Two recent paper published in The Specialist Forum by Prof Robin Green and Tammy Wolhuter, on the subject of the use of so-called "hypoallergenic milk feeds" for children who suffer from cow’s milk protein allergy (CMPA), contain a wealth of information for mothers and caregivers of babies who are allergic to cow’s milk. Professor Green is Associate Professor & Director of Paediatric Pulmonology and Paediatric Critical Care at the University of Pretoria, and Tammy Wolhuter, is a registered dietician working with Anne Till & Associates.
Symptoms of cow’s milk protein allergy
Babies with CMPA develop a variety of characteristic signs and symptoms which may affect:
the Digestive tract (frequent regurgitation of milk; vomiting and diarrhoea which can lead to dehydration; constipation; bloody stools and iron deficiency anaemia)
the Skin (atopic eczema (inflammation of the skin); swelling of the lips and eyelids; pruritus (itchy skin rash) and urticaria (hives),
and the Respiratory tract (runny nose; inflammation of the eye (conjunctivitis); chronic cough and wheezing).
Other symptoms that may point to CMPA include: persistent distress or colic with desperate crying and irritability for periods exceeding 3 hours a day on at least 3 days a week for longer than 3 weeks; refusal of foods; growth retardation and anaphylaxis (an acute multi-system, severe hypersensitivity reaction that can in some cases, prove fatal)
(Green, 2011; Wolhuter, 2011)
Parents or caregivers of an infant that develops one or more of these symptoms should have the child assessed by a paediatrician or at Child Care Clinic. If a diagnosis of CMPA is made, then it is essential to avoid all cow’s and goat’s milk, as well as foods that contain any of the following:
casein, whey, butter, protein concentrate, curds, yoghurt, cheese, cream, buttermilk, or maas.
Check all food labels carefully and if you see that the product contains cow’s milk, goat’s milk or anyone of the above mentioned ingredients, then avoid giving the product to the child.
According to Prof Green (2011), cow’s milk contains two major protein fractions, namely casein (80%) and whey (20%). Both these fractions contain potential allergens, that can trigger CMPA in susceptible infants.
Contrary to popular belief, goat’s milk is usually not suitable for children with CMPA as it contains similar allergic proteins (Green, 2011).
If your child is not able to use a milk formula that is made from cow’s milk or its fractions such as casein or whey, then Prof Green recommends the following substitutes:
a) Soya-based formulas and milks
Children who are not also allergic to soya proteins, can use soya-based formulas or milks, and soya products such as soya yoghurt, cheese or ice cream. However, between 15% and 50% of all children with CMPA are also allergic to soya and will not be able to use soya products.
b) Extensively hydrolysed formulas (eHF)
Prof Green states that more than 90% of infants with CMPA will be able to tolerate eHF formulas. These formulas are processed in such a way that the protein fraction in the formula no longer causes an allergic reaction. There are 2 types of eHF formulas available, namely eHF casein formulas such as Nutramigen (Mead Johnson*); Alimentum (Abbott); Pepticate (Nutriticia); and the eHF whey formula AL110 (Nestle).
c) Amino acid formulas (AAF)
Prof Green (2011) recommends the use of these specialised formulas for short periods to allow the infant’s bowel to rest and assist the child to gain some weight. AAF such as Neocate (Pharmaplan) and Neotrician (Cipla Medpro), help to rapidly stop the distressing symptoms of CMPA and give the child a chance to recover.
Prof Green mentions that AAF “should be considered an important adjunct, at least temporarily, in many more infants with CMPA”. After using AAF for a short period, many children with CMPA will be able to tolerate the standard eHF mentioned above under b), which are less expensive than the specialised AAF.
(* The names of manufacturers are listed in brackets after product names)
Things to keep in mind
Breast is Best!
Always keep in mind that breastfeeding is the preferred method of feeding infants until they are at least 6 months old. Breastfeeding should be continued for as long as possible, because according to Tammy Wolhuter (2011), CMPA is less likely to occur in breastfed infants than in formula fed infants. The concentrations of cow’s milk protein (CMP) in breastmilk are 100,000 times lower than in cow’s milk. In addition, so-called "immunomodulators" in breastmilk and differences in intestinal microorganisms in breastfed babies, may help to protect these infants against CMPA (Wolhuter, 2011).
Some women are, however, not able to breastfeed for various reason such as ill health, having to take essential medications that pass into breastmilk and can harm the child, or being forced to return to work because of economic constraints and not being able to express sufficient breastmilk to sustain the baby. In such cases, it may be necessary to use an infant formula as a substitute for breastmilk. If your baby should then develop symptoms such as the ones listed above that indicate CMPA, and your doctor or healthcare worker has diagnosed CMPA, then you may have to use an eHF or AAF for your child’s well-being.
Avoid highly restrictive diets
Children diagnosed with CMPA are often placed on very restrictive diets by their overanxious mothers or caregivers. Prof Green (2011) lists a variety of negative effects this type of overprotection can have:
Starvation or malnutrition of the child because of its highly restricted diet
Overprotection of the child which can have negative psychological consequences
Social isolation of the child because the parent is too scared to let the child socialise with other children because he or she may be given foods that contain cow’s milk
Increased stress and anxiety in the family because of strictly regimented food intake and hypervigilance to "protect" the CMPA infant.
If your child has been diagnosed with CMPA and you are overdoing your care so that the child is exposed to the risk of starvation or deficiency diseases, then please consult a dietician to assist you with food selection and choices so that you child can still eat a varied, balanced diet. Visit the Association for Dietetics in SA website cto find a dietician in your area. The dietician will also assist you with "re-challenges” (i.e. introducing very small quantities of cow’s milk to the diet at regular intervals to test if the child is still allergic).
The good news
The good news according to Prof Green (2011), is that “Cow’s milk allergy is outgrown in the vast majority of children by the age of 5-7 years”. This is good news indeed, and something anxious parents need to keep in mind - in most cases, CMPA will no longer affect your child and she will be able to eat a normal diet by the time she goes to school.
(Green R (2011). Approach to hypoallergenic milk feeds for cow’s milk protein allergic children. The Specialist Forum, 11(5):22-24. Wolhuter T (2011). Cow’s milk protein allergy. The Specialist Forum, 11(5):32)