Cows’ Milk Protein Allergy (CMPA) is an allergy to the cows’ milk protein found in all dairy products such as milk, butter, cheese and yoghurt. CMPA is most commonly diagnosed because it leads to the symptoms of reflux.
CMPA is not the same as lactose intolerance, which is very rare in babies, where there is a lack of ‘lactase’, the enzyme needed in the gut to break down the naturally occurring lactose sugars which milk contains. Changing to lactose free products is helpful in lactose intolerance, since it removes the lactose, which cannot be digested and causes symptoms. Instead CMPA is an allergy to the actual protein in milk, so changing to lactose free products will not be helpful.
Goats’ milk has proteins which are very similar to the cows’ milk protein and so changing to goat milk is very unlikely to help in a baby with CMPA. Approximately 50% of babies with CMPA will also have an allergy to soya as well, since the soya protein is very similar to the cows’ milk protein. Therefore exclusion of soya may well be required.
My baby has CMPA and is breastfed, what next?
It is still possible to breastfeed, but means that mum must give up all items containing dairy (milk, cheese, butter, cream, yoghurt, casein, whey and albumin). The cows’ milk protein can hang around, and still be transferred in breast milk for a number of weeks after starting a dairy exclusion diet, therefore, its important to wait 4-8 weeks before drawing any conclusions. It is important to be very careful with a dairy exclusion diet, which involves the time-consuming process of checking food labels, however, there are now some really useful apps which help speed up the process. I found FoodMaestro the best, which enables the user to input their dietary exclusion criteria, and then scan the bar code of the food, with a resultant happy or unhappy face that depicts if the item is safe or not.
Mum’s on a diary free diet need to be seen by a dietician for advice on calcium supplementation. Readybrek cereal is packed full of calcium, and it is a good idea to drink the dairy free milks which are fortified with calcium such as Oatly and Koko.
There are also lots of ideas for dairy free meals and snacks on the internet now, with a much greater variety in the supermarket. I also befriended my local cafe who used to bake me dairy free banana bread, as every mum needs the option of cake on maternity leave!
My baby has CMPA, what formula milk can I give them?
If your baby is formula fed, then they will need to change to a special formula where the proteins are mostly broken down called extensively hydrolysed (such as Nutramagen and Althera) or fully broken down into amino acids (such as Neocate and Alfamino). These milks must be prescribed by a doctor in the UK. These milks can be particularly smelly and unpalatable. Read Help! Extensively hydrolysed and amino acid based formula milks taste disgusting! for tips on how to make them more palatable.
Types of CMPA
There are two types of CMPA allergy, IgE mediated, and non-IgE mediated. Babies with IgE mediated CMPA usually have a rapid onset of symptoms such as hives, facial swelling, and difficult breathing.
Babies with non-IgE mediated CMPA usually have a slower onset of symptoms (24-48 hours), such as tummy pain, reflux, explosive poos, sore bottom, disturbed sleeping, and more rarely difficulty breathing.
It is possible for the same baby to have a mixture of both IgE and non-IgE mediated CMPA which can change over time. Unfortunately lots of these symptoms can be attributed to a ‘normal’ baby or other diagnosis, and there is no clear blood or diagnostic test that can determine if the reflux or symptoms are caused by allergy. Instead, diagnosis often relies on the pattern of symptoms.
Once your child has been diagnosed with CMPA, it is important that they have a skin prick test at about one year of age, to see if it is IgE mediated or not, as this determines where you can start the introduction of dairy into their diet. Best practice at about one year of age is to introduce dairy products using the ‘Milk Ladder‘, which is a series of 12 steps from least allergenic (cooked dairy in biscuits) to most allergenic (fresh cows’ milk). If your child has an IgE mediated component to their allergic response, the first step of introduction should ideally be performed in an allergy clinic in hospital.
Most babies (up to 90%) will grow out of the CMPA/soya allergy by 5 years of age. Once your child has reached their first birthday, they may drink dairy free milks instead of cows milk while they are going up the dairy ladder. There are lots of milks to choose from such as nut milks (almond and hazelnut), coconut milks, and oat milks. To boost calcium intake, look out for those that are fortified with calcium.
The CMPA Support also has useful information.
Other allergies can also cause reflux such as egg, and similarly egg exclusion from mother’s diet if breastfeeding, followed by step-wise introduction after a year of age is usually necessary.