Cow's Milk Allergy

Cow's milk allergy is said to occur in 2 - 8% of infants. About 5 -15% of infants have a reaction to the cow's milk protein, but not all of these are allergic reactions.

For example, lactose intolerance is not an allergy as such, but children do have a reaction to cow's milk. Read more about lactose intolerance.

Allergic reactions to cow's milk may be:

  • immediate - within minutes up to 1 hour after having cow's milk. Symptoms include hives, eczema, facial swelling, wheeze, vomiting, diarrhea. Severe reactions include anaphylaxis - read more
  • These are IgE mediated reactions - read more
  • delayed - these can occur several hours or even days after having the milk. Symptoms include eczema, vomiting, diarrhea or asthma. Babies may even fail to thrive. These are non IgE mediated reactions so are caused by other immune substances but not IgE. 

Examples include:

  • Cow's milk protein intolerance - sometimes you will see blood in the stool.
  • Food Protein Induced Enterocolitis Syndrome (FPIES) - this is the most severe form of non-IgE mediated allergy and causes vomiting 1-3 hours after ingesting milk (or whatever other protein may be involved) and diarrhea about 5-8 hours after ingestion. This can lead to severe dehydration and shock. Babies look pale and lethargic

This page answers the following questions:

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How is Cow's Milk Allergy diagnosed?

The first thing is a good story (history) of a reaction after having cow's milk.

If your infant has had an immediate reaction, then skin prick tests, or blood tests (such as CAP, EAST, RAST) will usually be helpful. These tests detect IgE mediated allergies.

In other cases, milk and dairy products may need to be eliminated from the diet in a trial of treatment. If the symptoms resolve and then return when milk is reintroduced into the diet, this is diagnostic for allergy - called Elimination/Reintroduction. If your child has had a severe reaction to milk products, then reintroduction should be done under medical supervision.

Some centers offer patch testing, which may be useful in detecting non IgE mediated allergies.

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What is the treatment of cow's milk allergy?

Cow's milk will need to be excluded from your baby's diet. This can be difficult and you may need the help of a dietician. As cow's milk is in all dairy products, cow's milk allergy is sometimes called dairy allergy.

Some breast-fed babies will get symptoms if their mother has cow's milk (dairy) products in her diet. In these cases, the mother will need to exclude dairy products from her diet.

Foods to be avoided in cow's milk allergy include:

  • any food with cow's milk or goat's milk
  • cheese
  • butter
  • ghee
  • milk powder
  • cream fraiche, sour cream, cottage cream
  • whey
  • casein
  • margarine
  • custard
  • lactalbumin, lactulose, lactoglobulin
  • any foods containing any of the above list

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What milk alternative should I feed my infant with cow's milk allergy?

If you can continue breast feeding, that will be best for your baby. If not, alternatives to cow's milk include:

  • soy protein formula - about half children who are allergic to cow's milk will also be allergic to soy. Soy formula is not recommended for infants under 6 months but can be tried first as an alternative milk in infants over 6 months of age, but do not be surprised if your infant shows an allergic reaction
  • extensively hydrolysed formula (EHF) - this is milk that has been treated to break down most of the enzymes that cause allergic symptoms. These are the first choice alternative for infants under 6 months with cow's milk allergy. Examples of EHF include PeptiJunior and Alfare. Partially hydrolysed formula (PHF) are not suitable for cow's milk allergic infants
  • amino acid based formula - AAF - this is milk that is completely broken down eliminating the protein that causes allergy. It will be necessary in about 10% of cow's milk allergic children. Examples of an amino acid based formula include Neocate and Elecare.
    AAF should be used in children who do not tolerate EHF (after a 2-4 week trial) or as a first choice in infants with an anaphylactic reaction

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Should I give my baby goat's milk for cow's milk allergy?

No. Goat's milk and cow's milk share similar proteins so children who are allergic to one will be allergic to the other. Goat's milk, sheep's milk, and rice milk are not suitable alternatives in cow's milk allergic children.

Sometimes a baby will seem to prefer a goat's milk formula to a cow's milk formula. This is not due to a milk allergy. It's merely a preference.

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Can I give my child yoghurt, cheese or cookies?

Some cow's milk allergic children will tolerate yoghurt or cheese and have no problem at all with cookies with milk as an ingredient. This is because heating changes the shape of the protein and this can make it less likely to cause an allergic reaction.

Once your child has been symptom free for at least six months, you could try a small piece of cookie (that has milk as an ingredient) - if your child tolerates it, then you can give cookies freely. You could then try yoghurt or cheese as the same may apply. Some children will show a reaction to cookies, yoghurt and cheese and you will just have to keep these out of the diet for a bit longer - you could try again in about 6 months. Remember leave about 2 weeks between trying a new food.

