calcium can also come from tinned fish, pulses, almonds, kale, oranges and soya products such as soya milk and tofu[8].

Babies who are being weaned, and older children with persisting CMPA, will need to follow a cow’s milk-free diet as above.

Parents must be advised about how to check the ingredients of processed foods for milk-derived constituents. Children should be referred to a paediatric dietician for advice about maintaining a balanced diet while excluding allergens.

New treatments

Immunotherapy, in which children are given a gradually increasing dose of milk over a period of several months, is one option which has been tried for children with persisting severe allergy. The results own been extremely promising, although a Cochrane review concluded that further studies of higher quality were necessary before it can be recommended without reservation[19].


Signs and symptoms

Food allergies can own rapid-onset (from minutes up to 2 hours), delayed-onset (up to 48 hours or even 1 week), or combinations of both, depending on the mechanisms involved.

The difference depends on the types of white blood cells involved. B cells, a subset of white blood cells, rapidly synthesize and secrete immunoglobulin E (IgE), a class of antibody which bind to antigens, i.e., the foreign proteins. Thus, immediate reactions are described as IgE-mediated. The delayed reactions involve non-IgE-mediated immune mechanisms initiated by B cells, T cells, and other white blood cells. Unlike with IgE reactions, there are no specific biomarker molecules circulating in the blood, and so, confirmation is by removing the suspect food from the diet and see if the symptoms resolve.[18]

IgE-mediated symptoms include: rash, hives, itching of the mouth, lips, tongue, throat, eyes, skin, or other areas, swelling of the lips, tongue, eyelids, or the whole face, difficulty swallowing, runny or congested nose, hoarse voice, wheezing, shortness of breath, diarrhea, abdominal pain, lightheadedness, fainting, nausea and vomiting.

Symptoms of allergies vary from person to person and may also vary from incident to incident.[19] Serious harm regarding allergies can start when the respiratory tract or blood circulation is affected. The previous can be indicated by wheezing, a blocked airway and cyanosis, the latter by feeble pulse, pale skin, and fainting. When these symptoms happen, the allergic reaction is called anaphylaxis.[19] Anaphylaxis occurs when IgE antibodies are involved, and areas of the body that are not in direct contact with the food become affected and show severe symptoms.[19][20] Untreated, this can proceed to vasodilation, a low blood pressure situation called anaphylactic shock, and extremely rarely, death.[6][20]

For milk allergy, non-IgE-mediated responses are more common than IgE-mediated.[21] The presence of certain symptoms, such as angioedema or atopic eczema, is more likely related to IgE-mediated allergies, whereas non-IgE-mediated reactions manifest as gastrointestinal symptoms, without skin or respiratory symptoms.[18][22] Within non-IgE cow’s milk allergy, clinicians distinguish among food protein-induced enterocolitis syndrome (FPIES), food protein-induced allergic proctocolitis (FPIAP) and food protein-induced enteropathy (FPE).

Common trigger foods for every are cow’s milk and soy foods (including soy baby formula).[22][23] FPIAP is considered to be at the milder finish of the spectrum, and is characterized by intermittent bloody stools. FPE is identified by chronic diarrhea which will resolve when the offending food is removed from the infant’s diet. FPIES can be severe, characterized by persistent vomiting, 1 to 4 hours after an allergen-containing food is ingested, to the point of lethargy.

Watery and sometimes bloody diarrhea can develop 5 to 10 hours after the triggering meal, to the point of dehydration and low blood pressure. Infants reacting to cow’s milk may also react to soy formula, and vice versa.[23][24] International consensus guidelines own been established for the diagnosis and treatment of FPIES.[24]


Differential diagnosis

With such a wide range of symptoms that can be caused by CMPA, the differential diagnosis is extensive, and includes other food allergies, non-food allergies such as pollen, animal dander, other gastrointestinal disorders, pancreatic insufficiency such as in cystic fibrosis, and infections — eg urinary tract infection.


Diagnosis[8]

Allergic reactions can be immunoglobulin E (IgE)-mediated reactions or non-IgE-mediated reactions.

Cow’s milk proteins can cause reactions of either type or both together, which can make them hard to diagnose.

IgE-mediated reactions

IgE-mediated reactions trigger histamine release and happen within two hours of milk being consumed. They include skin reactions such as itching, erythema, urticaria and acute angio-oedema, most commonly of the face. There can be abdominal symptoms such as colicky pain, nausea, vomiting and diarrhoea. Respiratory symptoms can be upper or lower respiratory tract: nasal itching, sneezing, rhinorrhoea, congestion, cough, chest tightness or wheeze.

It is extremely rare for cow’s milk to trigger an anaphylactic reaction.

Antihistamines can be used to treat the symptoms. Allergic reactions may be more severe in people with asthma, particularly if the asthma is poorly controlled[9].

This type of allergy can be diagnosed with a skin prick test or a blood test (specific IgE, previously known as RAST). If this type of allergy is suspected, refer the kid to a paediatrician who will arrange for the test to be done in hospital.

Non-IgE-mediated reactions

Non-IgE-mediated reactions happen hours or days after consuming milk. Skin reactions such as atopic eczema are common, as well as itching and erythema.

Abdominal symptoms include colicky pain (including infantile colic), reflux, blood or mucus in stools, constipation or diarrhoea. There may be lower respiratory tract symptoms such as cough, wheeze, breathlessness or chest tightness.The kid may be pale and tired, and growth may be faltering.

The best way to establish if cow’s milk is causing these symptoms is to exclude it from the diet. There should be an improvement in symptoms within two weeks.


Epidemiology[2, 3]

CMPA affects about 7% of formula-fed babies but only about 0.5% of exclusively breast-fed babies, who also tend to own milder reactions.

What can i eat if i own a milk protein allergy

Exclusive breast-feeding may also protect babies from developing an allergy to cow’s milk protein after they are weaned[4].

