What are the other Names of this Condition? (Also known as/Synonyms)

• Allergy to Cow’s Milk
• CMA (Cow’s Milk Allergy)
• Cow’s Milk Protein Allergy (CMPA)

What is Cow’s Milk Allergy? (Definition/Background Information)

• Cow’s Milk Allergy (CMA) is a common condition that manifests as an abnormal immune reaction/response to cow’s milk, in individuals who consume them. Onset of the condition is mostly observed in young children below the age of 3 years
• Cow milk has several proteins (such as casein and whey), lactose or milk sugar, and fatty substances. The child may be allergic to any of the proteins contained in cow milk
• Cow’s Milk Allergy is often confused with lactose intolerance. In the case of CMA, it is the presence of certain milk proteins that cause the condition. However, lactose intolerance is caused when the body cannot digest lactose in milk, resulting in a different set of symptoms
• Cow’s Milk Allergy may occur immediately, or after a few hours following exposure. In some cases, the symptoms are noted after a period of a few days. The exposure is normally through ingestion of cow milk or milk-based products, such as butter, cheese, and yogurt
• Numerous signs and symptoms of the allergic reaction may be noted including constant crying, runny nose, hives, breathing difficulties, nausea and vomiting, and indigestion. In some rare cases, Cow’s Milk Allergy may lead to an anaphylactic shock, which is a medical emergency
• Such food allergies are generally diagnosed using an antibody blood test, a skin-prick test, and an oral food challenge test; but, it can be challenging, in some cases. The diagnosis can also help identify cow milk based food items that are to be avoided (in future)
• Anti-allergic medications form the first line of treatment for mild Cow’s Milk Allergies. However, in the case of a severe allergic reaction (anaphylaxis), epinephrine or adrenaline injections are recommended
• The prognosis of Cow’s Milk Allergy is generally good and most of the children overcome the condition during early childhood, although in some individuals it may be present lifelong. Awareness of such allergies and avoidance of specific foods that causes the allergy (via allergen-free foods) is the best form of prevention

Who gets Cow’s Milk Allergy? (Age and Sex Distribution)

• Cow’s Milk Allergies usually occur in infants and young children below the age of 3 years. Several reports indicate the incidence of CMA as being 1 in 40-50 among infants
• The condition can also occur in older children and adults, but is reported to a lesser extent
• No gender preference is noted and both males and females are affected
• All racial and ethnic groups are equally vulnerable to the condition

What are the Risk Factors for Cow’s Milk Allergy? (Predisposing Factors)

The risk factors for Cow’s Milk Allergy may include:

• Consuming cow’s milk and cow milk products and preparations
• Any family history of an associated food allergy
• Infants and young growing children are more at risk
• Having one form of (food) allergy puts one at risk for other forms

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Cow’s Milk Allergy? (Etiology)

An allergic reaction occurs in an individual with Cow’s Milk Allergy, because the immune system recognizes certain proteins in cow’s milk as being dangerous and harmful to the body.

• Intake of cow’s milk results in the production of antibodies i.e., immunoglobulins such as IgA, IgD, IgE, IgG, and IgM. The next time the individual is exposed to the same protein, the antibodies that are circulating in blood causes an antibody-antigen reaction
• The antibody-antigen reaction results in the production of histamine and other chemical messengers, which cause the symptoms seen during an allergic reaction
• Cow’s Milk Allergy is subdivided into IgE mediated (immediate set of reactions) or non-IgE mediated type. Due to this, the set of symptoms observed and their period of onset vary. It is also diagnostically challenging to detect non-IgE mediated CMA (due to delayed symptom presentation)
• Young children are more prone to the condition, mostly due to an under-developed digestive system
• The quantity of food that triggers an allergy may not be significantly large. Sometimes, consuming tiny amounts of the allergen (cow milk or related products) is sufficient to trigger Cow’s Milk Allergy

Occasionally, a severe allergic reaction termed as anaphylaxis may occur, which is a medical emergency that requires immediate medical attention.

What are the Signs and Symptoms of Cow’s Milk Allergy?

