Cow's Milk Allergy in Infants

What is Cow's Milk Allergy in Infants?

Cow's milk allergy in infants is an abnormal response of the baby's immune system to milk protein, unlike healthy infants. Due to this response, certain symptoms appear in babies who consume cow's milk protein or in breastfed babies whose mothers consume milk protein. This condition is called Cow's Milk Allergy.

Why Do Babies Get Milk Allergies?

Cow's milk allergy in infants arises due to genetic changes in the immune cells and the communication system between these cells, which are the building blocks of the immune system. Additionally, genetic changes affecting the barrier function of the outermost layer of our skin, which protects our body from external factors, also contribute to the development of cow's milk allergy in infants.

Environmental factors also play a role. Especially infants with eczema at 3-4 months of age are at higher risk for milk allergy and other food allergies.

What Are the Symptoms of Cow's Milk Allergy in Infants?

Symptoms of cow's milk allergy in infants are categorized into three main groups:

1. Immediate-Type (IgE-Mediated) Milk Allergy

This type typically appears suddenly within minutes or within the first two hours after a baby, often around six months when solid foods are introduced, or younger babies consuming formula containing cow's milk protein, develops redness and hives on the skin, usually on the face.

In more severe cases, symptoms like widespread itching, severe abdominal pain, vomiting, coughing, sneezing, runny nose, nasal congestion, shortness of breath, wheezing from the chest, difficulty swallowing, hoarseness, muffled voice, palpitations, feeling faint, and in very severe cases, fainting and loss of consciousness may occur.

Skin involvement is the most common symptom among these. If other organs or systems that are life-threatening are affected, this condition is called anaphylaxis.

2. Mixed-Type Cow's Milk Allergy

In mixed-type cow's milk allergy, symptoms appear hours or days after the baby consumes a food containing cow's milk. These complaints are generally in the form of moderate to severe atopic dermatitis, also known as eczema.

Even in exclusively breastfed infants, eczema rashes can appear if the mother consumes cow's milk itself or foods containing milk protein. Besides eczema, this group also includes a condition characterized by inflammation of the esophagus called eosinophilic esophagitis.

Eosinophilic esophagitis can occur due to food allergies. Cow's milk allergy-related eosinophilic esophagitis can appear at any age, including in young infants, and is a chronic condition. In infants, the main symptoms are intermittent vomiting, arching of the back during feeding, fussiness, crying, refusal to suckle, feeding refusal, loss of appetite, difficulty swallowing, and weight loss.

3. Delayed-Type (Non-IgE-Mediated Food Allergy)

In infants, allergic proctocolitis is the most common cause of delayed-type symptoms in exclusively breastfed infants. Proctocolitis presents with bloody, mucous stools and is typically seen in exclusively breastfed infants younger than six months. The baby's general condition is usually good, but this condition worries parents. If symptoms disappear when the mother removes milk and all milk-containing foods from her diet, this is an important clue for diagnosis. A food challenge test provides a definitive diagnosis. If bloody, mucous stools reappear when cow's milk is reintroduced into the mother's diet, a definitive diagnosis is confirmed.

Cow's milk-induced enterocolitis is also one of the delayed-type food allergies. In this condition, the baby or child experiences vomiting within 1-3 hours of consuming milk itself or a milk-containing food. In severe cases, vomiting can be repetitive and severe enough to cause dehydration, lasting for hours. Some patients also experience diarrhea along with vomiting.

Cow's milk allergy in infants can also manifest as gastroesophageal reflux related to cow's milk consumption. Normally, babies experience mild reflux-like spitting up after feeding and burping, which continues until about one year of age. However, if the amount of spitting up is frequent and excessive, slows down the baby's weight gain, and is accompanied by feeding refusal, breast refusal, fussiness, and frequent crying, this is an abnormal situation. While different diseases can cause this discomfort in young infants, cow's milk protein-related gastroesophageal reflux can also lead to this clinical picture.

One of the delayed-type milk allergies in infants is constipation that cannot be explained by other causes. If constipation resolves when the breastfeeding mother and baby remove milk-containing foods from their diet, and then reappears when milk-containing foods are reintroduced, a diagnosis is made. Constipation due to milk allergy is only considered in cases that do not respond to standard functional constipation treatment and where other causes have been ruled out.

How Is Cow's Milk Allergy Diagnosed in Infants?

To diagnose cow's milk allergy in infants, a specialist physician first takes a detailed history from the parents regarding the symptoms. It's crucial for the doctor to know when and with which type of food the symptoms started, how widespread and severe they were if they were an immediate-type reaction, how they were treated, and how frequently and how delayed-type symptoms recurred. After evaluating and examining the baby from this perspective, a definitive diagnosis of cow's milk allergy is made based on the results of necessary skin tests and blood tests, and if required, a food challenge test.

Which Tests Provide a Definitive Diagnosis for Cow's Milk Allergy?

