The Facts About Cow’s Milk Protein Allergy

Good advice from Kiran Tiwana, Paediatric Allergy Dietitian, Children’s Allergy Service, St Thomas’ Hospital, London.

Cow’s milk protein allergy is uncommon in adults with an estimated prevalence of approximately 1 adult in 200. (Woods RK et al 2002). It occurs when the body’s immune system reacts to proteins found in milk. Allergic reactions can be immediate, so within minutes to 2 hours of taking milk or milk product or delayed, between 2-72 hours.

Symptoms
Symptoms of cow’s milk protein allergy can vary from mild to severe from diarrhoea or constipation through to breathing difficulties

Table 1. Symptoms of Cow’s Milk Protein Allergy

Delayed Food Allergy Immediate Food Allergy
Diarrhoea Itchy skin rashes (redness or hives)
Constipation Swelling of the face, eyes or lips
Reflux or vomiting Eczema flares (also called atopic dermatitis)
Abdominal bloating or distention Swallowing or breathing difficulties (rare)
Mucus in stools
Eczema flares (also called atopic dermatitis)


Diagnosis

If you think you have an immediate or delayed allergy to cow’s milk protein, you should seek advice from your GP to get a diagnosis. They may refer you to a specialist allergy clinic depending on the symptoms you have and may perform some tests. The type of tests will depend on your symptoms.

      Food allergy tests being offered by complementary or alternative health practitioners are not supported by scientific evidence and the National Institute for Health and Care Excellence ( NICE 2014) states they have no place in the diagnosis of food allergy. These tests include, Vega test, applied kineiology, hair analysis and IgG antibody blood testing.

Table 2. Tests for Food Allergy

Test for Immediate Food Allergy Test for Delayed Food Allergy
Food Challenge* Elimination if the offending food for 4 to 6 weeks followed by reintroduction
Skin Prick Test
Specific IgE Tests

*An increasing amount of the suspected food is given and symptoms monitored. This will only be carried out in a safe hospital setting.

      Skin prick tests or blood tests that measure specific IgE antibodies may be used to help with the diagnosis. These results can be difficult to interpret without an allergy specialist. Sometimes, a food challenge may be needed before a diagnosis can be made. This would only occur in a hospital setting.

      At present, the most reliable method for diagnosing delayed reactions is a food exclusion and reintroduction diet. This involves the removal of the suspected food(s) from the diet for a set period of time. The food is slowly re­ introduced to see if it causes a reaction. This can be difficult and a registered dietitian can help to ensure it’s done safely and key nutrients aren’t being left out of the diet.

Lactose Intolerance
Lactose intolerance is not a milk allergy, instead, it is the inability to digest lactose, a milk sugar. This is usually because of a temporary deficiency in the enzyme lactase due to a bout of gastroenteritis (a vomiting and diarrhoea bug). Some people have a permanent form of lactose intolerance which they have inherited but this is uncommon. Symptoms of lactose intolerance include loose, watery stools and abdominal bloating or pain after eating foods containing lactose. Most people with lactose intolerance can tolerate low lactose products such as hard cheddar cheese, butter and yoghurt.

Milk and Nutrition
Milk and milk products are an excellent source of a  variety of nutrients including protein, fat, calcium, phosphorous, iodine and Vitamins  A,  Bl,  B2, and B12. Some milks, yoghurts and margarines are also fortified with Vitamin D.

Calcium is important at all age groups for strong bones and teeth and has critical roles in muscle contractions, nerve impulses and blood clotting.

Table 3. Calcium Recommendations

Age group Requirements
Infant (0-12 months) 525mg
Children
1-3 years: 350mg
4-6 years: 450mg
7-10 years: 550mg
Adolescents (11-18 years) Girls: 800mg
Boys: 1000mg
Adults (19+) 700mg
Breastfeed mothers 1200mg
Adults with coeliac disease 1000-1500mg
Adults with osteoporosis 1000mg

      To obtain the level of calcium we get from one 2050mls glass of milk, we would have to consume 5 servings of spring greens, 19 servings of brussel sprouts, or 9 servings of broccoli.

Table 4. Calcium Sources

Dairy Products and Dairy Free Alternatives  
Food Portion size Calcium
Cow’s milk (all types) 1/3 pint (200mls) 240mg
Calcium fortified milks e.g. soya/oat/coconut/rice/hazelnut/almond/hemp/quinoa

200ml (1/3 Pint)                             240mg

Calcium fortified soya yoghurts/desserts/custard or calcium fortified coconut yoghurt

1 medium pot (125g)                     160mg

Yoghurt (plain/fruit) 1 medium pot (125g) 200mg
Cheese, hard e.g. Cheddar Matchbox size (30g) 220mg
Cheese triangle 1 triangle (15g) 60mg
Cottage cheese 1 pot (100g) 127mg
Custard 1 serving (120ml) 120mg
Horlicks 25g serving in 200ml milk 710mg
Ovaltine 25g serving in 200ml milk 444mg
Breads and cereals
Food Portion size Calcium
Chapatti/Pitta bread 2 small (120g) 80mg
White Bread 2 medium slices (72g) 80mg
Wholemeal Bread 2 medium slices (72g) 80mg
Instant porridge (fortified with calcium) 1 tablespoon dry cereal (15g) 180mg
Cereals (fortified with calcium) 1 medium portion (30g) 137mg
Plain scone 1 plain scone (50g) 89mg
Protein sources
Food Portion size Calcium
Anchovies 1 small tin (50g) 150mg
Prawns 1 medium portion (60g) 66mg
Scampi in breadcrumbs 10 pieces (150g) 315mg
Tinned Salmon (including bones) 1 small can (120g) 363mg
Tinned Sardines or pilchards (including bones) 1 sardine or pilchard (25g-55g) 125mg-138mg
Whitebait 1 small portion (50g) 430mg
Fruit and vegetable
Food Portion size Calcium
Broccoli 2 spears (boiled) (85g) 35mg
Spring Greens 1 medium portion (75g) 56mg
Orange 1 medium (160g) 75mg

