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.

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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.

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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.