There are a number of diverse proteins in cows milk: there are five protein components in each of the casein and whey fractions of milk. A kid can be allergic to one or more components within either group.

CMPA is more likely in children who own other atopic conditions such as asthma, eczema or hay fever, or if shut family members own those conditions.

The presence of atopic eczema is a predictor for sensitisation to common food allergens. The earlier the eczema starts and the more severe it is, the higher the risk of food allergy[5].

If there are other food allergies, it is more likely that CMPA will persist into later childhood.

Some work has been done looking at the development of food allergies and whether this can be prevented by feeding infants at risk with hydrolysed formula. However, the results own so far not been clear[6, 7].


Lactose intolerance[20]

Many people confuse lactose intolerance with CMPA.

Lactose intolerance is an inability to digest lactose, due to an inadequate production of the digestive enzyme lactase.

It is generally a condition of older childhood and adulthood. Worldwide it is extremely common, although it is less prevalent in northern European races. It is unusual for babies and young children to be intolerant of lactose, although they do fairly commonly develop a transient lactose intolerance following an episode of gastroenteritis.

People with a lactose intolerance can often consume products such as yoghurt and cheese in which the lactose has been altered and they may be capable to own little amounts of milk without symptoms. They can generally tolerate lactose-free milk.

Clinical Editor’s comments (October 2017)
Dr Hayley Willacy recommends the recently released international Milk Allergy in primary care guideline[1].

The guideline includes updated recommendations on presentation and recognition of cow’s milk allergy (CMA); diagnosis; management of mild-to-moderate confirmed non-IgE-mediated CMA within primary care; suspected severe non-IgE-mediated CMA and referral. A number of additional resources own been developed alongside the guideline to support parents and carers, including an initial factsheet for parents; a home reintroduction protocol to confirm diagnosis; a milk ladder and milk ladder recipes.

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  • lactalbumin, lactoalbumin phosphate, lactaglobulin, lactose, lactoferrin, lactulose
  • Leonard SA, Nowak-Wegrzyn AH; Baked Milk and Egg Diets for Milk and Egg Allergy Management.

    Immunol Allergy Clin North Am. 2016 Feb36(1):147-59. doi: 10.1016/j.iac.2015.08.013.

  • Miraglia Del Giudice M, D'Auria E, Peroni D, et al; Flavor, relative palatability and components of cow's milk hydrolysed formulas and amino acid-based formula. Ital J Pediatr. 2015 Jun 341:42. doi: 10.1186/s13052-015-0141-7.

  • Venter C, Brown T, Meyer R, et al; Better recognition, diagnosis and management of non-IgE-mediated cow's milk allergy in infancy: iMAP-an international interpretation of the MAP (Milk Allergy in Primary Care) guideline.

    Clin Transl Allergy. 2017 Aug 237:26. doi: 10.1186/s13601-017-0162-y. eCollection 2017.

  • casein, calcium casein, casein hydrolysate, magenesium casein, potassium casein, rennet casein, sodium casein
  • Vandenplas Y, Koletzko S, Isolauri E, et al; Guidelines for the diagnosis and management of cow's milk protein allergy in infants. Arch Dis Kid. 2007 Oct92(10):902-8.

  • non-dairy creamers
  • The Milk Ladder; MAP Guideline

  • Hill DJ, Hosking CS; Food allergy and atopic dermatitis in infancy: an epidemiologic study.

    Pediatr Allergy Immunol. 2004 Oct15(5):421-7.

  • whey, whey hydrolysate
  • Bloom KA, Huang FR, Bencharitiwong R, et al; Effect of heat treatment on milk and egg proteins allergenicity. Pediatr Allergy Immunol. 2014 Dec25(8):740-6. doi: 10.1111/pai.12283. Epub 2014 Dec 18.

  • Ludman S, Shah N, Fox AT; Managing cows' milk allergy in children. BMJ. 2013 Sep 16347:f5424. doi: 10.1136/bmj.f5424.

  • Host A, Halken S; Cow's milk allergy: where own we come from and where are we going? Endocr Metab Immune Disord Drug Targets. 2014 Mar14(1):2-8.

  • Cows milk protein allergy in children; NICE CKS, June 2015 (UK access only)

  • Yeung JP, Kloda LA, McDevitt J, et al; Oral immunotherapy for milk allergy.

    What can i eat if i own a milk protein allergy

    Cochrane Database Syst Rev. 2012 Nov 1411:CD009542. doi: 10.1002/14651858.CD009542.pub2.

  • dairy products love cheese, yogurt, milk, pudding, sour cream, and cottage cheese
  • butter, butter flavoring (such as diacetyl), butter fat, butter oil, ghee
  • Osborn DA, Sinn J; Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants. Cochrane Database Syst Rev. 2006 Oct 18(4):CD003664.

  • Boyano-Martinez T, Garcia-Ara C, Pedrosa M, et al; Accidental allergic reactions in children allergic to cow's milk proteins. J Allergy Clin Immunol. 2009 Apr123(4):883-8. doi: 10.1016/j.jaci.2008.12.1125.

    Epub 2009 Feb 20.

  • Boyle RJ, Ierodiakonou D, Khan T, et al; Hydrolysed formula and risk of allergic or autoimmune disease: systematic review and meta-analysis. BMJ. 2016 Mar 8352:i974. doi: 10.1136/bmj.i974.

  • Agostoni C, Terracciano L, Varin E, et al; The Nutritional Worth of Protein-hydrolyzed Formulae. Crit Rev Food Sci Nutr. 201656(1):65-9. doi: 10.1080/10408398.2012.713047.

  • To provide guidance on formula choice in the initial diagnosis of CMA based on the current international guidelines.

  • Dupont C, Hol J, Nieuwenhuis EE; An extensively hydrolysed casein-based formula for infants with cows' milk protein allergy: tolerance/hypo-allergenicity and growth catch-up.