The signs and symptoms of Cow’s Milk Allergy depend on the type of allergy - whether IgE mediated or non-IgE mediated. The symptoms are also common to other types of food allergies. In some, the symptoms are mild, while in others they are severe. In many cases, systemic signs and symptoms may be noted. 70% of the children show skin symptoms, while about 60% of them show gastrointestinal symptoms.

The common signs and symptoms of Cow’s Milk Allergy may include:

• Itching of skin
• Urticaria (hives) and/or angioedema (swelling of the tissues due to fluid accumulation)
• Coughing, sneezing
• Shortness of breath (trouble breathing), wheezing
• Runny or stuffy nose
• Swollen eyes
• Nausea and vomiting
• Abdominal distention (bloating) and pain
• Colic
• Babies crying continually is observed frequently

The signs and symptoms specific to IgE mediated Cow’s Milk Allergy include the following (below). Often, a rapid onset of symptoms (within minutes) are noted; or, within a maximum period of 2 hours.

• Swollen tongue
• Hoarseness
• Diarrhea (sometimes with blood)
• Hay fever like symptoms
• Lack of response in young children
• Anaphylaxis, very rarely

The signs and symptoms specific to non-IgE mediated Cow’s Milk Allergy include the following (below). These may be onset 8 hours to even 1-3 days after consuming cow’s milk. Thus, there is a delayed to very delayed reaction with this form of CMA.

• Eczema
• Unusual bowel movement
• Constipation
• In infants, failure to thrive

Generally, not all episodes of allergy will be of the same severity. In some individuals, the most severe symptom caused is anaphylaxis; however, anaphylaxis occurs only rarely in Cow’s Milk Allergy.

• Anaphylaxis (sometimes called an anaphylactic shock) is a life-threatening, whole-body allergic reaction
• During anaphylaxis, tissues in various body parts release histamine and other messenger chemicals, which causes swelling of the throat and other symptoms
• Swelling of the throat is especially dangerous as this can cause shortness of breath. If the swelling is not reduced soon, then there is a possibility that the individual could die from a lack of sufficient oxygen
• It can also result in a bluish skin, weak pulse, and decreased blood pressure (hypotension)

How is Cow’s Milk Allergy Diagnosed?

The diagnosis of Cow’s Milk Allergy may involve the following:

• Physical examination, assessment of symptoms, and medical history evaluation (history of allergies in the family)
• Food diary: Once an allergy is suspected, the healthcare provider may request to maintain a food diary, to note what is being consumed on a regular basis and the corresponding symptoms observed. The healthcare provider can help check if cow’s milk is causing an allergy, through a process of elimination

The tests that are usually conducted to diagnose Cow’s Milk Allergy include:

• Oral food challenge testing; when the individual is administered the allergens in a controlled manner to check for symptoms that develop
• Radioallergosorbent (RAS) test; to determine the specific allergy-causing substance
• Skin-prick test:
  • For this test, tiny amounts of certain substances are injected right underneath the skin (forearm, upper arm, or back)
  • After 15-20 minutes, if the spot where the chemical was injected swells, or if there is redness noticed, then this indicates that the individual may be allergic to the substance
• Blood test to detect antibodies (antibody test)

Note:

• The diagnosis of non-IgE form of CMA can be challenging due to late presentation of symptoms
• Do-it-yourself allergy testing kits that are commercially available are usually not recommended by healthcare providers

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Cow’s Milk Allergy?

The complication of Cow’s Milk Allergy is associated with the allergic reaction itself and it depends on the severity of the reaction. It may include:

• Anaphylactic shock/reaction that may be life-threatening; though, it is rare
• Having one form of allergy can make the individual prone to other allergy types
• In severe reactions, a tracheostomy may have to be performed during an emergency situation 

How is Cow’s Milk Allergy Treated?

The treatment of Cow’s Milk Allergy may be undertaken in the following manner:

• Avoiding consumption of cow’s milk and other dairy products (including ghee, butter, cheese, curd, ice creams, and low-fat or skimmed milk, milk powder, etc.)
• Use of alternatives to cow milk, for source of vitamin D, calcium, and protein, such as extensively hydrolyzed formula (EHF - a type of treated cow’s milk without the allergy causing proteins), soy-based milk formulas, rice protein or amino acid based formulas
• Anti-allergic medication for mild reactions; antihistamine therapy, that is prescribed by the allergy physician
• Symptomatic treatment; use of decongestants, especially for nose block including steroid sprays
• In the case of anaphylaxis (severe allergic reaction), epinephrine or adrenaline is immediately administered
• Breathing support as necessary, control asthma symptoms and low blood pressure
• Immunotherapy, in case of severe allergies, for long-term tolerance development
• Mothers, who are breastfeeding their children, should continue to breastfeed, even though the child may have Cow’s Milk Allergy, unless advised otherwise by the physician

Provide psychological support to children with such food allergies.

