Katie Fischer Certified baby, toddler and children's sleep consultant for Crouch End, Muswell Hill, Highgate & North London

Diagnosing and managing a cow's milk allergy in the first year of life

If a cow’s milk allergy is being explored as a possible cause for your baby’s symptoms, there are now some very clear, updated guidelines for presentation of suspected CMA in the first year of life, as well as how it should be managed by primary clinicians.

Allergies can cause unsettled sleep and more frequent night wakings, as well as skin, gut and respiratory symptoms, so getting to the bottom of the food that is causing problems is likely to unlock better health, wellbeing and sleep for your child.

Here’s a summary of the iMAP fact sheet published for parents:

Food allergy has become more common and happens when a child’s immune system wrongly reacts against some of the proteins in food, thinking they may be harmful. This will then result in either the onset of an immediate allergic reaction or a more delayed onset reaction.
The typical mild-to-moderate symptoms include one or usually more than one of the following:

• Irritability (colic), reflux, vomiting, refusing or disliking being fed, loose or frequent stools, constipation (especially straining to pass even a soft stool), signs of pain in the tummy, a little blood or slime in the stools
• Itching of the skin, redness of the skin, a tendency to ‘rashes’, eczema
• CMA is more likely to be the cause of these symptoms if there is a history of eczema, asthma, hay fever or food allergy in any close family members, but does not have to be present.

There are no skin or blood tests for delayed onset CMA. The only reliable test is to take all the cow’s milk protein out of your diet if you’re exclusively breast feeding or out of the diet of your baby if they're bottle fed by switching to an extensively hydrolysed formula, and then to later reintroduce it in a planned way.

The period of exclusion should be up to 4 weeks (minimum or 2), as this is the time it may take for the symptoms to improve. During the trial, the symptoms will either begin to clearly improve, suggesting the presence of CMA, or there will be no significant change, which usually excludes the diagnosis of allergy.

At the end of the trial, it’s really important to reintroduce the cow’s milk protein. This will then show you whether any clear improvement seen in symptoms during the trial was actually due to CMA and not just your baby improving naturally. If allergy is the cause, the symptoms can be expected to return within a few days of reintroducing the milk protein, but will usually settle well again as the milk-free diet is restarted. If the diagnosis is confirmed, these guidelines are here to ensure that your baby gets appropriate care and the on-going support of a dietician.

Immediate onset of CMA:

• This usually affects older children and often due to other foods, such as egg, peanut, tree nuts or sea food. But it can also occur with cow’s milk and most commonly when cow’s milk-based formulas are used as top-ups or later when weaning with solids and dairy is introduced (yoghurt, cow’s milk, cheese etc).
• Symptoms usually develop within minutes following ingestion, which may be mild, such as reddening of the skin, hives and puffiness around the mouth or eyes or less common is anaphylaxis.

Click here for a link to Allergy UK's resources and the guidelines maps, which you can take with you when seeking a diagnosis or making an initial appointment with your GP.