    Br J Nutr. 2015 Apr 14113(7):1102-12. doi: 10.1017/S000711451500015X. Epub 2015 Mar 17.

  • Vandenplas Y, De Greef E, Devreker T; Treatment of Cow's Milk Protein Allergy. Pediatr Gastroenterol Hepatol Nutr. 2014 Mar17(1):1-5. doi: 10.5223/pghn.2014.17.1.1. Epub 2014 Mar 31.

  • Vandenplas Y; Lactose intolerance. Asia Pac J Clin Nutr. 201524 Suppl 1:S9-13. doi: 10.6133/apjcn.2015.24.s1.02.

  • Liao SL, Lai SH, Yeh KW, et al; Exclusive breastfeeding is associated with reduced cow's milk sensitization in early childhood.

    Pediatr Allergy Immunol. 2014 Aug25(5):456-61. doi: 10.1111/pai.12247.

  • 2)

    Severe and mild to moderate clinical expressions of CMA.

So numerous foods are made with milk and milk products these days that people with milk allergies own to pay attention to what’s in just about everything they eat. And a milk allergy is not the same as lactose intolerance — some people with food allergies can become suddenly and severely ill if they eat or even come in contact with the food they’re allergic to.

Some foods that contain milk are obvious, love pizza.

But others, love baked goods, might not be so obvious. Plus, teens need calcium and vitamin D, which milk has lots of, because their bones are still growing.

So what should a person who’s allergic to milk do? Read on to discover out.

Nomenclature

The first step in making the correct diagnosis and managing infants and children with cow’s milk allergy is to own a excellent understanding of the immune mechanisms involved. According to the European Academy for Allergy and Clinical Immunology (EAACI) and the World Allergy Organisation (WAO)[15], a hypersensitivity reaction to cow’s milk can be referred to as cow’s milk allergy if it involves the immune system.

Non-allergic cow’s milk hypersensitivity (lactose intolerance) on the other hand, does not involve the immune system. Cow’s milk allergy is further divided into IgE-mediated cow’s milk allergy and non-IgE-mediated cow’s milk allergy[7]. There is however clinical overlap between some presentations of cow’s milk allergy as indicated by the US food allergy guidelines[10].

Living With a Milk Allergy

It can be challenging to eliminate milk from your diet, but it’s not impossible. Because most people don’t get enough calcium in their diets even if they do drink milk, numerous other foods are now enriched with calcium, such as juices, cereals, and rice and soy beverages.

But before you eat or drink anything calcium-enriched, make certain it’s also dairy-free.

Milk and milk products can lurk in strange places, such as processed lunchmeats, margarine, baked goods, artificial butter flavor, and non-dairy products. Chocolate is another product that may contain dairy — so be certain to check the label before you eat it.

Manufacturers of foods sold in the United States must list on their labels whether a food contains any of the most common allergens. This means that you should be capable to discover the expression «milk» stated plainly in the ingredients list, in parentheses in the ingredients list, or somewhere on the label with a statement like: «Contains milk.»

It is optional, however, for food manufacturers to use «may contain» statements.

The U.S. Food and Drug istration does not control whether companies can tell things love «Processed in a facility that also processes milk products» or «May contain milk.» So call the manufacturer to be certain if you see statements love this on a food label.

New labeling requirements make it a little easier than reading the ingredients list — instead of needing to know that the ingredient «hydrolyzed casein» comes from milk protein, you should be capable to tell at a glance which foods to avoid.

But it’s still a excellent thought to get to know the «code words» for milk products when you see them in the ingredients of a food.

Some ingredients and foods that contain milk are:

  1. lactalbumin, lactoalbumin phosphate, lactaglobulin, lactose, lactoferrin, lactulose
  2. butter, butter flavoring (such as diacetyl), butter fat, butter oil, ghee
  3. dairy products love cheese, yogurt, milk, pudding, sour cream, and cottage cheese
  4. casein, calcium casein, casein hydrolysate, magenesium casein, potassium casein, rennet casein, sodium casein
  5. non-dairy creamers
  6. whey, whey hydrolysate

Vegan foods are made without animal products, such as eggs or milk.

You can purchase vegan products at health food stores. Be careful to read the labels of soy cheeses, though.

What can i eat if i own a milk protein allergy

They may tell «milk-free» but could contain milk protein.

For your sweet tooth, soy- or rice-based frozen desserts, sorbets, and puddings are excellent substitutes for ice cream (as endless as you’re not allergic to soy), as are ice pops. For baking, milk substitutes work as well as milk and some come out better. Dairy-free margarine works as well as butter for recipes and spreading on your bagel.

Try to avoid fried foods or foods with batter on them. Even if the batter doesn’t contain milk products, the oil used to fry the foods may own been used to fry something that contains milk.

People are generally understanding when it comes to food allergies — nobody wants to risk your health.

When dining out, tell the waitstaff about anything you’re allergic to. Order the simplest foods and enquire the waitstaff detailed questions about menu items. At a friend’s home, explain your situation and don’t be embarrassed to enquire questions if you’re staying for a meal.

Having a milk allergy doesn’t mean you can’t still enjoy eating. In fact, some people ponder that some of the milk substitutes — love vanilla soy milk — taste better than regular cow’s milk. As with any specialized diet, you’ll probably discover that avoiding milk gives you the chance to explore and discover some grand foods that you’d never own found otherwise!

Methodology

The NICE guideline was written to direct the diagnosis of every food allergies.

CMA is however, the most clinically complicated individual food allergy and therefore causes significant challenges in both recognising the numerous differing clinical presentations and also the varying approaches to management, both at primary care and specialist level. A subgroup of the clinicians on the NICE guideline development group (CV, JW, ATF, TB) felt that there was therefore a specific need to extend this into a more practical guideline for cow’s milk allergy for UK Primary Care use. This need was further emphasized by the publication of international and European guidelines on cow’s milk allergy[2, 7–9].

