Cow’s milk allergy in children

Cow’s milk (protein) allergy is one of the most common food allergies in children in their first years of life, with diverse manifestations such as urticaria, wheeze, vomiting, skin problems and gastrointestinal symptoms. It affects 2-3% of children in their first your of life, usually with symptoms beginning within the first month of life, or within a week after introduction of cow’s milk formula.

Cow’s milk allergy encompasses a wide range of clinical manifestations, from the relatively benign to those that are life threatening. In most cases more than one body system is usually affected-often the skin (50-70%; urticaria or atopic dermatitis), gastrointestinal tract (50-60%; nausea, vomiting, diarrhoea, or colic), and respiratory system (20-30%; rhinoconjunctivitis or wheeze).

Below is a summary some of the features that are suggestive of a diagnosis of cow’s milk allergy (remember, however, that the diagnosis can only be performed by a qualified health professional through the analysis of symptoms, exams and the response to treatment).

• Temporal association between symptoms and the ingestion of milk
• Several body systems affected. Most commonly the skin, gastrointestinal tract, and respiratory system, particularly if symptoms of atopic diseases are present (such as atopic dermatitis or asthma)
  Presence of a family history of atopy
• Exclusion of lactose intolerance, which manifests as explosive watery diarrhoea after ingestion of cow’s milk
• Positive allergy tests or indicators of inflammation
• Failure to respond to other treatments, including consideration of functional causes

The key to management is the elimination of cow’s milk proteins from the patient’s or the mother’s diet (or both). Extensively hydrolysed formulas are the mainstay of such diets, although about 10% of patients are intolerant of these and require amino acid formulas. Other mammalian, soya, or rice milks formulas are not recommended because of high antigenic crossover. Solids must be dairy free. Professional dietetic advice and support are important to ensure provision of adequate nutrients to the growing child and the mother.

On a positive note, a number of studies have shown that cow’s milk allergy usually resolves within the first few years of life, with 60-75% of patients becoming tolerant by the age of 2 years and 84-87% by 3 years. Moreover, strategies to prevent the development of cow’s milk allergy have received considerable interest. Reviews by the American Academy of Pediatrics and the European Academy of Allergology and Clinical Immunology found evidence that exclusive breast feeding, or the use of extensively hydrolysed formulas, alongside avoidance of solids that contain dairy products, for the first four to six months reduces the incidence of the disease in infants at high risk of developing milk allergy (those with a first degree relative with physician diagnosed atopic disease

Sources:
John R Apps, JR & Beattie, RM. 2009. Cow’s milk allergy in children. BMJ 2009 339: b2275.
Host A. Frequency of cow’’s Milk allergy in childhood. Ann Allergy Asthma Immunolol 2002;89:33-37

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