by Antony Ham Pong, MBBS
Dr. Ham-Pong is lecturer,
Department of Pediatrics, University of Ottawa; consultant, Children's
Hospital of Eastern Ontario; private practitioner.
Cow's milk allergy
is very common
and usually disappears by age two to three years, but may occasionally
be lifelong. Children who are milk allergic will often refuse to
take milk when given to them. Rashes, hives, vomiting or diarrhea
are the most likely symptoms. Milk allergic people react to the
milk protein, and not the milk sugar (lactose). There are many hidden
sources of cow's milk protein. Three quarters of children with food
allergies and eczema develop asthma and environmental allergies.
This is called the 'allergic march'. First eczema beginning at age
6 weeks to 3 months, then food allergies, then asthma usually before
age 5 years, then environmental allergies. The most common food
allergies in young children are milk, eggs and peanut.
What can happen during
an allergic reaction?
An allergic reaction to a food usually begins within minutes but
may be delayed for 2-4 hours and usually lasts less than one day.
The more severe the allergy, the smaller the amount required to
cause a reaction. Typical immediate allergic reactions to foods
include rash, hives or redness around the mouth, which may spread
to the rest of the body, immediate runny nose, sneezing and itchy
watery eyes, coughing, choking or gagging, wheezing and trouble
breathing, and cramps, vomiting and diarrhea. The allergic reaction
can stop at any stage, or may cause anaphylaxis. Anaphylaxis is
a severe allergic reaction which involves several parts of the body
and can lead to death.
Does milk or dairy
have to be eaten to cause a reaction?
No. A food does not have to be eaten to cause an allergic reaction
but eating it does cause greater amounts to get into the body and
usually causes the most severe reactions. Hives can occur on skin
contact with an allergenic food. If the food goes into the wet surfaces
e.g., through a cut in the skin, or at the lips (e.g., being kissed
by someone who has had milk), or in the eye (e.g., milk squirted
in the eye) severe reactions can occur. The smell of a food can
cause allergic reactions but not usually severe reactions unless
there is an extremely high concentration. These lesser degrees of
exposure by smell usually cause only minor allergic symptoms and
discomfort e.g., itchy eyes or runny nose. High concentrations should
be avoided e.g., being in the same room where milk sauces are cooking.
How cautious do we
have to be about avoiding milk and dairy?
Many cow's milk allergic children tolerate small amounts of milk
proteins in cooked or processed foods and do not need to restrict
their diet severely. A child with a mild milk allergy or one who
is outgrowing the allergy may tolerate small amounts of cheese,
yogurt or milk formula but not plain milk. Children with severe
milk allergy should avoid it strictly as even traces in cooked goods
can cause allergic reactions and anaphylaxis (see Table 2). Milk
allergic children have reacted to milk spilled on toys, bed sheets,
Is milk/dairy always
No. There are many hidden sources of milk, dairy (see Table 1, 3).
Milk and egg may be used as binders or fillers in foods e.g., bread,
meat, fish, chicken. If these foods are then used to make another
food or meal, the fillers do not have to be labelled even though
that food may contain milk or egg. Natural flavours and seasonings
are also terms to watch for as they can include milk proteins, soy,
egg, even fish, and may be labelled only as natural flavourings
or seasonings e.g., in tortilla or potato chips, canned and processed
meats e.g., weiners & sausages, and fish. Beef allergy can sometimes
occur with milk allergy, but usually with poorly cooked beef. Retail
poultry may sometimes be treated with milk derivatives to enhance
the texture. Hydrolyzed milk protein may also be added occasionally
to hydrolysed vegetable plant protein and not be labelled.
How do you treat a
Avoidance of the milk is the best treatment. Degree of avoidance
depends on the individual and the severity of the food allergy.
Mild milk allergy may be treated by avoiding milk and dairy but
being able to take trace amounts in cooked goods. For example, people
with mild milk allergy can continue to take bread or cakes cooked
with these foods in small amounts and do not have to be extremely
strict about reading labels. However, even a mild food allergy
can cause anaphylaxis if enough is eaten. Antihistamines such as
Benadryl are usually sufficient to treat an allergy to milk. If
you have breathing difficulties or anaphylaxis has been diagnosed,
then an EpiPen® is required (this is an autoinjectable medication,
epinephrine or adrenaline, which treats a severe allergy). Any
person with potential anaphylaxis to a food should use their EpiPen®
immediately when any reaction happens on eating that food, in order
to prevent anaphylaxis. Cow's milk does not cause mucus in people
not allergic to it and avoiding milk during asthma flare-ups, respiratory
infections and in children prone to colds is of no value if you
are not allergic to milk.