This subgroup, with the additional expertise of a paediatric gastro-enterologist (NS) has produced a UK Primary Care Guideline in the form of practical algorithms.

Prior to the development of this Primary Care Guideline, the group discussed significant questions that they wanted to address and which clear, practical messages they wanted to convey to UK primary care. These were:

  1. To provide guidance on formula choice in the initial diagnosis of CMA based on the current international guidelines.

  2. 2)

    Severe and mild to moderate clinical expressions of CMA.

  3. How to distinguish between:

    So numerous foods are made with milk and milk products these days that people with milk allergies own to pay attention to what’s in just about everything they eat.

    And a milk allergy is not the same as lactose intolerance — some people with food allergies can become suddenly and severely ill if they eat or even come in contact with the food they’re allergic to.

    Some foods that contain milk are obvious, love pizza.

    What can i eat if i own a milk protein allergy

    But others, love baked goods, might not be so obvious. Plus, teens need calcium and vitamin D, which milk has lots of, because their bones are still growing.

    So what should a person who’s allergic to milk do? Read on to discover out.

    Nomenclature

    The first step in making the correct diagnosis and managing infants and children with cow’s milk allergy is to own a excellent understanding of the immune mechanisms involved. According to the European Academy for Allergy and Clinical Immunology (EAACI) and the World Allergy Organisation (WAO)[15], a hypersensitivity reaction to cow’s milk can be referred to as cow’s milk allergy if it involves the immune system.

    Non-allergic cow’s milk hypersensitivity (lactose intolerance) on the other hand, does not involve the immune system. Cow’s milk allergy is further divided into IgE-mediated cow’s milk allergy and non-IgE-mediated cow’s milk allergy[7]. There is however clinical overlap between some presentations of cow’s milk allergy as indicated by the US food allergy guidelines[10].

    Living With a Milk Allergy

    It can be challenging to eliminate milk from your diet, but it’s not impossible. Because most people don’t get enough calcium in their diets even if they do drink milk, numerous other foods are now enriched with calcium, such as juices, cereals, and rice and soy beverages.

    But before you eat or drink anything calcium-enriched, make certain it’s also dairy-free.

    Milk and milk products can lurk in strange places, such as processed lunchmeats, margarine, baked goods, artificial butter flavor, and non-dairy products. Chocolate is another product that may contain dairy — so be certain to check the label before you eat it.

    Manufacturers of foods sold in the United States must list on their labels whether a food contains any of the most common allergens. This means that you should be capable to discover the expression «milk» stated plainly in the ingredients list, in parentheses in the ingredients list, or somewhere on the label with a statement like: «Contains milk.»

    It is optional, however, for food manufacturers to use «may contain» statements.

    The U.S. Food and Drug istration does not control whether companies can tell things love «Processed in a facility that also processes milk products» or «May contain milk.» So call the manufacturer to be certain if you see statements love this on a food label.

    New labeling requirements make it a little easier than reading the ingredients list — instead of needing to know that the ingredient «hydrolyzed casein» comes from milk protein, you should be capable to tell at a glance which foods to avoid. But it’s still a excellent thought to get to know the «code words» for milk products when you see them in the ingredients of a food.

    Some ingredients and foods that contain milk are:

    1. lactalbumin, lactoalbumin phosphate, lactaglobulin, lactose, lactoferrin, lactulose
    2. butter, butter flavoring (such as diacetyl), butter fat, butter oil, ghee
    3. dairy products love cheese, yogurt, milk, pudding, sour cream, and cottage cheese
    4. casein, calcium casein, casein hydrolysate, magenesium casein, potassium casein, rennet casein, sodium casein
    5. non-dairy creamers
    6. whey, whey hydrolysate

    Vegan foods are made without animal products, such as eggs or milk.

    You can purchase vegan products at health food stores. Be careful to read the labels of soy cheeses, though. They may tell «milk-free» but could contain milk protein.

    For your sweet tooth, soy- or rice-based frozen desserts, sorbets, and puddings are excellent substitutes for ice cream (as endless as you’re not allergic to soy), as are ice pops. For baking, milk substitutes work as well as milk and some come out better. Dairy-free margarine works as well as butter for recipes and spreading on your bagel.

    Try to avoid fried foods or foods with batter on them.

    Even if the batter doesn’t contain milk products, the oil used to fry the foods may own been used to fry something that contains milk.

    People are generally understanding when it comes to food allergies — nobody wants to risk your health. When dining out, tell the waitstaff about anything you’re allergic to. Order the simplest foods and enquire the waitstaff detailed questions about menu items. At a friend’s home, explain your situation and don’t be embarrassed to enquire questions if you’re staying for a meal.

    Having a milk allergy doesn’t mean you can’t still enjoy eating.

    In fact, some people ponder that some of the milk substitutes — love vanilla soy milk — taste better than regular cow’s milk. As with any specialized diet, you’ll probably discover that avoiding milk gives you the chance to explore and discover some grand foods that you’d never own found otherwise!

    Methodology

    The NICE guideline was written to direct the diagnosis of every food allergies. CMA is however, the most clinically complicated individual food allergy and therefore causes significant challenges in both recognising the numerous differing clinical presentations and also the varying approaches to management, both at primary care and specialist level.

    A subgroup of the clinicians on the NICE guideline development group (CV, JW, ATF, TB) felt that there was therefore a specific need to extend this into a more practical guideline for cow’s milk allergy for UK Primary Care use. This need was further emphasized by the publication of international and European guidelines on cow’s milk allergy[2, 7–9]. This subgroup, with the additional expertise of a paediatric gastro-enterologist (NS) has produced a UK Primary Care Guideline in the form of practical algorithms.

    Prior to the development of this Primary Care Guideline, the group discussed significant questions that they wanted to address and which clear, practical messages they wanted to convey to UK primary care.