      Spinach, dried fruits, beans, seeds and nuts are not good sources of calcium as they contain oxalates and/or phytates which reduce how much calcium your body can absorb from them. You should not rely on them as your main sources of calcium.

      There are a range of other products available for people who have an allergy to cow’s milk such as alternatives to cheese, yoghurt and cream. However, some of these are not fortified with calcium so check the nutritional information on the packaging.

Treatment
People who have been diagnosed with an allergy to cow’s milk protein must strictly avoid all products containing cow’s milk and other mammalian milks such as sheep and goat.

  • Check Food Labels -European Union (EU) food labelling laws require that labels must clearly state whether milk and other common allergens are ingredients in a food These laws apply to all packaged and manufactured foods and drinks sold throughout the EU.
  • For foods sold without packaging such as in a bakery, cafe or pub, allergen information has to be provided either in writing or verbally, the business must be able to provide further information if requested (in the UK only). More information on the changes can be found at www.food.gov.uk/science/allergy-intolerance/label/.

Eating Out

  • Check out the restaurant’s website – many now contain nutritional and allergy information.
  • Ring the restaurant in advance to ask if they can cater for your food If you call at off-peak times, the staff will have more time to deal with your query.
  • Get to know your local favourite restaurant and chef.
  • Speak to the chef or ask your waiter or waitress to do this on arrival to check they are all aware of your food allergy.
  • Ask them to confirm that the food you have asked for has not had any contact with cow’s milk or products that contain cow’s.
  • If in doubt, choose to go elsewhere.
  • Sauces and gravies contain many ingredients ts which cannot always be remembered by staff so stick to “simple”.
  • Remember cow’s milk may not be mentioned in the description of a dish, it is better not to order the menu item if it is not clear what it contains.
  • Be aware of the risk of cross-contamination in self-service areas; it is safer to avoid foods from here.
  • Make sure those you are dining with know about your allergies and know what to do if a reaction happens.
  • Carry any rescue medication with you, as recommended by your doctor and ensure it is not out of date.

Travel Tips

  •       If you are travelling abroad, check in advance how to describe your allergies in the local language. There are several websites that provide useful phrases and eating out translation cards in a variety of languages: www.allergyfreepassport.com and www.yellowcross.co.uk.
  •       Speak to your airline well in advance to check if they can meet your dietary needs. Make yourself known to the flight crew to ensure the correct meal is received – and ask for an ingredient list of the meals provided.
  •       Consider taking suitable snacks for the journey in case your flight is delayed or your meal is not available on the day of travel.
  •       Try to obtain a letter from your doctor or dietitian explaining why you need to take special food items. Any special food items not needed for the flight should be put in your suitcase. Do not take fruit, vegetables or meat as these are not allowed abroad.
  •       If you are taking an adrenaline auto-injector, obtain a letter from your doctor that confirms your carry your rescue medication e.g. antihistamines, adrenaline auto-injector and Allergy Action Plan with you and make sure they are not out of date.
  •       Make sure the friends you’re travelling with know about your allergies and what to do if a reaction occurs.
  •       If you are staying in a hotel, try to get a room with a kitchen in case there are no safe places to eat.
  •       Make sure you have the telephone number of the local hospital or emergency ser vice s and keep your medical insurance number handy in case you need it.
  • Ensure you wear a medical ID bracelet or card. ID cards, bracelets and travel containers to protect medicines from excessive heat or cold are available from medicalert.co.uk, www.sostalisman.com, www.yellowcross.co.uk and www.friouk.com

Online Shopping

Further Information
www.nhs.uk.conditions/food-allergy: NHS choices allergy and intolerance advice.  NHS choices anaphylaxis advice.www.bda.uk.com: The British Dietetic Association provides a fact sheet on food allergy & intolerance and allergy testing.

References

  • Prevalence of Food Allergies in Young Adults and Their Relationship to Asthma, Nasal Allergies, and Eczema. Woods RKl, Thien F, Raven J, Walters EH, Abramson M. Ann Allergy Asthma Immunol. 2002 Feb;88(2):183-9.
  • Cows Milk Free Diet for Adults – Food Allergy Specialist Group(FASG)of The British Dietetic Association (BDA) 2016.
  • BDA Calcium Food Fact  Sheet  https://www.bda.uk.com/food facts/ Calcium.pdf July 2017 
  • Getting Enough calcium 0n a Milk – Free Diet: Department of Nutrition and Dietetics, Guys and St Thomas’ NHS Foundation Trust, 2015.

This article first appeared in Allergy Newsletter No. 123. Summer 2018.

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2018-10-19T11:17:41+00:00