Healthcare professionals : Test your Knowledge on Cow’s Milk Allergy

Is your milk allergy knowledge up to date? Here are 5 questions designed to help make sure they remain so.

1. One can easily distinguish the “common” digestive discomfort of the infant, digestive discomfort caused by food protein-induced allergic proctocolitis (FPIAP), caused by cow’s milk proteins. TRUE or FALSE

FALSE – When considering digestive discomfort in isolation, it can be difficult to distinguish those related to FPIAP from those commonly experienced in healthy infants. By providing a general picture of the situation, the distinction will become more obvious. First of all, it is important to remember that several elements can contribute to so-called “common” discomfort in infants: an immature digestive system, excess swallowed air, gas, etc. Sometimes the parent interprets intense crying (colic) as a symptom of a food allergy. The health care professional who evaluates a patient and suspects a cow’s milk protein allergy should carefully consider the clinical history, keeping in mind that the digestive discomforts associated with FPIAP do not usually occur on their own. They are accompanied by other symptoms, such as intermittent blood in the stool.

2. A non-IgE-induced cow’s milk protein allergy can create symptoms similar to those of gastroesophageal reflux disease (GERD), without any other digestive symptoms. TRUE or FALSE?

TRUE: However, this situation is quite rare. Non-IgE-induced reactions, caused by cow’s milk proteins, manifest as regurgitation and vomiting, which are usually associated with digestive symptoms such as diarrhea, rectal bleeding, mucoid stools and abdominal discomfort. In addition, it is important to distinguish between gastroesophageal reflux and gastroesophageal reflux disease. Recall that 20% of healthy, one-month-old infants regurgitate or vomit after most feedings, while the statistic doubles in infants aged three to four months (41%). GERD occurs when gastroesophageal reflux causes complications or symptoms that interfere with daily functioning. The Canadian Paediatric Society (CPS) suggests paying attention to the positioning of the child during feedings, considering the integration of thickened foods (thickened breast milk in breastfed infants or thickened commercial infant formula) and the removal of cow’s milk protein as non-pharmacological treatments to be considered when GERD is suspected in a healthy infant. The CPS explains that, “avoiding cow’s milk does not treat GERD, although a subset of children who have cow’s milk protein allergy may experience symptoms similar to GERD and could benefit from this approach”.

3. All commercial infant formulas based on extensively hydrolyzed protein or amino acids are equivalent from one brand to another. TRUE or FALSE

TRUE and FALSE: It is true that all extensively hydrolyzed protein or amino acid-based infant formulas are designed to meet the known nutritional needs of a healthy, term infant. They are suitable substitutes for cow’s milk-based formulas containing whole proteins. Remember that extensively hydrolyzed protein formulas, which do not contain any peptides with a molecular weight of more than 5000 Daltons, are well tolerated by more than 90% of children diagnosed with cow’s milk protein allergy. However, some infants will need to opt for amino acid-based formulas. As formulas can vary from brand to brand in terms of cost, available size, ingredients, nutritional value and taste, it is essential to discuss with the parents of the allergic child to provide them with a prescription that will meet their needs.  

4. As part of a breastfeeding mother’s avoidance diet, traces of milk should be removed immediately when the infant is diagnosed with non-IgE-induced cow’s milk protein allergy. TRUE or FALSE

FALSE: During an avoidance diet for a breastfeeding mother with an infant who is allergic to cow’s milk protein (allergy not induced by IgE), the first step is usually to remove the “concentrated sources” of milk from the breastfeeding mother’s diet for 2 to 4 weeks. If there is no change or if a partial improvement is noted, the health professional may suggest the removal of soy protein, in addition to milk protein, or the removal of traces of milk and soy from the mother’s diet. In many infants, withdrawal from “concentrated sources” of milk* may be sufficient to notice an improvement in symptoms. To confirm the diagnosis, the health professional may also recommend the reinstatement of allergens removed from the mother’s diet.

* When withdrawing milk, it is suggested to avoid replacing all usual dairy products with soy products, as the infant may be reacting to a sudden increase in soy consumption.

5. Although little data exists on the subject, probiotics may be beneficial for children with cow’s milk protein allergy. TRUE or FALSE

TRUE: In its most recent position statement, the Canadian Paediatric Society informs us that there is currently insufficient data to recommend the use of probiotics in children with cow’s milk protein allergy. However, some studies would show a potential benefit to their use. For example, two randomized controlled studies^1,2 and one meta-analysis³ demonstrated that young children who received formulas containing L. rhamnosus GG became tolerant to cow’s milk protein faster than those who consumed a formula without supplements. A discussion with the health care professional will allow the parents of the young child allergic to cow’s milk protein to make an informed decision about the suitability of probiotics in their particular case.