Dietetics Leaflet: Cow’s Milk Free Diet for Infants and Children

Leaflet Details

Patient Information

Introduction

Cow’s milk allergy most commonly occurs during infancy and early childhood. Most children will develop symptoms before 6 months of age and it is, in practice, rare for it to start after the 1st year of life. It may either present as immediate onset IgE mediated allergy or as delayed onset (non-IgE) mediated allergy. Most children will present with non-IgE milk allergy, but a significant number will present with the more immediate onset IgE type of milk allergy.

Immediate cow’s milk allergy

Breast feeding is always the preferred way for an infant to be fed and fortunately immediate onset milk allergy rarely occurs in the exclusively breast fed infant. It usually occurs when formula milk is introduced to the infant’s diet or on weaning onto solids when other dairy products are introduced. There is often, but not always, a close family history of allergy such as eczema, hay fever, asthma or food allergy in a mother, father, brother or sister. Typically, the symptoms will present within minutes of the milk protein being ingested but there can be a delay of up to 2 hours.

Immediate symptoms may include a combination of the following:

• itchy skin rashes (redness or hives)
   
• swelling of the face, eyes or lips
   
• runny nose, itchy eyes
   
• eczema
   
• coughing
   
• vomiting
   
• swallowing or breathing difficulties (rare)

Delayed cow’s milk allergy

As with immediate onset milk allergy, there is often but not always a close family history of allergy such as eczema, hay fever, asthma or food allergy in a mother, father, brother or sister. It is much less easy to diagnose than immediate onset milk allergy because the symptoms can occur hours or even days after ingestion. The allergy tests for immediate allergy - skin prick tests and bloods tests, have no role to play because whereas immediate cow’s milk allergy involves the antibody called Immunoglobulin E, delayed cow’s milk allergy has a different mechanism which doesn’t appear positive in these tests. Also, the symptoms often mimic common ailments in infants such as colic, reflux, disturbed stools and eczema.

Many of the children with a cow’s milk allergy may also have a soya (soy) allergy. Reactions to both milk and soya, are more common in children with delayed food allergy where symptoms occur between 2hours - 48hours or longer after eating the food containing milk or soya.

Delayed symptoms may include a combination of the following:

• diarrhoea - often with a sore bottom (nappy rash)
   
• constipation - often associated with excessive straining
   
• gastro-oesophageal reflux disease
   
• nausea and / or profuse vomiting
   
• abdominal pain, bloating or distension
   
• mucous and / or blood in the stools
   
• painful wind, excess gas
   
• eczema
   
• food refusal / faltering growth

Management

Cow’s milk allergy should in most cases be treated with a strict cow’s milk free diet. Your Dietitian will help you to avoid milk while making sure that your child gets all the nutrition they need to grow and develop well.

Cooking and processing can alter some of the allergenic proteins in milk, making it less likely for the proteins to be recognised by the body. Therefore, some children are able to tolerate milk that has been baked at high temperature (e.g. milk in cakes or biscuits) for some time, but will still react to small amounts of less well-cooked milk (e.g. in custard, quiche), or to raw/uncooked milk (e.g. in some yogurts)

If your child can tolerate baked milk, your Dietitian will be able to provide you with lists of foods that will be safe for you (if you are breastfeeding) and / or your child to eat. It is important not to introduce these at home unless you have been advised to do so by your Dietitian or Doctor.

Milk Substitutes under 1 year

Breastfeeding provides the best source of nutrition for all babies with cow’s milk and soya allergy. It is important for breastfeeding mothers to receive support with breastfeeding if needed. Information on how to access breastfeeding support can be found at:

• https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/breastfeeding/help-and-support/

Occasionally, breast-fed babies can react to milk proteins transferred in breast milk from the mother’s diet. If your baby reacts to your breast milk, you may be advised to avoid milk (dairy) products whilst breastfeeding. This is usually done as a trial for between 2 to 4 weeks to see if your baby’s symptoms improve. If they do not, and you were following the diet strictly, you can return to your normal diet

Hypoallergenic formulas:

If your baby is having infant milk formula with or without any breast milk, it will need to be changed to a hypoallergenic infant formula. Your Dietitian will give advice on the best one for your baby. These are available on prescription from your GP and there are two main types:

• extensively hydrolysed formulas (where the cow’s milk protein is broken down into small pieces)
   
• extensively hydrolysed rice-based formula (where the protein is based on rice-milk appropriate for infants < 1years of age)
   
• amino acid formulas (this formula is not based on cow’s milk, and the protein is completely broken down)

Please note: any partially hydrolysed formulas such as HA formulas designed for prevention, anti- colic and constipation, ‘Comfort’ formulas and some anti-reflux formulas are not suitable for the treatment of cow’s milk allergy.

The formula may need to be changed depending on your child’s age, dietary intake, growth and severity of reactions to cow’s milk. Your GP or Dietitian will advise you if this is the case

From 1 year

After the age of 1 years, your baby may be able to move onto a shop bought milk substitute and your doctor or dietitian will be able to advise you regarding this.

Goats, sheep and other animal milks are not suitable for children with cow’s milk allergy as they have similar allergenic proteins to cow’s milk

Soya, Oat or Coconut based milk substitutes

Ready-made Soya and Oat milks (e.g. Alpro Soya Growing Up or Alpro Oat Growing Up, Asda or Marks and Spencer own brand) or coconut (e.g. Ko Ko Super) may be used. These milks are all fortified with calcium and iodine and should be used where possible.