What can be used instead
Soy formula are often used for milk allergic children. If this is
not tolerated, then special casein hydrolysate formulas e.g., Nutramigen,
Pregestmil and Alimentum can be used (very few milk-allergic children
react to these). Do not use goat's milk or lactose free cow's milk
which will cause allergies as well. Lactose intolerant people are
not milk allergic and can often take small amounts of milk without
problems since their problem is digestive, not allergic. Note that
soya milk is not soy formula and does not contain enough calories
or calcium for an infant although it may be used as a drink for
older children. However, there are some calcium enriched Soya milk
and orange juices which provide extra calcium. Calcium supplements
should be given to a young child who is not taking dairy or any
other formula. All formulas including Soya formula contain sufficient
calcium. Juices can be used if the child is on table foods, but
too much fruit juice, especially apple juice, can cause bloating,
cramps and diarrhea.
- Severe milk allergy:
Can develop anaphylaxis with even small amounts: Strict avoidance
of all traces of milk or dairy proteins and lactose. Consider
keeping milk out of house. Use EpiPen® immediately with any
reaction to eating of milk or dairy.
- Mild to moderate
milk allergy:Small traces of dairy in cooked goods can be
eaten unless it aggravates eczema; if so, avoid it. Lactose is
OK. Avoid eating cream, cheese, yogurt, ice cream, milk.
- Very mild milk
allergy: Will be outgrown soon. Can take small amounts of
processed dairy e.g.,. cheese, yogurt.
What is cow's milk
Cow's milk intolerance often causes delayed gastrointestinal symptoms,
such as vomiting, diarrhea, colic and poor growth if untreated.
Gastrointestinal reacting children can develop symptoms hours or
days after ingestion of a modest amount of cow's milk (over 120
ml or 4 oz). Delayed gastrointestinal responses to cow's milk also
can produce severe symptoms resembling anaphylactic shock although
this is rare. Allergy tests in this type of intolerance are negative
to milk, and these milk reactions usually do not cause eczema, hives,
or breathing difficulties. Antihistamines do not work for these
reactions. Milk intolerance often goes away by age 3 years. Strict
milk avoidance is not necessary, and traces in baking can be eaten
Lactose intolerance is not an allergy to milk or lactose. Lactose
intolerance is an inherited deficiency of intestinal lactase enzyme
which results in the milk sugar (lactose) remaining undigested in
the gut, and then being fermented by gut bacteria to produce lactic
acid. This causes bloating, gas, cramps and diarrhea, which often
occurs several hours after ingestion of lactose. This is treated
by substituting a lactose reduced milk (e.g., Lactaid milk) or taking
lactase enzyme (Lactaid tablets) with milk products. Lactose intolerant
people can often take small amounts of milk and lactose with no
symptoms (usually up to 100 ml or 3 oz. cow's milk) and strict milk
avoidance is unnecessary. Strict avoidance of lactose worsens the
problem. Continued ingestion of lactose helps the gut continue to
be able to digest some lactose.
|EXAMPLE OF AN UNSAFE FOOD LABEL
(but correct by current Canadian regulatory standards)
Corn, Vegetable oil, Colour, Cool Ranch seasoning,
Actual food components
Corn, Vegetable oil, Tartrazine, Salt, MSG,
Milk products, Cheese, Onion powder, Garlic powder,
Tomato powder, Imitation Parsley, May contain caramel, annatto
* This product caused a severe allergic
reaction in a milk allergic child.
TERMS INDICATING THE PRESENCE OF COW'S MILK PROTEINS
Butter/ butter fat / buttermilk
Lactaid milk / Lacteeze milk (tablets
or drops are ok)
cow's milk / dairy / pasteurized milk
Lactalbumin / lactoglobulin / bovine
milk formula/ whey / yogurt / ghee
casein / sodium & calcium caseinate
evaporated milk / skim milk
hydrolysed casein / Rennet casein
lactose free milk formula/ delactosed
hydrolysed milk protein
reduced allergenicity milk formula e.g.,
Recaldent (milk casein derivative used
in some Trident gum)
cream / cheese / curds / sour cream
/ sour milk
Kosher symbol 'D'
ice cream / milk solid / milk fat /
EXAMPLES OF FOODS TO BE CAUTIOUS ABOUT FOR MILK ALLERGY (I.E.,
MAY CONTAIN DAIRY)
|| cocoa, chocolate milk, milk shakes,
malted milk, Orange Julius®, milkshakes, some calcium fortified
|Bread & pastry with milk
||cake, cookies, pancakes, rolls, waffles,
||soy margarine usually has milk proteins;
artificial butter flavour
||milk chocolate and caramels
|Cream sauces or cereals
||some processed meats, frankfurters, hot
dogs, Vienna sausages, some poultry.
