Milk allergy
Milk and dairy products are major allergy triggers in infancy and childhood.
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Approximately 20% of children in Switzerland who have a food allergy have a reaction to milk. In adults the allergy is relatively rare. Cow’s milk protein allergy (CMPA), which involves the immune system, is completely different from lactose intolerance.
Triggers
The milk proteins responsible for the allergy can be roughly divided into two groups. Approximately 80% of the proteins in cow’s milk are caseins. The remaining 20% are the whey proteins alpha-lactalbumin and beta-lactoglobulin. Caseins are present in all animal milk, including that of goats, sheep and mares. Alpha-lactalbumin and beta-lactoglobulin can be found only in cow’s milk. Moreover, neither of the whey proteins are heat stable, which means that they break down at high temperatures.
Most sufferers do not have a reaction to just one specific milk protein. They usually cannot tolerate several allergens and must therefore avoid almost all types of animal milk. A few, however, only have a reaction to the alpha-lactalbumin and/or the beta-lactoglobulin and can therefore tolerate cooked or baked cow’s milk such as in cheese and yogurt as well as in a braid.
Presence
Cow’s milk is present not only in dairy products such as yogurt, cheese or curds but also in processed products such as biscuits and ice cream and is a hidden ingredient in salad sauces and sausage. Purchasing guide in German «Einkaufshilfe Milchallergie».
In Switzerland and the EU, milk is one of the 14 major allergens listed in legislation. This means that the ingredient and products made from it must be clearly declared and highlighted on the packaging – for example, in bold, italics or capital letters.
Find out more in the Declaration Brochure (available in German, French and Italian).
Course of the allergy
It is possible to outgrow cow’s milk allergy. Infants may thus be able to tolerate milk as they get older. An annual check with the treating specialist is therefore recommended.
Symptoms
With cow’s milk allergy, symptoms appear within minutes and to an hour after consumption and typically include itching in the mucous membranes of the mouth and on the skin with redness, wheals and swelling. Like other food allergies, respiratory symptoms may also occur. Isolated gastrointestinal symptoms are rare. They usually occur in combination with other allergy symptoms. In rare cases, the allergy may result in anaphylactic shock with breathing difficulties and circulatory collapse.
More information on anaphylaxis.
Non-IgE-mediated milk allergies, such as FPIAP (Food Protein-Induced Allergic Proctocolitis) and FPIES (Food Protein-Induced Enterocolitis Syndrome), mainly affect the gastrointestinal tract. Typical symptoms may include blood in the stool (FPIAP) or repeated vomiting (FPIES) and usually appear with a delayed onset.
Diagnosis
Self-monitoring – ideally recorded in a symptom diary – and a consultation with an allergy specialist, together with the results of skin and blood tests, are the essential basis for the diagnosis of cow’s milk allergy. If an IgE-mediated milk allergy is suspected, skin and blood tests can provide clarity. To confirm the diagnosis and to determine the tolerance level, provocation (or challenge) tests may also be required.
A non-IgE-mediated milk allergy cannot be confirmed by a skin or blood test. This makes diagnosis a challenge. In most cases, the suspected allergy is confirmed through a medically supervised elimination diet followed by reintroduction.
Treatment
IgE-mediated milk allergy:
Strict avoidance of the food causing the allergy is essential. It is also essential to watch for concealed sources in bakery products, sausage, spice blends and semi-cooked and ready meals. If there is a risk of an anaphylactic reaction, it is essential to strictly avoid even the tiniest amounts (traces / contaminants). Whether traces can be tolerated should be decided by an allergy specialist. They may use a provocation or challenge test to determine the level of tolerance to the allergen.
A specialist dietician can provide helpful support in implementing treatment in daily life. For example, to discuss the use of milk substitutes, to learn how to read ingredient lists, to receive practical advice and to discuss possible changes to one’s personal daily life. The supply of essential nutrients (protein, vitamins and minerals) should be assessed by a specialist dietician and monitored by the treating paediatrician/doctor.
Anyone who has already suffered a severe allergic reaction should always carry an emergency medical ID card and an emergency kit to ensure prompt treatment of any further severe allergic reaction. In any event, once first aid has been administered, they should then seek medical attention from an emergency doctor or hospital.
Allergen-specific immunotherapy is one of the new treatment strategies for food allergies and is being studied primarily in children. The goal is to increase tolerance to the relevant allergens and thereby reduce the risk of a severe reaction if small amounts are accidentally ingested. Since long-term studies are still lacking, it must currently be assumed that the food in question must continue to be consumed regularly for life in order to maintain the achieved effects.
Immunotherapy is currently recommended for allergies to milk, eggs, and peanuts, but may sometimes also be considered for other allergies, such as those to tree nuts or wheat. In all cases, the treatment must be prescribed and monitored by an allergist, as the risk of adverse side effects is not insignificant.
Non-IgE-mediated milk allergies
As with IgE-mediated milk allergies, the core of treatment is dietary avoidance (staying away from milk). How long and how strictly this needs to be followed should be discussed with an allergist. In most cases, reintroduction is possible before the age of 12 months and is well tolerated.
Editors: aha! Swiss Allergy Centre in co-operation with the Scientific Advisory Board.
Milk allergy: FAQs
Some milk substitutes are fortified with calcium. Calcium rich mineral water can also substantially help cover the daily requirement. Following a consultation with a medical professional, a calcium supplement may also be beneficial.
Milk contains both heat sensitive and heat stable allergens. Depending on the allergen that triggers the allergic reaction, sufferers can tolerate milk when heated or baked to a high temperature. This should be tested only under medical supervision.
Products labelled as vegan may contain traces of milk. Whether they can be tolerated depends on the individual level of tolerance of the person concerned.
Milk protein allergies typically first occur in infancy and childhood and in most cases are outgrown by school age. An annual check with an allergy specialist is therefore recommended. In rare cases, adults may also develop a milk protein allergy. These adults must then give up milk completely and choose milk substitutes.
No. Lactose free milk still contains the milk proteins that trigger a milk protein allergy.
None at all. Lactic acid is produced using lactic acid bacteria in starch – usually maize or potato starch – and contains no milk components. It is approved for use in the food industry as additive E270.
Typically, symptoms of FPIES do not appear until 1–4 hours after eating. The main symptom is severe, sometimes uncontrollable vomiting. Affected children also appear lethargic and pale. Hives or respiratory symptoms do not typically occur with FPIES.
Blood in the stool can have various causes, which should be medically evaluated. An appointment with a pediatrician is therefore the first step. If other diagnoses can be ruled out, FPIAP (Food Protein-Induced Allergic Proctocolitis) can be diagnosed by medically supervised elimination and reintroduction of cow’s milk. A child with FPIAP usually appears in good general health despite the blood in the stool.
If a breastfed child is diagnosed with a cow’s milk protein allergy, there is no general recommendation that the mother must follow a cow’s milk protein-free diet. If the infant’s symptoms do not improve, a cow’s milk protein-free diet for the mother may be tried for a limited period of time, following the recommendation of a doctor and/or a nutrition therapist. In this case, it is advisable to seek guidance from a specialized nutritionist. If there is no improvement, the mother should reintroduce dairy products.
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