    These were:

    1. To provide guidance on formula choice in the initial diagnosis of CMA based on the current international guidelines.

    2. 2)

      Severe and mild to moderate clinical expressions of CMA.

    3. How to distinguish between:

    4. 1)

      IgE-mediated and non-IgE-mediated presentations of CMA.

    5. Give guidance about the ongoing management of mild to moderate non-IgE-mediated CMA in primary care.

    A literature search was conducted to ensure that every major food allergies and cow’s milk allergy guidelines published in the past five years were included. These included the World Allergy Organisation’s Guidelines on Cow’s Milk Allergy[2], the NIAID Food Allergy Guidelines from the US[10], the UK NICE Guideline on Food Allergy in Children and Young People[6], the ESPGHAN guidelines on the diagnosis and management of cow’s milk allergy[7]and the Australian consensus statement on the diagnosis and management of cow’s milk allergy[11].

    Every these papers were informed by extensive systematic reviews of the literature and the group (CV, TB, JW, NS, ATF), felt that they were rigorous enough to build this proposed additional practical guideline on. It is intended to complement the NICE Food Allergy Guideline.

    How Is It Treated?

    To treat a milk allergy, the person who is allergic needs to completely avoid any foods that contain milk or milk products.

    Avoiding milk involves more than just leaving the cheese off your sandwich. If you are allergic to milk, you need to read food labels carefully and not eat anything that you’re not certain about.

    It’s a excellent thought to work with a registered dietitian to develop an eating plan that provides every the nutrients you need while avoiding things you can’t eat.

    If you own a severe milk allergy — or any helpful of serious allergy — your doctor may desire you to carry a shot of epinephrine (pronounced: eh-peh-NEH-frin) with you in case of an emergency. Epinephrine comes in an easy-to-carry container about the size of a large marker. It’s simple to use — your doctor will show you how.

    If you accidentally eat something with milk in it and start having serious allergic symptoms — love swelling inside your mouth, chest pain, or difficulty breathing — give yourself the shot correct away to counteract the reaction while you’re waiting for medical assist.

    Always call for emergency assist (911) when using epinephrine. You should make certain your school and even excellent friends’ houses hold injectable epinephrine on hand, too.

    Keeping epinephrine with youat every times should be just part of your action plan for living with a milk allergy. It’s also a excellent thought to carry an over-the-counter antihistamine, which can assist ease allergy symptoms in some people. But antihistamines should be used in addition to the epinephrine, not as a replacement for the shot.

    If you’ve had to take an epinephrine shot because of an allergic reaction, go immediately to a medical facility or hospital emergency room so they can give you additional treatment if you need it.

    Sometimes, anaphylactic reactions are followed bya second wave of symptoms a fewhours later. So you might need to be watched in a clinic or hospital for 4 to 8 hours following the reaction.

    What Happens With a Milk Allergy?

    Food allergies involve the body’s immune system, which normally fights infection. When someone is allergic to a specific food, the immune system overreacts to proteins in that food.

    People who are allergic to cow’s milk react to one or more of the proteins in it.

    Curd, the substance that forms chunks in sour milk, contains 80% of milk’s proteins, including several called caseins (pronounced: KAY-seenz). Whey (pronounced: WAY), the watery part of milk, holds the other 20%. A person may be allergic to proteins in either or both parts of milk.

    Every time the person eats these proteins, the body thinks they are harmful invaders. The immune system responds by kicking into high gear to fend off the «invader.» This causes an allergic reaction, in which chemicals love histamine are released in the body.

    The release of these chemicals can cause someone to own the following problems:

    1. hives
    2. vomiting
    3. stomachache
    4. wheezing
    5. red spots
    6. hoarseness
    7. swelling
    8. diarrhea
    9. trouble breathing
    10. itchy, watery, or swollen eyes
    11. throat tightness
    12. coughing
    13. a drop in blood pressure

    Milk allergy is love most food allergy reactions: It generally happens within minutes to hours after eating foods that contain milk proteins.

    Although it’s not common, milk allergies can cause a severe reaction called anaphylaxis.

    Anaphylaxis may start with some of the same symptoms as a less severe reaction, but then quickly worsen. A person might own trouble breathing, feel lightheaded, or pass out. If it’s not treated, anaphylaxis can be life-threatening.

    Milk allergy is often confused with lactose intolerance because people can own the same kinds of things happening to them (like stomach pains or bloating, for example) with both conditions. But they’re not related:

    1. Milk allergy is a problem involving the immune system.
    2. Lactose intolerance involves the digestive system (which doesn’t produce enough of the enzyme needed to break below the sugar in milk).

    The diverse manifestations of CMA

    According to the UK NICE guideline[6], food allergy can manifest as a number of diverse clinical presentations, mainly affecting the skin, gastro-intestinal tract and respiratory systems.

    The NICE guideline[6] emphasises that food allergies should be particularly considered 1) in infants where there is a family history of allergic disease (but the absence of a family history of allergy does not exclude the possibility of becoming allergic), 2) in infants where symptoms are persistent and affecting diverse organ systems and 3) in infants who own been treated for moderate to severe atopic eczema, gastro-oesophageal reflux disease (GORD) or other persisting gastrointestinal symptoms (including ‘colic’ , loose stools, constipation), but own not responded to the usual initial therapeutic interventions.

    In Figure 2 of the algorithms, we own divided IgE and non-IgE-mediated CMA into “mild-moderate presentations” and “severe presentations” to aid in the diagnostic process, management of CMA and appropriate onward referral.

    Therefore, most importantly, Figure 2 gives a clear message about which infants can be safely diagnosed and managed in UK primary care without any onward referral to secondary or tertiary care.

    How Can Doctors Tell It’s a Milk Allergy?

    If your doctor suspects you might own a milk allergy, he or she will probably refer you to an allergist or allergy specialist for more testing. The allergy specialist will enquire you questions — love how often you own the reaction, the time it takes between eating a specific food and the start of the symptoms, and whether any family members own allergies or conditions love eczema and asthma.

