Babies can have allergies and intolerances to food just as children and adults can. The most common culprit causing a reaction for babies is cows’ milk and a reaction to soy is also very common. There are various names for this including cows’ milk protein allergy (CMPA), cows’ milk protein intolerance (CMPI), food sensitivity and related conditions such as allergic proctocolitis or food protein-induced enterocolitis syndrome (FPIES). Lactose intolerance is not the same as CMPA, see Lactose Intolerance in Babies for more information. This article discusses infant food allergy with a particular focus on milk allergy in babies including causes, common symptoms, diagnosis and treatments.
Can breastfed babies have milk allergies?
Although it is much more likely that a baby would react to a food he was given directly such as baby formula or dairy produce; a breastfed baby can have a reaction to tiny traces of proteins from his mother’s diet passing into breast milk. The most common food to trigger a reaction in susceptible babies through mother’s milk is cows’ milk 1 2. However, less than 1% of exclusively breastfed babies appear to develop allergic reactions to cows’ milk proteins in their mother’s milk 3 compared to 1.9-4.9% infants with CMPA generally 4.
What can cause milk allergy in babies?
A family history of allergy including hay fever, asthma, or eczema, can mean a baby is at high risk of having allergies. Also, giving a breastfed baby an early supplement of formula (including soy formula) may predispose or “sensitise” that baby to allergy. The younger the baby is when he has some formula, the more likely this is to happen. Although symptoms of allergy may not be seen with the first exposure, when they next encounter that protein, a reaction is triggered (Wambach & Riordan, 2015; Mohrbacher, 2010). Sensitisation could even occur during pregnancy 5 6.
Marsha Walker has written an interesting paper on the effects of early formula supplements on a breastfed baby:
in susceptible families, breastfed babies can be sensitized to cow’s milk protein by the giving of just one bottle, (inadvertent supplementation, unnecessary supplementation, or planned supplements), in the newborn nursery during the first three days of life.
Note: Sometimes supplements may be medically necessary if your baby is not gaining weight or has high levels of jaundice. Your health professional will help you weigh up the best decision for your baby, and your IBCLC lactation consultant can help you increase your milk supply.
Allergy or intolerance? What is the difference?
A food intolerance is an inability to digest a certain food or substance in the food. Symptoms might include tummy ache, bloating, diarrhoea or headache. Symptoms may be similar to food allergy but are not life threatening 7.
A food allergy is more serious than an ‘intolerance’ but less common. The body makes an immune system reaction to a food, even tiny traces of the food, and occasionally this can be life threatening e.g. anaphylaxis. Allergic responses tend to be either:
- Immediate (IgE-mediated). Symptoms such as swollen eyes and lips, hives, rashes, or difficulty breathing could be seen within minutes to two hours 8.
- Delayed (non-IgE-mediated). Symptoms such as eczema, diarrhoea/constipation, blood in the stool, respiratory symptoms, or reflux might appear within hours to several days 9.
- It’s possible to have a combination of types.
How long does it take to trigger a reaction to an allergenic food?
An allergic individual can react to trigger foods eaten directly almost immediately. Common allergens include peanut, tree nuts, egg, wheat, soy, fish shellfish and milk 10. But how long does it take for cows’ milk and other allergens in a mother’s diet to affect her breastfed baby? Kelly Bonyata IBCLC says:
Food reactions may occur within minutes, but symptoms in breastfed babies more commonly show up 4-24 hours after exposure. If baby has an acute reaction to a new food, or to a food that mom ate a large amount of, then he will probably be back to normal within a couple of hours. If baby is sensitive to a food that mom eats frequently, symptoms may be ongoing.
Symptoms of milk allergy
The most common symptoms of food allergy in the breastfed baby are seen in the skin (eczema) and the stomach and intestines (e.g. blood in the stools) but symptoms in a baby can include:
- Skin problems such as eczema, patches of dry skin, cradle cap, nappy rash/sore bottom, rashes, hives, swelling of the eyelids or lips, flushed cheeks, skin may be unusually pale.
- Stomach or intestinal problems such as reflux, signs of tummy ache or diarrhoea, green poos, allergic proctocolitis (poop with blood in it), FPIES 11, or an inflamed oesophagus (eosinophilic oesophagitis) 12, flatulence, constipation.
