Medicine Mommy

PART 2

Dr Nické Theron, Pediatrician.

Whether you are pregnant and wondering how to prevent allergies in your little one, or have a baby that has already been diagnosed with Cow’s Milk Protein Allergy and struggling with treatment, read on to find the latest research and tips here:

PREVENTION OF COW’S MILK PROTEIN ALLERGY (CMPA):

There are several risk factors for allergies and unfortunately not so many proven measures to reduce these risks. If you have a family history of allergies or atopic disease (especially eczema or asthma), your children will have an increased risk of developing CMPA – up to 3 times higher in one study. This is the most important factor to consider. Other risks include: Caesarean Section delivery, Prematurity, Older maternal age and Environmental factors.

Measures that have been proven to reduce the risk of CMPA (ONLY necessary when you have a family history of allergies or atopy):

• Exclusive breastfeeding is the preferred method of feeding up to the age of 6months. Although it has not been proven to prevent CMPA specifically there is good data to prove it has a significantly protective effect against eczema.
• If you cannot exclusively breastfeed, it is important to use a “partially hydrolysed” infant formula (eg Nan HA, Similac) to decrease the exposure to the full cow’s milk protein. In these formulas the very “offensive” part of the protein has been removed, but it is still perceived by the body as a cow’s milk protein and thus “exercises” the immune system.
• “Extensively hydrolysed” formula has also been proven to reduce the risk of CMPA, but they are very expensive and have a bad taste, thus rather used in the treatment of CMPA.
• “Amino Acid formulas” are NOT used in the prevention of CMPA.
• The mother DOES NOT have to exclude any allergens during pregnancy.
• When you start solid foods, it is recommended to start no earlier than 17 weeks (4 months) and no later than 27weeks (6 months). It is important to give a varied diet from the start (a restricted diet has a higher risk of allergies) and to introduce allergens such as cow’s milk, fish, peanuts, eggs, soy, wheat early and regularly. Although this is not proven to prevent CMPA specifically, it does decrease your risk for peanut and egg allergy.
• Unfortunately the studies on the use of pre- and probiotics in babies does not show any reduction in the risk of CMPA. Although we know that your microbiome plays a big role in the fight against allergies and atopic diseases, scientists are struggling to find out exactly which organisms and how much of what gives us an advantage. I am sure there will still be very interesting research in this field!
• Having pets at home reduces your risk for CMPA according to some studies. 😉

TREATMENT OF CMPA:

Unfortunately none of the above are fool proof to reduce CMPA and if your baby had the symptoms and a positive exclusion test (symptoms improved when cow’s milk protein was removed) you are facing the realities of treating an allergy. Although it can be scary (especially if your child has dramatic, immediate symptoms) and difficult to screen ALL food for cow’s milk protein, it is worth it to see the improvement in your child. I will walk through the basics of the treatment with you, but in the end a dietitian is invaluable to help you with the specifics of exclusion and re-introduction of cow’s milk protein. Please remember that this is just a generalised guideline to explain some of the concepts to you. There is such a big variety in the types of CMPA and the rest of your child’s unique case that you should always discuss any management plans with your pediatrician and dietitian.

Diagnostic Elimination:

• Breastfeeding infants: Mothers are encouraged to keep on breastfeeding, but to cut out all cow’s milk products (fresh milk, yoghurt, cheese, but also reading all labels for hidden sources) from her own diet for 2 – 4weeks.
• Formula-fed infants: All cow’s milk protein should be eliminated from baby’s diet and formula changed to an “extensively hydrolysed formula” (eg Similac Alimentum, Pepticate) for 2 – 4weeks. If there is still no improvement in symptoms you can try an “amino acid formula”. However, these are all very expensive and babies take some time to get used to the taste.

If your baby’s symptoms improved after removing cow’s milk, you continue the exclusion diet:

• Breastfeeding infants: Mother continues to eliminate cow’s milk protein and should drink Calcium supplements (your breastmilk will use the calcium from your bones to provide enough for your baby if you do not eat enough calcium).
• Formula-fed infants: Most recommendations are to continue “extensively hydrolysed formula” for baby.
• What about Soy formula (eg Isomil)? This is a much cheaper option, but there are some concerns about cross reaction (in up to 15% of babies) of the allergy, and certain hormonal contents of soy (isoflavone is a phyto-estrogen). Be careful when choosing this option in babies below 6 months.
• Other mammalian milks such as goat, sheep, camel also has a risk of cross-reacting and might not be nutritionally adapted for use in babies. Please work closely with your pediatrician and dietitian.
• Rice formulas are gaining popularity but are not yet available everywhere. There is no risk for cross-reactions, but there is a concern that these formulas contain arsenic and have not been studied in CMPA, so once again, be careful.
• If your baby starts solids, all cow’s milk protein should be excluded from their diet, but all other food groups should be introduced between 17-27weeks, especially the other high-risk allergens.
• A Dietitian can help to assess your child’s diet to ensure whether the supply of nutrients, especially proteins, calcium, vitamin D, and vitamin A, is sufficient.