Rice milk

Rice milk is not advised before the age of 4½ years because of its potential high natural arsenic content.

Nut milks

These can be potentially lower in calories and protein. The fortified nut milks can be used if your child is growing well as an alternative to the above.

Organic milk substitutes are not fortified with calcium and therefore not recommended.

Weaning / Solids

Home-made Infant Food

Suitable Stage 1 first weaning foods are pureed or mashed fruit and vegetables. Use water or milk substitute to puree into a smooth consistency. Meat and / or pulses can then be added.

Stages Two and Three

Stage Two is mashed with soft lumps and soft finger foods. Stage Three is minced or chopped family foods and hard finger foods.

Suitable Finger Foods:

At 6-7 months of age your baby can be offered finger foods, to help encourage chewing and self-feeding. Suitable cow’s milk free finger foods include:

• Rice cakes with milk free margarine
   
• Pieces of peeled apple or banana or soft tinned fruit
   
• Slices of peeled and cooked carrot or parsnip
   
• Milk free savoury snacks e.g. bread sticks, Nairns, Orgran
   
• Cooked pasta shapes

Calcium

Milk is a good source of calcium which is needed for healthy bones and other body processes. It is important to ensure that breast feeding mums and children on a cow’s milk free diet are meeting their calcium requirements. Good sources of calcium include alternatives to milk, yoghurt and custard that are fortified with calcium. Many now contain as much calcium as you would find in cow’ milk (120mg/100g). Try to have around three portions each day.

Other sources rich in calcium include calcium fortified cereals and hot oat cereals including Ready Brek, supermarket own brands. Non-fortified rich sources include tinned fish, white bread, oranges and spring greens.

Spinach, dried fruits, beans, seeds and nuts are not good sources of calcium. This is because they contain oxalates and/or phytates which reduce how much calcium your body can absorb. You should not rely on them as your main sources of calcium.

Iodine

Milk is a good source of iodine which is needed for the development of a baby’s brain during pregnancy and early life. It is important that a milk-free diet contains other iodine rich foods such as fish.

Further information on foods containing iodine can be found at:
https://www.bda.uk.com/resource/iodine.html

Alternatives I can give

Yoghurt / Dessert Alternatives

• Fortified with calcium: Ko Ko Yoghurts, Alpro soya yoghurts, supermarket own brand soya yoghurts
   
• You can also offer homemade rice pudding, Birds / Tesco / Asda / Oat based custard, jelly as dessert options
   
• Frozen ice-based desserts from a range of supermarkets

Cheese Alternatives

• Fortified with calcium: Ko Ko dairy free cheddar
   
• You can also offer milk free cheese based on soya, nuts, rice or coconut to increase the variety in the child’s weaning diet

Spreads Alternatives

• Milk-free and vegan spread

Creams / Crème Fraiche

• Oat or coconut-based options available

Vitamin Supplements

Babies and Infants

• All breastfed babies should take a vitamin D containing supplement from birth.
   
• Formula fed babies are likely to obtain enough vitamin D if drinking 600ml infant formula daily. If drinking less than this, a vitamin D containing supplement should be given.
   
• The following amounts are recommended:
   
• Babies under 1 year of age: 8.5-10 µg (340-400 IU) vitamin D.
   
• Everyone over 1 year of age (including pregnant and breastfeeding mothers): 10 µg (400IU) vitamin D.

Breastfeeding Mothers

Whilst you are breastfeeding, your calcium requirement is approximately 1200mg each day. When eliminating cow’s milk protein from your diet you need to ensure you are meeting your calcium requirements as well as your babies. You will need to take a calcium supplement and some examples include:

1. Pregnacare Breastfeeding - 2 tablets/day = 700mg calcium
    
2. Boots breast feeding - 2 tablets/day = 700mg calcium
    
3. Osteocare Liquid - 2 x 5mls twice/day (4tsp/day) = 600mg calcium

Checking Food Labels

European Union (EU) food allergen labelling law requires that common food allergens used as ingredients or processing aids must be declared on the packaging or at the point of sale. The list of 14 common food allergens includes milk and soya.

These laws apply to all packaged and manufactured foods and drinks sold throughout the EU. They also apply to foods sold loose (e.g. from a bakery, delicatessen, butcher or café) and foods packed or pre-packed for direct sale (e.g. café, sandwich bar, food outlet, market stall, some catering products). If you travel outside the EU, be aware that labelling laws are different so check ingredients carefully.

For pre-packed products (e.g. made in a factory) allergens must be listed in one place on the product label (i.e. in the ingredients list) and highlighted (e.g. in bold or underlined). The labelling for milk comes in many ways, examples are listed in the table below:

Milk ingredients:

Medicines

Many medications and nutritional supplements contain lactose. If this is medical grade lactose, the cow’s milk protein content will be minimal. Therefore, most milk allergic children will not need to avoid products containing medical grade lactose. Contact your pharmacist and Dietitian if you think your child has reacted to a certain medicine

Useful resources:

• https://www.allergyuk.org
   
• https://www.bda.uk.com/resource/calcium.html
   
• https://www.bda.uk.com/resource/iodine.html