- Breathing problems for example snuffles or cold-like symptoms, frequent ear infections, a persistent cough, wheezing or asthma
- Other signs might be fussing, crying, difficulty gaining weight or trouble sleeping.
However there can be other reasons for symptoms of reflux, waking at night, green poop or fussy behaviour that may not necessarily be to do with the mother’s diet or allergy. They are more likely to be due to food allergy if there is a family history of allergies. Discussing symptoms with your health professional and IBCLC lactation consultant will help you determine the most likely causes for your baby’s symptoms.
More about allergic proctocolitis
Allergic proctocolitis is an inflammatory response in the large intestine to certain proteins in the diet. The main symptom is mucous and streaks of blood seen in the baby’s dirty nappy. Poops may also be watery and often green 13. For further information there is an excellent website dedicated to infant proctocolitis; infantproctocolitis.org and the Academy of Breastfeeding Medicine (ABM) have developed a protocol specifically tailored for the breastfed baby with allergic proctocolitis:
It should be emphasized that breastfed infants with allergic proctocolitis are generally ‘‘well appearing’’ other than the presence of blood within the stool. Blood loss is typically modest but can occasionally produce anemia and/or hypoalbuminemia. In very rare cases, symptoms may lead to failure to thrive.
Diagnosis of milk allergy
Your medical professional or lactation consultant can help diagnose whether your baby has a food allergy by taking a full medical history including a family allergy history. A sample questionnaire and discussion around interpreting it can be found in Maureen Minchin’s book Crying Babies and Food: In the early years, 2015
According to CMPA Support 14, an elimination diet (avoiding trigger foods) is said to be a more accurate form of diagnosis than allergy tests:
Although there are medical tests available, they are not conclusive. Allergy Tests often return false positive and false negative results. Allergy testing only tests for IgE antibodies meaning that a non-IgE allergy will produce a negative result. The most common and accurate way to diagnose CMPA is by eliminating Cow’s Milk Protein (CMP) from the diet (aka an elimination diet) for a period of time to see if the symptoms improve, and then re-introduce CMP to see if a reaction re-occurs.
CMPA Support also provide the MAP (milk allergy in primary care) guidelines to help GP’s to diagnose and manage CMPA in primary care.
Treatment for milk allergy
The first line of treatment recommended for suspected milk allergy in babies is to trial an elimination diet to eliminate trigger foods (infantproctocolitis.org, Wambach & Riordan 2015, ABM, 2011). Your dietitian is an important partner in the process to ensure you are still getting a healthy diet. See the separate article Elimination Diet for information on suitable diets to follow.
Blood in baby’s stools
The Academy of Breastfeeding Medicine suggest the following protocol for mild to moderate symptoms if an elimination diet doesn’t seem to help allergic proctocolitis:
- Consider eliminating other allergens.
- Breastfeeding may continue with monitoring of weight gain and growth.
- Consider following hemoglobin and albumin levels if continued moderate degree of blood loss (blood is visible) in stools.
- Consider use of pancreatic enzymes* for the mother. Dosage is generally one or two capsules with snacks and two to four with meals as needed dependent on the baby’s symptoms.
- In severe cases with impaired growth, decreasing hemoglobin level, or decreasing serum albumin level, the use of a hypoallergenic formula may be considered; however, one should consider referral to a specialist.
*The ABM Protocol recommends the use of pancreatic enzymes by the mother be an area for future research to establish their safety and efficiency as a treatment option. The theory behind it is that the enzymes break down potential allergens before they can get into the breast milk.
FAQs on cows’ milk protein allergy
I’ve tried a careful elimination diet but my baby is no better, what next?
If you have tried an elimination diet for dairy with no improvement you may need to look at other common allergens in your diet such as corn, wheat, eggs or soy. Some mothers have found they needed to eliminate all beef and beef containing products when going dairy free. For others, cutting out caffeine, nicotine, or artificial flavourings, sweeteners and preservatives was key. Another option is to follow a low allergy diet until your baby’s symptoms clear and then gradually reintroduce more food groups and notice if your baby reacts (see Elimination Diet). And your health professional and IBCLC lactation consultant can help rule out other causes for your baby’s symptoms that may have nothing to do with your diet and discuss next steps.
Are probiotics helpful?
Diana Cassar-Uhl IBCLC suggests considering probiotics (live bacteria and yeasts) for mother and baby may be helpful for food allergies 15 however probiotic products themselves could contain allergens however author Maureen Minchin recommends caution in Are Baby Biotics Bugging You?