Reintroducing Cow’s Milk Protein:

It is recommended that the cow’s milk is eliminated until at least 1 year of age, or for at least 6 months from diagnosis. If however the diagnosis was not confirmed with positive blood tests, or if the symptoms were very mild to start with, your doctor might reintroduce cow’s milk after 1 month.

There are different ways of reintroducing the allergen (also called a “challenge”). If your child was very ill / has immediate reactions, the reintroduction should be done in a hospital. If your baby just had eczema / reflux, you can reintroduce the cow’s milk at home with the guidance of a dietitian.
(See the “Milk Ladder” below.)
If the symptoms return, go back to the previous diet and retry after 6 months.

My take-home message is to take heart! Equip yourself with knowledge, a friendly dietitian and explore some new recipes! Your life does not have to be ruled by fear and FOMO for your child’s sake. Most children will outgrow their CMPA and you can make such a difference in their symptoms until then. The world of allergies is evolving so fast, you can play your part in the education of other moms and who knows, you might just support someone else with a new diagnosis!

“Praise be to the God and Father of our Lord Jesus Christ, the Father of compassion and the God of all comfort, 4 who comforts us in all our troubles, so that we can comfort those in any trouble with the comfort we ourselves receive from God.”

2 Cor 1:3-4

RESOURCES:

1. Ralf G. Heine, Fawaz AlRefaee, Prashant Bachina, Julie C. De Leon, Lanlan Geng, Sitang Gong, José Armando Madrazo, Jarungchit Ngamphaiboon, Christina Ong, and Jossie M. Rogacion;  “Lactose intolerance and gastrointestinal cow’s milk allergy in infants and children – common misconceptions revisited”; World Allergy Organ J. 2017; 10(1): 41.
2. Yvan Vandenplas, Martin Brueton, Christophe Dupont, David Hill, Erika Isolauri, Sibylle Koletzko, Arnold P Oranje, and Annamaria Staiano; “Guidelines for the diagnosis and management of cow’s milk protein allergy in infants”; Arch Dis Child. 2007 Oct; 92(10): 902–908.
3. Koletzko S, Niggemann B, Arato A, Dias JA, Heuschkel R, Husby S, Mearin ML, Papadopoulou A, Ruemmele FM, Staiano A, Schappi MG, and Vandenplas Y; “Diagnostic Approach and Management of Cow’s-Milk Protein Allergy in Infants and Children: ESPGHAN GI Committee Practical Guidelines”
4. http://www.uptodate.com
5. Vandenplas Y, Al-Hussaini B, Al-Mannaei K, Al-Sunaid A, Ayesh WH, El-Degeir M, El-Kabbany N, Haddad J, Hashmi A, Kreishan F and Tawfik E; “Prevention of Allergic Sensitization and Treatment of Cow’s Milk Protein Allergy in Early Life: The Middle-East Step-Down Consensus”; Nutrients. 2019 Jul; 11(7): 1444
6. Sardecka I, Łoś-Rycharska E, Ludwig H, Gawryjołek J, Krogulska A; “Early risk factors for cow’s milk allergy in children in the first year of life”; Allergy Asthma Proc. 2018 Nov 1;39(6):e44-e54.

Written by Dr Nické Theron, Pediatrician.

Cow’s milk protein allergy. So many misconceptions, misunderstandings, fears and confusion locked up behind those few words for both moms and health-care professionals. I was privileged to attend the congress of the European Academy of Pediatrics two weeks ago and the master course focused on nutrition in childhood. I finally have a better understanding of CMPA (Cow’s Milk Protein Allergy) and I hope I can explain it better to you too.

As with many food allergies, CMPA is an allergy (where the immune system mistakenly identifies a protein as harmful and reacts to cause symptoms) to one or multiple of the different protein-structures in cow’s milk. Unfortunately the occurrence of all types of allergies are increasing in Western societies at an alarming rate, with CMPA being the most common (2-7% of babies). Food allergies specifically can cause a lot of anxiety in parents and children as you have to be on alert at all times, and any symptom can be seen as an allergic response. It is high maintenance to totally exclude a specific food group from your child’s diet and this can also cause deficiencies in their diet. It is thus important that your child is diagnosed correctly, and that you have the necessary dietary assistance to help you and your child reach the top of this mountain.

The good news about CMPA specifically is that many babies outgrow it by 1 year of age, and most children should tolerate cow’s milk proteins by the age of 3 years and can return to a normal diet. Having a sibling with CMPA does not increase a new baby’s chance to develop CMPA, but if there is a family history of atopy/allergies the 2nd child will have the same type of risks as the first.