    The allergy specialist may do a skin test on you.

    This involves placing liquid extracts of milk protein on your forearm or back, pricking the skin a tiny bit, and waiting to see if a reddish, raised spot forms, indicating an allergic reaction.

    You may need to stop taking anti-allergy medications (such as over-the-counter antihistamines) or prescription medicine 5 to 7 days before the skin test because they can affect the results. Most freezing medicines and some antidepressants also may affect skin testing.

    Check with the allergist’s office if you are unsure about what medications need to be stopped and for how long.

    The doctor also might take a blood sample and send it to a lab, where it will be mixed with some of the suspected allergen and checked for IgE antibodies.

    These types of tests are used for diagnosing what doctors call a fast-onset type of milk allergy. But for people whose allergic reactions to milk develop more slowly, skin and blood tests are not as helpful.

    In these cases, doctors attempt to diagnose the person using a food challenge. The person is told not to eat or drink anything made with milk for a period of time — generally a few weeks.

    Then, during the challenge, the person eats foods containing milk under a doctor’s shut supervision. If symptoms come back after eating milk products, it’s a beautiful certain bet the person has a milk allergy.

    Prevalence of CMA

    Population based studies report that the prevalence of Cow’s Milk Allergy (CMA) ranges from 1.9 – 4.9% in young children[2]. UK data from 2008 indicated 2.3% of 1–3 year olds suffer from CMA, the majority of these presenting with non-IgE-mediated CMA[3]. A meta-analysis by Rona et al.[4] reported that Cow’s milk (CM) is one of the most common foods which is responsible for allergic reactions in European children.

    In general, the prognosis for CMA is excellent, with up to 80-90% of children developing tolerance before three years of age[12]. However, CMA may persist up to school age and may be associated with the later development of other allergic diseases such as asthma, rhinoconjunctivitis, and atopic dermatitis[13], as well as other disease manifestations such as recurrent abdominal pain[14]. It is also well-known that perceived prevalence may be much higher[4, 12] than that confirmed by appropriate tests.

    Cow’s milk formula or cow’s milk containing foods frolic an significant role in the nutritional intake of children particularly in early infancy. Onset after infancy has also been uncommonly reported[3].

    Diagnosis of Cow’s milk allergy

    Non-IgE -Mediated CMA

    There are no validated tests for the diagnosis of non-IgE CMA, apart from the planned avoidance of cow’s milk and cow’s milk containing foods, followed by reintroduction as a home challenge to confirm the diagnosis[17]. Home reintroduction/challenges may not be acceptable in children with severe forms of non-IgE- mediated cow’s milk allergy, and these children should be referred to secondary/tertiary care[6].

    IgE-Mediated CMA

    For the diagnosis of IgE-mediated CMA, the use of skin prick tests (SPT) or specific serum IgE tests are recommended, but these should only be performed by those capable to interpret the tests[16].

    It is significant to understand that a positive SPT or specific serum IgE test merely indicates sensitisation and does not confirm clinical allergy. However, a positive test coupled with a clear history of a reaction should generally be sufficient to confirm a diagnosis. Although a diagnostic oral food challenge (after a short period of cow’s milk avoidance) may not be required in most of these cases, if such a challenge is conducted, it may need to be performed in a supervised setting in the majority of cases. Liasion with or referral to a local paediatric allergy team is recommended (see Figure 3).

    History taking

    Taking an allergy focused history forms the cornerstone of the diagnosis of food allergies including CMA and the UK NICE guideline[6] recommends that questions should be asked regarding:

    1. Presenting symptoms and signs that may be indicating possible CMA.

    2. The infant’s feeding history.

    3. Any personal history of early atopic disease.

    4. Any family history of atopic disease in parents or siblings.

    5. Details of previous management, including any medication and the perceived response to any management.

    6. Was there any attempt to change the diet and what was the outcome?

    An EAACI task force also dealt with the significant questions that should be asked during an allergy focused diet history, and will be available later this year.

    Following on from these questions is the significant step to attempt to differentiate between possible IgE and non-IgE -mediated allergies (Figure 2) and which “tests” to do.

    The role of dietary interventions in the diagnosis of IgE and non-IgE-mediated CMA

    Maternal avoidance of cow’s milk in the case of breast fed infants, or choosing an appropriate formula for bottle fed/partially bottle fed infants are crucial steps in the diagnosis of CMA.

    Mothers excluding cow’s milk from their diet should be supplemented with calcium and vitamin D[18] (Figure 2).

    Choosing the most appropriate formula (Figure 3, Figure 4; Table 1) for the baby based on the clinical presentation is debated with clear differences between countries. This choice is really a clinical decision which should be based on clinical presentation and the nutritional composition and residual allergenicity of the proposed hypoallergenic formula.

    The problem clinicians face is that it may appear there is a large body of evidence about alternatives to cow’s milk formulae, but most of the research is of low quality and there are a relatively little number of studies about each type of formula.

    There are extremely few studies comparing the diverse formulae in RCTs head to head and the clinical profiles of the patients who improved and did not improve are often extremely poorly described. This puts the physician and dietitian in a extremely hard position when choosing the most appropriate formula for a specific clinical presentation. In some cases choosing a soya or an extensively hydrolysed formula (eHF), which the baby may also react to, may lead to a untrue negative diagnosis.

    What can i eat if i own a milk protein allergy

    Alternatively, choosing an amino acid formula (AAF) when not indicated increases the cost burden of managing CMA and may affect development of tolerance (albeit the data is extremely preliminary at this time)[19, 20].

