HEALTH Could your baby be reacting to cows’ milk?

Could your baby be reacting to cows’ milk?


Doctor's insight
Dr Ronan Clancy

Feeding problems in infants
Part 2

In my last article on feeding problems in infants, I looked at infant colic, lactose intolerance and gastro-esophageal reflux disease, as well as some treatment options. This week, I’ll focus on a condition that can share common symptoms with all three of these, but differs from them because it is an immune-system-mediated problem: Cows’ milk protein intolerance (CMPI).
With CMPI, the immune system reacts to one of dozens of the proteins within the cows’ milk – the most common one is called alpha S1-casein. The condition is the most-frequently seen food intolerance in early childhood, affecting between 2 and 3 percent of infants. Happily, 85 to 90 percent will lose their intolerance by the age of three.
Exclusive breast feeding during the first four to six months of life reduces the risk for CMPI and its more severe allergic manifestations. However, CMPI can develop in exclusively breast-fed infants when cows’ milk protein passes from the mother’s circulation into her breast milk and is ingested by the infant. For babies who are not breastfed, cows’ milk and products containing cows’ milk protein can cause the problem.
Symptoms
The principal symptoms involve the baby’s gut, skin and respiratory systems. The gut symptoms include vomiting, diarrhoea, abdominal pain, flatulence, constipation, colic and gastroesophageal reflux, blood in the stool and weight loss or failure to thrive. The baby’s skin may show hives, rashes and/or eczema. Respiratory wise, the baby may wheeze and/or sneeze. Their eyelids and lips may also swell.
CMPI can either occur quickly, shortly after ingesting cows’ milk protein, or it can occur more slowly, manifesting perhaps one to two days after exposure.
Rapid reactions are termed Immunglobulin E-associated reactions, and as such are seen as true allergic reactions. Here, symptoms include hives, swelling of the lips and eyelids, vomiting and sudden skin rashes shortly after exposure to cows’ milk protein.
Reactions that develop more slowly are termed intolerances, and here the symptoms include ongoing or slowly worsening eczema and gut symptoms (excluding vomiting).


Investigation
Diagnosis of CMPI is often based on symptoms and an examination of the infant, and trial elimination diets to see if there’s an improvement.
If the symptoms are more severe, the baby may have a skin prick test or blood test to check whether the allergy to cows’ milk is Immunoglobulin E mediated. If it is, it is likely that the CMPI will persist for longer, and that the child is at higher risk for developing other allergic conditions, such as atopic eczema, asthma and hayfever.

Management
It is important to talk to your doctor if you think your baby might have CMPI in order to make a complete and accurate assessment. Some of the symptoms are shared with other common feeding problems, and it’s important that the diagnosis is correct. In severe cases, infants can become quite unwell and fail to thrive if the condition is not properly diagnosed or treated. Elimination diet plans can be complex, and the reintroduction of cows’ milk after an agreed period of time should be done under medical supervision.
In breastfed infants, cows’ milk and foods containing dairy and beef should be completely eliminated from the mother’s diet for at least two to four weeks. If there is an improvement, cows’ milk protein can be reintroduced in the mother’s diet for a short period. If the symptoms return, cows’ milk protein is likely the cause, which means mum will have to avoid cows’ milk protein completely while breast feeding continues. All other components of the baby’s diet should also be free of cows’ milk protein until he or she reaches at least nine to 12 months of age.
Options for bottle-fed and weaned infants include soy-based formulas and hypoallergenic formulas, such as Nutramigen and Neocate, where complex proteins have been partially or extensively broken down (hydrolysed) to a level where they shouldn’t trigger an immune system reaction. Again, if the baby’s symptoms improve, these formulas should be continued until he or she is at least nine to 12 months.
In all cases, cows’ milk protein can be reintroduced on a trial basis at an agreed time under medical supervision, as most children outgrow the condition within the first three years.

Dr Ronan Clancy is a GP at the newly opened Clancy Medical Practice, James street, Westport (www.westportgp.ie). He is in practice with Sarah Kavanagh, chartered physiotherapist.