|"Non dairy" substitutes
||coffee whiteners e.g., Coffee-Mate®
||butter in crust or cream filling
||macaroni, spaghetti, custard, milk pudding,
pet foods especially dog food
|Seasonings, natural flavours, binding agents,
||some seasonings and natural flavours for
meat & poultry; natural egg flavour, canned fish, seasoned
& ranch style potato & tortilla chips, seasoned French
|Pareve (parve) foods & Kosher symbol
||these may be contaminated with milk proteins
due to shared manufacturing equipment
PRODUCTS WHICH MAY CONTAIN MILK PROTEINS
- tablets e.g., Claritin, Allegro, Reaction, Benadryl (use liquid
preparation which are usually lactose free)
- indictable medications e.g., glucagon
- some dry powder asthma inhalers e.g., Ventodisk, Serevent diskhaler
& diskus, Flovent diskus, Ventalin rotacaps, Foradil aerolizer
capsules and Oxeze. Metered dose inhalers do not contain lactose.
MoRu-Viraten Berna Measles-Rubella
vaccine - contains gelatin, lactalbumin & lactose but the standard
measles, mumps & Rubella (MMR) vaccine do not.
Some diaper ointment,
cow's milk & goat's milk shampoo, lactobacillus acidophilus
Milk paint (used for
(1) Lactose is
purified from cow's milk and may contain trace impurities, including
milk proteins. Pharmaceutical grade lactose is purer than food grade
lactose. Individuals with cow's milk anaphylaxis may be prudent
to avoid lactose in any form but those less severe allergy may be
able to tolerate small amounts of milk protein in lactose.
FOODS OR TERMS WHICH ARE SAFE FOR COW'S MILK ALLERGY (1)
- lactic acid / lactulose
/ stearyl lactulate
- lactose (2, 3)
- beef (3) / gelatin
(3) / oleo
- casein hydrolysate
formula (3) (e.g., Nutramigen, Pregestimil, Alimentum)
- Corn or canola oil
margarine (1) (e.g., Fleishmann's salt free, Lactantia light
diet, Becel RSF calorie reduced, Canola Harvest low fat)
- nut butters
- peanut butter
- coconut milk
- soy milk / soy formula
/ cream of wheat/ rice milk
- cocoa butter
(1) Always read the label for hidden ingredients however.
(2) See discussion in Table 4.
(3) Usually safe but occasionally can cause allergic reactions
in milk allergic individuals.
SUBSTITUTES FOR COW'S MILK ALLERGIC CHILDREN
- Soy formula (1)
- Casein hydrolysate
formula e.g., Alimentum, Pregestimil, Nutramigen
- Amino acid derived
formula e.g., Neocate
- Soy milk (2) / Rice
- Meat based formula
(not commercially available and not validated clinically)
(1) Soy allergy may coexist with cow's milk allergies in 8-14%
of children and 25% of infants with cow's milk intolerance sensitive
(2) Not nutritionally complete, and not a substitute for formula,
but useful for cooking and as a drink. Choose calcium fortified
|Age 1-3 years needs:
||500 mg elemental Calcium / day
e.g., 4 tsp Calcium Sandoz or 2-1/2 Turns antacids or
1 Calcium Sandoz Forte effervescent tablet ( 500 mg ) per day
|Age 4-6 years needs:
||600 mg elemental Calcium / day
e.g., 5 tsp Calcium Sandoz or 3 Turns antacid or
just over 1 Calcium Sandoz Forte effervescent tablets
( 500mg ).
or 1/2 tab Sandoz Gramcal (1000 mg tab)
Some calcium supplements are derived from cow's milk e.g., calcium
lactobionate, and may contain trace impurities with milk proteins.
This should be safe for cow's milk allergy except in the case of
anaphylaxis when it should be avoided as a precaution.
Dolomite, bone meal or
some other natural source calcium e.g., fossilized oyster shells
may contain significant amounts of lead which exceed tolerable daily
intakes for children, and should be avoided.
Calcium Sandoz, and some
other liquid calcium supplements containing sorbitol as a sweetener,
can cause osmotic diarrhea and abdominal cramps.
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