It is important to know that not all symptoms caused by ingesting food are caused by an allergy.

Dr Nické Theron

Lactose intolerance is one example, where poor breakdown (by an enzyme called lactase) and absorption of the sugar component (lactose) in cow’s milk, causes too much lactose to end up in the large intestines resulting in symptoms such as bloating, diarrhoea and abdominal pain. This is very rare in infants who usually have enough lactase-enzymes to digest the lactose in up to 1 litre of breast milk per day. Any left-over lactose in an infant’s gut acts as a prebiotic and improves the development of the immune system. As a baby starts to wean, the lactase percentage drops slowly in about 70% of the population, and this could lead to symptoms of lactose intolerance after the age of 5 years. Even in these children it is usually not necessary to cut out all lactose from their diets as they can cope with a small amount. Premature babies might have lactose intolerance due to their immature gut, and very rarely babies are born with a congenital abnormality where they produce no lactase and they will then present with severe diarrhoea.

Another more common cause of lactose intolerance is a sick gut (secondary lactose intolerance). If your baby had a bout of infective diarrhoea or has severe inflammation of the gut due to eg CMPA, the inside lining of the intestines becomes very thin and then lactase cannot be produced. Removing lactose from the diet can then help to give the intestines a chance to restore the lining and lactose can be reintroduced after 2-4 weeks.

Ok, back to CMPA:
This allergy can develop in exclusively breastfed babies as the cow’s milk protein is passed relatively unchanged through the breastmilk. It can also present later when cow’s milk is introduced into a baby’s diet.

SYMPTOMS

Unfortunately there is not one specific symptom for CMPA, and babies and children can present with a wide variety of symptoms. It can cause anything from vomiting, regurgitation (can be misdiagnosed as reflux), blood in the stools, diarrhoea, constipation, eczema, wheezing or anaphylaxis (a state of shock where the allergic reaction overwhelms the body and is a medical emergency). See the table below for more detail.

Some babies become critically ill shortly after ingesting the protein, while others are happy, healthy and growing with some nagging symptoms. I am sure you can now understand why it is so difficult to diagnose CMPA!

To complicate the matter and the diagnosis even more, there are different types of CMPA because of the different ways the immune system responds to the protein. Some children will have “IgE-mediated CMPA”. (IgE is a specific antibody of the immune system that recognizes proteins as bad and rapidly responds to it.) Children with asthma and eczema also have high levels of IgE in their blood. The advantage is that we can test for this type. They will usually have a positive skin-prick test and positive blood results specifically for CMPA. The disadvantage of this type is that the children usually take longer to outgrow the allergy, and they are more prone to develop other atopic diseases later in life. Their reaction to CMP is also usually more severe and they can develop anaphylaxis.

The immune system can also respond without IgE, leading to a more delayed reaction (some children can still get very ill!) that is usually outgrown earlier. However there are no tests we can do to prove this type of allergy and this can be very frustrating to parents and doctors!

The latest guidelines have thus suggested that the best way to diagnose any type of CMPA is with a good history and physical examination, followed by an elimination of the cow’s milk protein from the diet. If the symptoms improve the child should be “challenged” by giving the cow’s milk protein again, and if the symptoms return the diagnosis is confirmed.

Other tests that might be done are blood tests for total IgE and specific food allergies or a skin-prick test where the reaction of the skin to different allergens are tested.

I will leave you so that you can digest this chunky piece of information, please feel free to ask if you do not understand anything! In my next post I will address the management of Cow’s Milk Protein Allergy from a medical perspective and help you to understand where a Dietitian fits into the picture.

RESOURCES

1. Ralf G. Heine, Fawaz AlRefaee, Prashant Bachina, Julie C. De Leon, Lanlan Geng, Sitang Gong, José Armando Madrazo, Jarungchit Ngamphaiboon, Christina Ong, and Jossie M. Rogacion; “Lactose intolerance and gastrointestinal cow’s milk allergy in infants and children – common misconceptions revisited”; World Allergy Organ J. 2017; 10(1): 41.
2. Yvan Vandenplas, Martin Brueton, Christophe Dupont, David Hill, Erika Isolauri, Sibylle Koletzko, Arnold P Oranje, and Annamaria Staiano; “Guidelines for the diagnosis and management of cow’s milk protein allergy in infants”; Arch Dis Child. 2007 Oct; 92(10): 902–908.
3. Koletzko S, Niggemann B, Arato A, Dias JA, Heuschkel R, Husby S, Mearin ML, Papadopoulou A, Ruemmele FM, Staiano A, Schappi MG, and Vandenplas Y; “Diagnostic Approach and Management of Cow’s-Milk Protein Allergy in Infants and Children: ESPGHAN GI Committee Practical Guidelines”
4. http://www.uptodate.com