    Table 1 summarises the current international guidelines on the use of hypo-allergenic formulae in the diagnosis and management of CMA. It is accepted that the majority of children with CMA will improve on an extensively hydrolysed formula. It is therefore not surprising that in general, the guidelines propose the use of an AAF, as a first line treatment, only for more severe presentations of CMA such as a history of anaphylaxis, Heiner Syndrome, Eosinophilic Eosophagitis and severe gastro-intestinal and/or skin presentations, generally in association with faltering growth.

    They recommend the use of an eHF for every other clinical presentations.

    Unfortunately, apart from the ESPGHAN guidelines[21], none of the guidelines[2, 6, 10, 11, 22] discuss the use of formulae in two significant patient groups, namely those with multiple food allergies, and those infants who do not reply to maternal avoidance of cow’s milk (and other suspected allergens) despite a excellent clinical suspicion that these infants may be reacting to residual allergens. These cases own been reviewed by Hill et al.[23], Niggeman et al.[24] and Van den Plas et al.[8] with data suggesting that these groups may benefit from an AAF.

    The systematic review by Hill et al.[23] further suggested that those infants presenting with symptoms of CMA whilst exclusively breast fed, who may need a top-up formula or a replacement of breast milk may also benefit from an AAF.

    The use of soya formula in the diagnosis and management of CMA is also debated, with clear differences between the Australian consensus panel[11] and the ESPGHAN[7]/AAP[22, 25] guidelines. ESPGHAN and AAP acknowledge that only about 10-14% of infants with IgE- mediated CMA will also react to soya, but that this figure is much higher in infants with non-IgE- mediated CMA (25–60%). The two societies therefore recommend that cow’s-milk-based hypoallergenic formulae should ideally be chosen rather than soya formula in the management of CMA.

    In addition, soya formula contains phytate which may affect nutrient absorption and isoflavonoids in amounts that make soya milk unsuitable for use in every infants under six months of age. Soya can however be used in infants older than 6 months if eHF is not accepted or tolerated, if these hypoallergenic formulae are too expensive, or if there are strong parental preferences (e.g. vegan diet).

    In addition, there own been some questions raised regarding the use of hypoallergenic formulae containing lactose in the diagnosis and management of infants and young children with CMA.

    ESPGHAN[7] advises that adverse reactions to lactose in children with CMA is not reported in the literature and finish avoidance of lactose is not needed in the majority of cases, apart from those children who own an enteropathy with severe diarrhoea where there is a secondary lactose intolerance. Two randomised trials suggested that rice based hydrolysed formula is well tolerated by infants with CMA[26, 27] although there are some concerns about the effect of these formulae on weight gain[28].

    Therefore, to summarise the above discussion, taking into account the lack of excellent quality studies in this field:

    1. eHF is recommended as a first line of choice for infants with mild to moderate presentations of CMA e.g.

      colic, reflux, diarrhoea, vomiting, eczema in the absence of faltering growth. eHF containing whey may not be suitable as a first line of treatment of those infants with possible secondary lactose intolerance[7].

    2. AAF is recommended as a first line of treatment for those infants with a history of anaphylaxis to cow’s milk, Heiner Syndrome, Eosinophilic Eosophagitis and severe gastro-intestinal and/or skin presentations, particularly in association with faltering growth.

    3. Breast-feeding is always the preferred way to feed any baby. In any case where there is a need to exclude cow’s milk from the maternal diet and a top-up formula is needed, we propose in agreement with Hill et al.[23] an amino acid based formula as the B-lactoglobulin levels and peptide sizes of cow’s milk protein in breast milk and those of eHF are similar to the ranges of B-lactoglobulin seen in breast milk[29–33].

    4. Soya formula can be used in infants over 6 months of age who do not tolerate the eHF, particularly if they are suffering from IgE mediated CMA in the absence of sensitisation to soya.

    Not to be confused with Lactose intolerance.

    Milk allergy is an adverse immune reaction to one or more proteins in cow’s milk.

    When allergy symptoms happen, they can happen rapidly or own a gradual onset. The previous may include anaphylaxis, a potentially life-threatening condition which requires treatment with epinephrine among other measures. The latter can take hours to days to appear, with symptoms including atopic dermatitis, inflammation of the esophagus, enteropathy involving the little intestine and proctocolitis involving the rectum and colon.[2]

    In the United States, 90% of allergic responses to foods are caused by eight foods, with cow’s milk being the most common.[3] Recognition that a little number of foods are responsible for the majority of food allergies has led to requirements to prominently list these common allergens, including dairy, on food labels.[4][5][6][7] One function of the immune system is to defend against infections by recognizing foreign proteins, but it should not over-react to food proteins.

    Heating milk proteins can cause them to become denatured, meaning to lose their 3-dimensional configuration, and thus lose allergenicity; for this reason dairy-containing baked goods may be tolerated while unused milk triggers an allergic reaction.

    Management is by avoiding eating any dairy foods or foods that contain dairy ingredients.[8] In people with rapid reactions (IgE-mediated milk allergy), the dose capable of provoking an allergic response can be as low as a few milligrams, so recommendations are to avoid dairy strictly.[9][10] The declaration of the presence of trace amounts of milk or dairy in foods is not mandatory in any country, with the exception of Brazil.[5][11][12]

    Milk allergy affects between 2% and 3% of babies and young children.[8][13] To reduce risk, recommendations are that babies should be exclusively breastfed for at least four months, preferably six months, before introducing cow’s milk.

    If there is a family history of dairy allergy, then soy baby formula can be considered, but about 10 to 15% of babies allergic to cow’s milk will also react to soy.[14] The majority of children outgrow milk allergy, but for about 0.4% the condition persists into adulthood.[15]Oral immunotherapy is being researched, but it is of unclear benefit.[16][17]


    Mechanisms

    Conditions caused by food allergies are classified into three groups according to the mechanism of the allergic response:[25]

    • IgE-mediated (classic) – the most common type, manifesting as acute changes that happen shortly after eating, and may progress to anaphylaxis
    • Non-IgE mediated – characterized by an immune response not involving IgE; may happen hours to days after eating, complicating the diagnosis
    • IgE- and non-IgE-mediated – a hybrid of the above two types

    Allergic reactions are hyperactive responses of the immune system to generally innocuous substances, such as proteins in the foods we eat.