In infants and children who have experienced severe symptoms like anaphylaxis or anaphylactic shock after cow's milk consumption, a definitive diagnosis can be made if the blood serum cow's milk-specific immunoglobulin E level and/or the results of cow's milk allergy skin tests are above a certain level, as determined by the doctor after evaluation. For infants who have experienced milder reactions and have different types of milk allergy, a cow's milk challenge test, which involves removing the food from the diet for a period and then reintroducing it, provides a definitive diagnosis for cow's milk allergy.

How Common Is Milk Allergy in Infants?

Cow's milk allergy and food allergies have been increasing in recent years. According to studies, the incidence of milk allergy in infants, while varying depending on whether it's an immediate or delayed type, is observed in 2% to 5% of infants worldwide. However, because symptoms related to cow's milk allergy can also occur in other conditions, they are seen more frequently in infants than these percentages suggest, leading parents to frequently seek medical attention for these symptoms in their babies. In patients presenting with these symptoms, whether it's a true allergy should be determined by specialist physicians through evaluation and tests.

Treatment for Cow's Milk Allergy in Infants

For an infant diagnosed with cow's milk allergy, the foods they can consume are determined at the time of diagnosis. If the baby has reached six months of age and started solid foods, the cow's milk protein form causing the allergy is removed from the diet, and growth is monitored with a calcium-rich diet appropriate for their age.

If a breastfed baby with cow's milk allergy shows symptoms due to the mother's milk protein intake, breastfeeding is not stopped. Instead, the responsible foods are removed from the mother's diet. The mother is also provided with a calcium-rich, healthy diet containing appropriate carbohydrates, fats, and proteins, along with calcium-Vitamin D supplementation. If necessary, a dietitian's consultation is sought.

Foods containing cow's milk protein include baby formulas, cheese, yogurt, baked goods like cakes, cookies, muffins, pastries, pancakes, desserts like ice cream, rice pudding (sütlaç),keşkül, and other milk-based sweets, and cow's milk itself. However, not every patient may be allergic to all these forms of food. The patient needs to be evaluated from this perspective as well. In cow's milk allergy, there are different treatment methods applied by pediatric allergists to cure the allergy, such as allergen immunotherapy.

There are also methods that activate the immune system to resolve and treat the allergy using the type of milk protein that children can consume. For these, close follow-up by a pediatric allergist is very important.

What Foods Contain Cow's Milk?

Foods containing cow's milk include baby formulas, cheese, yogurt, baked or cooked foods that contain milk like cakes, cookies, muffins, pastries, and pancakes, as well as milk-based desserts like ice cream, rice pudding (sütlaç),keşkül, and cakes, and cow's milk itself. Additionally, cow's milk is frequently used during the preparation of various table dishes, such as in cooking chicken, beef, or lamb, with different vegetables, and in soups.

Which Foods Are Removed from the Diet in Cow's Milk Allergy?

In cow's milk protein allergy, foods containing cow's milk that cause symptoms are removed from the diet. These foods include baby formulas, cheese, yogurt, baked or cooked foods containing milk like cakes, cookies, muffins, pastries, and pancakes, as well as milk-based desserts like ice cream, rice pudding (sütlaç),keşkül, and cakes, and cow's milk itself. However, not every patient may be allergic to all these forms of food.

For example, a one-year-old baby might experience symptoms when consuming formula containing cow's milk but can comfortably eat pancakes containing cow's milk. On the other hand, a different child might react even to cakes containing cow's milk. This is because the degree to which these different types of foods trigger an allergic reaction varies.

Furthermore, every baby and child with an allergy is different. Therefore, each patient should be individually evaluated by a pediatric allergist during both diagnosis and follow-up. This approach is the healthiest for our patients.

Can a Baby with Cow's Milk Allergy Also Have Other Food Allergies?

It is very rare for a baby or child with cow's milk allergy to also have an allergy to eggs or other foods.

We only suspect this situation if a baby with milk allergy experiences a reaction to a different food. In such cases, if necessary after a diagnostic evaluation, the other food should also be removed from the diet. Nutrition is of great importance for the growth of infants and children. It is healthiest for our patients to remove a food from their diet only when a true allergy is present.

Should a Breastfeeding Mother with a Baby Who Has a Milk Allergy Consume Foods Containing Cow's Milk?

If a baby is exclusively breastfed and has no symptoms, but symptoms appear when the baby itself consumes a food containing cow's milk, then there is no need for the mother to remove cow's milk from her diet.

However, in some clinical situations, the baby may develop allergy-related symptoms while the mother is consuming foods containing cow's milk. It is important to distinguish these different clinical scenarios. This is because breastfeeding mothers need a higher amount of nutrient-dense and high-calorie foods than average individuals. Cow's milk protein is extremely important for both maternal and infant nutrition. For correct diagnosis and appropriate elimination methods, the advice of a pediatric allergist should be sought.