How can Cow’s Milk Allergy be Prevented?

The best way to prevent Cow’s Milk Allergy is to avoid cow’s milk and cow milk products that the individual/child is allergic to. Additionally, the following factors may be considered:

• Check ingredients of food before using; educate oneself on foods that potentially contain cow milk products
• Parents must be watchful and read food labels, to ensure they do not inadvertently give their child cow milk-containing foods
• Studies have shown that breastfeeding children for 4-6 months or over, can help build their body immunity and make them less prone to allergies
• In case of known allergy in child, supervise breastfeeding mother’s diet (avoiding dairy products)
• Appropriate maternal diet during pregnancy can help build stronger resistance (against allergies) in children
• Washing hands with soap and water, in case of contact with an allergen, especially before eating
• Avoiding contaminating food items during food preparation; use separate food utensils for preparing allergy-free meals, when possible
• Use alternatives, where possible: It is important to note that children who are allergic to cow’s milk will also be allergic to other milks, such as milk obtained from goat, sheep, or buffalo (in about 90% of the cases)
• While eating out, explain your food allergy to hotel/restaurant service staff and ensure that your food is without the substances you are allergic to
• In hotels and restaurants, separating the preparation of potential food allergens (such as milk, tree nuts, soy, fish) from general food preparation counters may be beneficial to individuals with food allergies. This can help avoid cross-contact (allergens getting transferred from one food type to another)
• Generating public awareness on various food allergies
• It is important to note that cooking to high-flame or cooking to recommended standards will NOT ensure elimination of the allergen

In case the child or adult is susceptible to an anaphylactic shock (high-risk individuals) from Cow’s Milk Allergy, the following should be considered:

• Being watchful of triggers and avoiding them
• Wearing medical alert information bracelets or suitable devices
• Carry auto-injector epinephrine or adrenaline medications such as EpiPen, Anapen, or Twinject. Since the condition may recur, it is advised to carry 2 doses (2 pens)
• Supervise children on how to self-administer the injection, if required
• If child is prone to anaphylactic reaction, then information (preferably written instructions) should be given to day care, school authorities accordingly
• Adults should inform their spouses, colleagues, and friends, about the condition, in case of a future emergency

Presently, in many countries, due to labeling and consumer protection laws, foods have suitable labels that indicate their content.

What is the Prognosis of Cow’s Milk Allergy? (Outcomes/Resolutions)

The prognosis of Cow’s Milk Allergy depends on the severity of the signs and symptoms, but it is generally good.

• Many children grow out of this condition by age 3-5 years (in about 80% of the cases); but, reverting to a cow milk based diet should only be made after consultation with a pediatrician/dietitian
• Some individuals may have the allergy for the rest of their lives, but are able to cope well with modified diets that exclude cow’s milk and related products
• A qualified dietitian should be consulted for formulating suitable plan to help provide adequate proteins to children (in the absence of cow’s milk)
• In some cases, the allergic reaction may be severe, causing anaphylaxis. This is a medical emergency that can lead to a respiratory failure. It requires an immediate treatment of the condition. In such cases, the prognosis is guarded and it depends on whether immediate medical assistance is provided

Additional and Relevant Useful Information for Cow’s Milk Allergy:

• In some cases, camel milk could be an alternative in children with CMA. However, camel milk may not be available readily and this makes such treatment recommendations challenging
• Camel milk is available in many regions of the world, chiefly in certain Arab, Asian, and African countries. It is also available in Israel, Russia, China, Australia, and Netherlands, among others
• Some individuals, who are allergic to cow’s milk, do tolerate cow milk products in baked or cooked food items, such as cakes, biscuits, etc. But, this should be evaluated by your healthcare provider