    Some proteins trigger allergic reactions while others do not. One theory is resistance to digestion, the thinking being that when largely intact proteins reach the little intestine the white blood cells involved in immune reactions will be activated.[26] The heat of cooking structurally degrades protein molecules, potentially making them less allergenic.[27] Allergic responses can be divided into two phases: an acute response that occurs immediately after exposure to an allergen, which can then either subside or progress into a «late-phase reaction,» prolonging the symptoms of a response and resulting in more tissue damage.[28][29]

    In the early stages of acute allergic reaction, lymphocytes previously sensitized to a specific protein or protein part react by quickly producing a specific type of antibody known as secreted IgE (sIgE), which circulates in the blood and binds to IgE-specific receptors on the surface of other kinds of immune cells called mast cells and basophils.

    Both of these are involved in the acute inflammatory response.[28] Activated mast cells and basophils undergo a process called degranulation, during which they release histamine and other inflammatory chemical mediators (cytokines, interleukins, leukotrienes, and prostaglandins) into the surrounding tissue causing several systemic effects, such as vasodilation, mucous secretion, nerve stimulation, and smooth muscle contraction. This results in runny nose, itchiness, shortness of breath, and potentially anaphylaxis. Depending on the individual, the allergen, and the mode of introduction, the symptoms can be system-wide (classical anaphylaxis), or localized to specific body systems; asthma is localized to the respiratory system, while eczema is localized to the skin.[28]

    After the chemical mediators of the acute response subside, late-phase responses can often happen due to the migration of other white blood cells such as neutrophils, lymphocytes, eosinophils, and macrophages to the initial reaction sites.

    This is generally seen 2–24 hours after the original reaction.[29] Cytokines from mast cells may also frolic a role in the persistence of long-term effects. Late-phase responses seen in asthma are slightly diverse from those seen in other allergic responses, although they are still caused by release of mediators from eosinophils.[30]

    Six major allergenic proteins from cow’s milk own been identified: αs1-, αs2-, β-, and κ-casein from casein proteins and α-lactalbumin and β-lactoglobulin from whey proteins.

    There is some cross-reactivity with soy protein, particularly in non-IgE mediated allergy. Heat can reduce allergenic potential, so dairy ingredients in baked goods may be less likely to trigger a reaction than milk or cheese. For milk allergy, non-IgE-mediated responses are more common than IgE-mediated. The previous can manifest as atopic dermatitis and gastrointestinal symptoms, especially in infants and young children. Some will display both, so that a kid could react to an oral food challenge with respiratory symptoms and hives (skin rash), followed a day or two later with a flare up of atopic dermatitis and gastrointestinal symptoms, including chronic diarrhea, blood in the stools, gastroesophageal reflux disease (GERD), constipation, chronic vomiting and colic.[2]

    Allergic reactions are hyperactive responses of the immune system to generally innocuous substances, such as proteins in the foods we eat.

    Some proteins trigger allergic reactions while others do not. One theory is resistance to digestion, the thinking being that when largely intact proteins reach the little intestine the white blood cells involved in immune reactions will be activated.[26] The heat of cooking structurally degrades protein molecules, potentially making them less allergenic.[27] Allergic responses can be divided into two phases: an acute response that occurs immediately after exposure to an allergen, which can then either subside or progress into a «late-phase reaction,» prolonging the symptoms of a response and resulting in more tissue damage.[28][29]

    In the early stages of acute allergic reaction, lymphocytes previously sensitized to a specific protein or protein part react by quickly producing a specific type of antibody known as secreted IgE (sIgE), which circulates in the blood and binds to IgE-specific receptors on the surface of other kinds of immune cells called mast cells and basophils.

    Both of these are involved in the acute inflammatory response.[28] Activated mast cells and basophils undergo a process called degranulation, during which they release histamine and other inflammatory chemical mediators (cytokines, interleukins, leukotrienes, and prostaglandins) into the surrounding tissue causing several systemic effects, such as vasodilation, mucous secretion, nerve stimulation, and smooth muscle contraction. This results in runny nose, itchiness, shortness of breath, and potentially anaphylaxis.

    Depending on the individual, the allergen, and the mode of introduction, the symptoms can be system-wide (classical anaphylaxis), or localized to specific body systems; asthma is localized to the respiratory system, while eczema is localized to the skin.[28]

    After the chemical mediators of the acute response subside, late-phase responses can often happen due to the migration of other white blood cells such as neutrophils, lymphocytes, eosinophils, and macrophages to the initial reaction sites. This is generally seen 2–24 hours after the original reaction.[29] Cytokines from mast cells may also frolic a role in the persistence of long-term effects.

    Late-phase responses seen in asthma are slightly diverse from those seen in other allergic responses, although they are still caused by release of mediators from eosinophils.[30]

    Six major allergenic proteins from cow’s milk own been identified: αs1-, αs2-, β-, and κ-casein from casein proteins and α-lactalbumin and β-lactoglobulin from whey proteins. There is some cross-reactivity with soy protein, particularly in non-IgE mediated allergy. Heat can reduce allergenic potential, so dairy ingredients in baked goods may be less likely to trigger a reaction than milk or cheese. For milk allergy, non-IgE-mediated responses are more common than IgE-mediated.

    The previous can manifest as atopic dermatitis and gastrointestinal symptoms, especially in infants and young children. Some will display both, so that a kid could react to an oral food challenge with respiratory symptoms and hives (skin rash), followed a day or two later with a flare up of atopic dermatitis and gastrointestinal symptoms, including chronic diarrhea, blood in the stools, gastroesophageal reflux disease (GERD), constipation, chronic vomiting and colic.[2]


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