What if my doctor says I should stop breastfeeding?
Some doctors are concerned that an exclusion diet isn’t healthy for mother or baby and advise that weaning to a specially modified formula would be better for both. However there’s no evidence that industrially made hydrolysed formulas are ‘better’ for the prevention of allergy in preference to exclusive breastfeeding 16 17. While it can be challenging to follow an elimination diet, with careful supervision and help from a dietitian it can still be a healthy diet. And your breast milk will be easier for your baby to digest.
Absolutely! Your body makes sure that your breast milk contains all of the essential nutrients, antibodies and other factors your baby needs to grow and develop. Even though you may feel your diet is missing something, chances are that you are getting all the nutrients you need from the foods you are still able to eat. Even in mothers who do not have enough food to eat, levels of micronutrients such as folate, calcium, iron, copper and zinc in their breast milk remain relatively high. A multi-vitamin is a good idea for all breastfeeding mothers, and taking 500 mg of Calcium twice a day with meals plus 1,000 to 2,000 IUs of vitamin D3 will help protect your bone health while you are avoiding dairy.
What can I share with my doctor?
Some doctors may be unaware of the latest recommendations and excellent resources available on this topic:
- The ABM Protocol on Allergic Proctocolitis
- The Infant Proctocolitis website designed to educate healthcare professionals as well as families. It has a special medical section for your doctors. The recommendation that mothers work with a registered dietitian will reassure your health professionals that your health is being looked after. The section for “Frequently Asked Questions” (FAQ) on infantproctocolitis.org is very useful. Should I Switch to Formula? explains Allergic Proctocolitis doesn’t require switching to special formulas which are often expensive and don’t always suit the baby and that breastfeeding with an elimination diet is the healthiest choice.
- The GP Infant Feeding Network website has comprehensive information for GPs on CMPA, explaining it is rarely necessary to stop breastfeeding, how breastfeeding is important for allergic children and when to refer to a paediatric allergy clinic.
If I need to supplement, what sort of formula can I use?
There may be situations where a breastfeeding mother needs to supplement her allergic baby. Or situations where a baby’s allergic symptoms are very severe and a special formula may need to be considered (ABM, 2011). Extensively hydrolysed formulas are often recommended and in some cases, elemental amino acid based formulas are needed (infantproctocolitis.org). The differences between the two are explained in a fact sheet from The British Dietetic Association.
What about soya based formulas, goat’s milk or sheep’s milk?
Soya based formulas, goat’s milk formulas or sheep’s milk are not recommended as many infants will have similar allergic reactions to the proteins they contain 18. Soy is itself a highly allergenic protein often causing reactions 19.
UK Department of Health Government advice 2014 states
goats’ milk-based formula is not suitable for infants diagnosed as being allergic to cow’s milk. GPs will prescribe an appropriate infant formula with fully hydrolysed proteins
Will my baby grow out of allergies?
A high proportion of children (90%) can grow out of their allergies by three years of age 20.
How can I protect my next baby from allergies?
Allergy prevention is a concern in high risk babies with a family history of allergies. Preventative measures according to breastfeeding authors Wambach & Riordan, 2015, p 761 include breastfeeding exclusively, introducing complementary foods between four and six months of age and using hydrolysed formula if supplements are ever needed. However, introducing complementary foods between four and six months has not been proven to be better than introducing them in the period six to twelve months (Minchin, 2015), see Starting Solid Foods for further guidance. Also, there is no evidence that using hydrolysed formula can prevent allergies21.
Allergy organisations agree that introducing solids while continuing to breastfeed is a good idea (Minchin, 2015). For current opinion on whether to avoid eating allergenic food during your next pregnancy or while breastfeeding to protect a subsequent baby from allergies see Elimination Diet.
Cows’ milk and dairy produce in a mother’s diet can be common allergens in breast milk. Known as cows’ milk protein allergy there are a number of related symptoms and conditions such as allergic proctocolitis. Lactose intolerance is not the same as milk allergy, see Lactose Intolerance in Babies. Once identified, an elimination diet for mother will remove the allergens from breast milk. Many babies will grow out of allergy over time.
Information in this article is not tailored for you and your baby. Always consult with your health professionals for advice that takes yours and your baby’s medical history into account.