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Should I stop breast-feeding my cow's milk allergic baby?

This is not necessary in most cases so keep breast feeding your baby as breast milk is best. Cow's milk allergy is less likely in breast fed infants.

If your baby has symptoms of cow's milk protein allergy, then you should exclude dairy products and eggs from your diet - you need to continue this for at least 2 weeks, but probably for 4 weeks, to see if there is an improvement. If there is improvement, one food per week can be introduced into your diet until you know what food is causing your baby's problems and then you can just avoid that food.

If you need to continue to eliminate milk from your diet, you may need a calcium supplement.

If and when you do wean your baby, you should use an extensively hydrolysed formula (or soy if your baby is over 6 months of age but as mentioned above about 50% of babies allergic to milk will be allergic to soy).

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Will my child grow out of her allergy?

Most children grow out of their cow's milk allergy by age 3 years. Once your child is over 12 months old and has been without dairy products in the diet for at least 6 months, you could try introducing some dairy products into the diet - you might want to start with yoghurt or cheese as these are sometimes tolerated better than actual milk.

If your child had a severe reaction to the milk in the first place, like anaphylaxis, then you should have the milk challenge under medical supervision - do not try re-introducing milk at home.

Some children grow out of the dairy allergy but develop other allergic diseases, like asthma as they grow older.

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Does dairy allergy cause mucus?

Symptoms that relate to the respiratory system, such as runny nose and mucus, usually are a result of what we breath not what we eat. Any symptoms of mucus after ingesting milk are not dangerous and in infants are more likely to be the result of a respiratory tract infection rather than an allergy.

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Is eczema caused by milk allergy?

In most cases of eczema, there will not be any allergy. However, in some infants, particularly young babies with severe eczema, allergy may be a factor. In these cases, skin prick tests may be positive and even if they are not, it may be worthwhile trying an elimination diet (no dairy, including cow's milk) for 4 weeks to see if there is improvement. If no improvement occurs, cow's milk is unlikely to be contributing to the eczema. This type of elimination diet is best supervised by your doctor or a dietician.

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Should I delay introduction of milk and dairy to prevent eczema or asthma?

No, there is no evidence that delaying the introduction of milk or other dairy products will make any difference to whether your child develops eczema or asthma or allergy.

Unless your child has shown a clear allergic reaction to milk and dairy, there is no advantage in delaying introduction of it, so give it at the usual time. This is even when there is a history of allergy, eczema or asthma in your family.

There is also no evidence that giving a hydrolysed formula to your baby when there is a family history of allergy will prevent your baby getting allergy, therefore we do not advise this.

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What is lactose intolerance?

Lactose intolerance occurs because the body lacks an enzyme, lactase, that is necessary to digest the milk sugar, lactose. People with lactose intolerance will get diarrhea, vomiting and tummy pains - these symptoms are similar to cow's milk allergy, but do not involve the skin. Although the symptoms are a nuisance, lactose intolerance is not dangerous.

If you have lactose intolerance, you can usually manage to eat small amounts of cow's milk. Other dairy products, such as yoghurt and cheese, are usually well tolerated because they have easier to digest milk sugars.

The diagnosis is made on a stool test which shows sugars (reducing substances) in the stool or a breath hydrogen test. Treatment is reducing or avoiding products containing lactose (milk sugar) - so reducing or avoiding dairy products. Infants require a lactose-free formula.

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References

  • American Academy of Allergy, Asthma and Immunology. The Allergy Report
  • Australasian Society of Clinical Immunology and Allergy
  • Tromp II; Kiefte-de Jong JC; Lebon A; Renders CM; Jaddoe VW; Hofman A; de Jongste JC; Moll HA. The introduction of allergenic foods and the development of reported wheezing and eczema in childhood: the Generation R study.Arch Pediatr Adolesc Med.  2011; 165(10):933-8 (ISSN: 1538-3628)
  • Vanderplas et al. Guidelines for the diagnosis and management of cow's milk protein allergy in infants. Arch Dis Child. 2007; 92:902-908
  • Rance F. Food allergy in children suffering from atopic eczema. Pediatr Allergy Immunol 2008;19:279-284

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Last reviewed 18 March 2016

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Dr Maud MD

Dr Maud MD (MBChB, FRACP, FRCPCH), a specialist pediatrician, provides health information and medical advice for parents of babies and toddlers. Read more about Dr Maud.



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