What is the best formula for babies with milk allergy

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.

What is the best formula for babies with milk allergy

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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  • 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)

  • 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.

  • 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.

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

  • Yeung JP, Kloda LA, McDevitt J, et al; Oral immunotherapy for milk allergy. Cochrane Database Syst Rev. 2012 Nov 1411:CD009542. doi: 10.1002/14651858.CD009542.pub2.

  • 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.

  • 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.

  • The Milk Ladder; MAP Guideline

  • 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.

  • 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.

  • 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.

  • Osborn DA, Sinn J; Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants. Cochrane Database Syst Rev.

    What is the best formula for babies with milk allergy

    2006 Oct 18(4):CD003664.

  • 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.

  • Hill DJ, Hosking CS; Food allergy and atopic dermatitis in infancy: an epidemiologic study. Pediatr Allergy Immunol. 2004 Oct15(5):421-7.

  • 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.

  • 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.

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As your baby’s first birthday approaches, you may be wondering how you’re going to start introducing cow’s milk into their diet, and what the reaction will be when you do. What if it bothers their stomach? What if they hate the taste? Do I really not offer a drop until we’re cutting the first birthday cake? Do we tell goodbye to bottles too?

You should know that the American Academy of Pediatrics still recommends a combination of solid foods and breastmilk or formula for children under 12 months.

Only after 1 year do they propose introducing whole cow’s milk.

Why whole milk? Because it has more fat, which helps with healthy brain development, much of which takes put during the first two years of life.

And Children’s Hospital pediatricians consent. “We don’t recommend anything other than breast milk or formula as the primary liquids in an infant’s diet until after she turns 1,” says Joseph Gwiszcz, MD, FAAP, a pediatrician at Cut Primary Care, Haverford. But he does add that it’s OK to attempt offering a sippy cup of about an ounce of whole milk once a day after your baby turns 11 months ancient for a couple weeks before the full switch.

“This can assist you test how your baby will tolerate the taste of cow’s milk and assist her practice using a sippy cup,” says. Dr. Gwiszcz.

It is OK to give babies foods made with dairy products (like yogurt, ice cream and cheese) as appropriate for their age starting after 6 months ancient, as endless as there is not a strong family or personal history of a cow’s milk allergy, in which case you should discuss with your pediatrician before introducing.

After 1 year of age, if breastfeeding is not going to be exclusively continued, whole milk can take over as your baby’s main drink, along with water.

Ready to start weaning your 1-year-old and offering cow’s milk?

Here are some tips from Dr. Gwiszcz on getting started, and what to expect during the transition:

As your baby’s first birthday approaches, you may be wondering how you’re going to start introducing cow’s milk into their diet, and what the reaction will be when you do. What if it bothers their stomach? What if they hate the taste? Do I really not offer a drop until we’re cutting the first birthday cake? Do we tell goodbye to bottles too?

You should know that the American Academy of Pediatrics still recommends a combination of solid foods and breastmilk or formula for children under 12 months.

Only after 1 year do they propose introducing whole cow’s milk.

Why whole milk?

What is the best formula for babies with milk allergy

Because it has more fat, which helps with healthy brain development, much of which takes put during the first two years of life.

And Children’s Hospital pediatricians consent. “We don’t recommend anything other than breast milk or formula as the primary liquids in an infant’s diet until after she turns 1,” says Joseph Gwiszcz, MD, FAAP, a pediatrician at Cut Primary Care, Haverford. But he does add that it’s OK to attempt offering a sippy cup of about an ounce of whole milk once a day after your baby turns 11 months ancient for a couple weeks before the full switch. “This can assist you test how your baby will tolerate the taste of cow’s milk and assist her practice using a sippy cup,” says.

Dr. Gwiszcz.

It is OK to give babies foods made with dairy products (like yogurt, ice cream and cheese) as appropriate for their age starting after 6 months ancient, as endless as there is not a strong family or personal history of a cow’s milk allergy, in which case you should discuss with your pediatrician before introducing.

After 1 year of age, if breastfeeding is not going to be exclusively continued, whole milk can take over as your baby’s main drink, along with water.

Ready to start weaning your 1-year-old and offering cow’s milk? Here are some tips from Dr.

What is the best formula for babies with milk allergy

Gwiszcz on getting started, and what to expect during the transition:


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.

What is the best formula for babies with milk allergy

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.


Move from bottle to sippy cup

Transitioning to whole milk is also a excellent time to attempt transitioning off of bottles altogether.

“The goal is to transition off of bottles and onto sippy or straw cups completely as soon after your baby’s first birthday as possible,” says Dr. Gwiszcz. This can assist reduce the risk of milk-bottle cavities.


Management [10]

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.

What is the best formula for babies with milk allergy

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.

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.

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.

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.

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].


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. 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].


Ease into it

If your baby isn’t a large fan of how cow’s milk tastes, you can stir equal parts whole milk and either breast milk or prepared formula (don’t stir powdered formula with whole milk instead of water).

Then, gradually decrease the ratio of breast milk/formula to whole milk.


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