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Managing Cow’s Milk Allergy (CMA) in Breast-Fed and Formula-Fed Babies: Food protein-induced allergic proctocolitis: FPIAP

CDHF

Written by: CDHF

Updated: November 15th, 2022

Cow’s milk allergy (CMA) is an allergic reaction to one or more proteins found in cow’s milk and milk products. Often confused with lactose intolerance, CMA is one of the most common food allergies in infancy and early childhood. To break it down, CMA is a reaction to the PROTEIN(S) in milk involving the immune system while lactose intolerance is an intolerance to a SUGAR (lactose) in milk and does not involve the immune system (2). There are typically three types of CMA – This article will focus on a type of non-IgE mediated CMA – Food protein-induced allergic proctocolitis (FPIAP).

If your baby experienced symptoms of CMA and has since been diagnosed with it, there are ways to manage it! These will vary depending on whether your baby is being breast-fed and/or formula-fed and we outlined the strategies below.

Babies who are exclusively Breast-Fed

If your baby has been diagnosed with CMA, the good news is that mom can continue to breastfeed. However, it is recommended that mom strictly removes milk from her diet for a minimum of two weeks (3). 10-15% of babies will also have a reaction to soy protein, so it is often recommended to remove soy at the same time (5). After elimination, the reflux and regurgitation symptoms in the baby should improve within three to five days, while the bloody and looser stool can take up to two weeks to resolve. It is important to note that symptoms may not completely resolve in two weeks, but there should be improvements.

If after two weeks there is no change in symptoms, then the family should visit their doctor to discuss any hidden sources of milk and/or soy in the mother’s and/or baby’s diet as well as evaluate for other potential allergens. The input of a registered dietitian can be especially helpful to ensure mom maintains optimal nutrition with an elimination diet.

Black woman nurses her newborn baby with CMA

Babies who are Formula-Fed

When managing CMA in babies who are formula-fed, traditional formulas are replaced with hypoallergenic extensively hydrolyzed formulas. These formulas have the protein components broken down so that the immune system will not react to them. Two hypoallergenic extensively hydrolyzed formulas available in Canada are Alimentum and Nutramigen. Be aware of formulas with ‘partially broken-down protein’, these proteins are not broken down enough and are not suitable for babies with CMA.

When providing the baby with a hypoallergenic extensively hydrolyzed formula, it is recommended that this be the only formula they are given for a minimum of two weeks (3). Symptoms including reflux and regurgitation should improve within three to five days, and improvements in blood in the stool and looser stool within two weeks. If your doctor finds no change in symptoms, they may recommend switching the formula to an amino acid-based formula, where the protein is broken down to even smaller components, called amino acids. It is rare that babies with CMA need the amino acid-based formula (3).  If your baby is both breast-fed and formula-fed, then mom must remove cow’s milk from their diet in addition to using the hypoallergenic extensively hydrolyzed formula.

If symptoms have not improved within two weeks, it is advised to consult your doctor.

Soy formulas can be given to babies over the age of six months who have a diagnosis of CMA, assuming the baby does not also have a reaction to soy. Soy can be given if there is a concern with the taste of hypoallergenic extensively hydrolyzed formula or the price of the hypoallergenic extensively hydrolyzed formula. There are some concerns over possible effects from the phytoestrogens (plant hormones) in soy although there is very limited data (6). As a precaution, it is not recommended to use soy formula during the first 6 months of life and not in preterm babies (6). Be sure to check with your registered dietitian or doctor before giving your baby any alternatives to make sure they fit your baby’s specific dietary requirements, and to ensure tolerance. 

It is important to remember that CMA will not impact your child’s ability to meet developmental milestones if the allergy is managed. Once the cow’s milk protein is removed and a baby is receiving good nutrition and hydration, then the baby should be able to thrive and grow as normal!

Unless otherwise indicated, the information in this article is from our CDHF Talks with pediatric gastroenterologist, Dr. Lara Hart here.


References:

  1. CDHF. (2021, December). CDHF Talks: Cow’s Milk Allergy. Canadian Digestive Health Foundation. Retrieved July 30, 2022, from https://cdhf.ca/en/cdhf-talks-cows-milk-allergy/
  2. Fiocchi, A., Brozek, J., Schünemann, H., Bahna, S. L., von Berg, A., Beyer, K., Bozzola, M., Bradsher, J., Compalati, E., Ebisawa, M., Guzman, M. A., Li, H., Heine, R. G., Keith, P., Lack, G., Landi, M., Martelli, A., Rancé, F., Sampson, H., . . . Vieths, S. (2010). World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow’s Milk Allergy (DRACMA) Guidelines. World Allergy Organization Journal3(4), 57–161. https://onlinelibrary.wiley.com/doi/10.1111/j.1399-3038.2010.01068.x
  3. Labrosse, R., Graham, F., & Caubet, J. C. (2020). Non-IgE-Mediated Gastrointestinal Food Allergies in Children: An Update. Nutrients12(7), 2086. https://www.mdpi.com/2072-6643/12/7/2086/htm#B106-nutrients-12-02086
  4. Society, C. P. (2021, April 27). Non-ige-mediated food allergy: Evaluation and Management: Canadian Paediatric Society. Non-IgE-mediated food allergy: Evaluation and management | Canadian Paediatric Society. Retrieved July 30, 2022, from https://cps.ca/en/documents/position/non-ige-mediated-food-allergy-evaluation-and-management
  5. Vandenplas, Y., De Greef, E., & Devreker, T. (2014). Treatment of Cow’s Milk Protein Allergy. Pediatric gastroenterology, hepatology & nutrition, 17(1), 1–5. https://doi.org/10.5223/pghn.2014.17.1.1
  6. Verduci, E., di Profio, E., Cerrato, L., Nuzzi, G., Riva, L., Vizzari, G., D’Auria, E., Giannì, M. L., Zuccotti, G., & Peroni, D. G. (2020). Use of Soy-Based Formulas and Cow’s Milk Allergy: Lights and Shadows. Frontiers in Pediatrics8https://www.frontiersin.org/articles/10.3389/fped.2020.591988/full

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