Is it teething time for your little one?
 
What does it actually mean?
Cow’s milk protein allergy (CMPA) is an adverse immunological response to cow’s milk protein. Proteins found in cow’s milk are normally broken down by digestive enzymes into small peptides and amino acids – but when a baby has a cow’s milk protein allergy, their gastrointestinal tract does not manage this effectively, and the proteins cause an immunological response when they enter the gut tissues. CMPA may be caused by two types of immunological response: IgE-mediated or non-IgE mediated mechanisms, or sometimes a combination or both.
 
An intolerance to cow's milk is different to an allergy as, whilst it can lead to a lot of discomfort, it does not provoke an immune response.
Cow's milk allergy (CMA) or cow's milk protein allergy (CMPA) is the most common food allergy diagnosed in young babies due to their heavy reliance on milk, exclusively for the first six months. There is not always a known reason when a baby develops a CMPA, but risk factors include a family history, asthma, and atopic dermatitis.
 
Cow's milk protein allergy needs to be diagnosed by a doctor, who may use a blood test to help with their clinical analysis. Sometimes a blood test will come back negative, as only one type of immunological response is possible to test for – IgE mediated. So, if your baby has a non-IgE mediated form of an immunological response to cow's milk protein, it will not show a positive blood test yet the condition is still present. You can see why it can be difficult to confirm CMPA and why it is important to visit your GP if you feel it is an issue for your child.
 
Children who suffer from an IgE mediated reaction can be very sensitive to very small amounts of cow's milk protein. Their symptoms tend to have a rapid onset of action, often within 20 minutes, but usually any time up to two hours. 5-6% of children in Ireland have some form of food allergy, and the most common foods which produce this type of immune response are milk, eggs, peanuts, nuts, fish and shellfish. Most children outgrow milk and egg allergies by the age of three but not peanut, treenut, fish or shellfish allergies.
 
Children who suffer from a non IgE mediated reaction or a mixed mediated reaction tend to display their symptoms with a more delayed response; for example, more than 24 hours after exposure. It is often dependant on how much cow's milk protein they have been exposed to, and so the effect can build up gradually.
 
 
So, what symptoms are we talking about?
Symptoms can vary from baby to baby, and a child with CMPA may have just some or all of these symptoms.
 
Severe symptoms include:
  • Wheezing
  • Itching
  • Swelling of the lips
  • Red, blotchy skin
  • Vomiting
  • Anaphylaxis (a severe reaction associated with lower respiratory and cardiovascular symptoms which requires emergency medical attention). This type of reaction is possible but rare for CMPA.
Other symptoms may include:
  • Reflux
  • Eczema or rash
  • Swelling around the eyes and/or lips
  • Diarrhoea or constipation
  • Colic, wind, or tummy pain
  • Poor weight gain
  • Blood in stools
  • Upset or irritable baby
  • A baby unwilling to feed well
  • Coughing, sneezing and congestion
Diagnosis
As mentioned earlier, a blood test may be performed to diagnose a CMPA. As a blood test is only successful at identifying a IgE mediated immune response, it may be necessary to try a 2-4 week trial of elimination of cow's milk to find out if your child is suffering from the non IgE mediated type of reaction. This is something that should be suggested by your doctor. Information for both breastfeeding and bottle-feeding mums will now be discussed.
 
 
Breastfeeding and CMPA
Exclusively breastfed infants have a lower incidence of CMPA – and actually it has been shown in one study that early formula top ups can actually increase the liklihood of a baby developing CMPA.  Mothers who suspect their breastfed baby has CMPA should continue to breastfeed and discuss a trial elimination of dairy products from their diet to see if there is an improvement.  Maternal elimination of dairy should only be undertaken if necessary so to avoid a calcium or other nutrient deficiency in the mother.  This should be undertaken with the guidance of your GP.
 
If a trial elimination of dairy is recommended to you then a calcium supplement should be considered. If formula must be given to a breastfed baby it should be an extensively hydrolysed formula which is prescribed.  I would like to add at this point that whilst exclusive breastfeeding is best for your baby it is not always possible and I strongly believe that a happy mother and baby is the most important thing.  Society can be very pressuring nowadays and on a personal level I feel the most important thing is to be well informed and make the best decisions you can for you and your baby taking all of your personal circumstances into consideration. As a healthcare professional I am proud to stand in support of mums whether they are looking for advice for breast or bottle feeding and am lucky to have the absolute pleasure of lots of experience with both!
 
Bottlefeeding and CMPA
Bottle-fed babies will need a specialised hypoallergenic formula which should be prescribed by your doctor. These milks may smell or look different to normal formula, but babies are much more willing than grown-ups to try them! I found that offering a warm bottle in this case helped!
 
There are two main types which are suitable:
  1. EHF’s (Extensively hydrolysed formulas): These are made from cow's milk which has been specially treated so that the proteins are broken down and there is a greatly reduced risk of reaction; e.g:  Aptamil Pepti and Nutramigen.
  2. AAF’s (Amino acid formulas): These are not made from cow's milk, they are made with amino acids. They are safe but more expensive; e.g: Neocate.
  • Soy is not recommended, as 50% of babies with CMPA are also allergic to soy, and there are also separate concerns about its oestrogenic activity.
  • Goat's milk is not nutritionally suitable and can also cause a reaction.
  • Lactose-free milk contains cow's milk protein and should be avoided.
  • Comfort and anti-reflux formulas contain CMP and should be avoided in the case of allergy, also.
Weaning and CMPA
As you start to wean your baby onto solids from around six months of age, and they have a CMPA, then it is important to remember the following:
  • The prescription milk or breast milk should be used when making up food – not any other form of milk.
  • You will need to read the labels of foods very carefully, as they many contain milk which may not be obvious initially, such as some baby rice cereals and snacks.
  • Preparing food from scratch allows you the confidence of knowing what is in it, but isn’t always possible.
  • If your baby is very sensitive to small amounts of CMP, then wash their utensils separately and be careful to avoid cross-contamination when preparing food.
  • Introduce one new food every three days to allow for identification of other food allergies or sensitivities.
I hope you have found this article helpful, and if you have any questions at all, please, don’t hesitate to contact me by sending a private message to the WonderBaba facebook page (www.facebook.com/wonderbabacare) or by calling me (Sheena) at Milltown totalhealth Pharmacy in Dublin 6 on 012600262. I’m always happy to help!
Pharmacist
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