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Cow's Milk Allergy: Overview, Diagnosis, and Treatment

About Cow's Milk Allergy

Cow’s milk allergy (CMA) is the most common cause of food allergy in the pediatric population.1,2 The prevalence of CMA in children living in the developed world is approximately 2 percent to 3 percent.1 Nearly all infants who have a hypersensitivity reaction to milk will experience it in their first year of life.3 Although approximately 80 percent of these children are likely to outgrow their milk allergies, recent research suggests that they are outgrowing their milk allergy more slowly than before, with many still allergic to cow’s milk beyond age five.3

The most common symptoms of cow’s milk allergy are acute urticaria, atopic dermatitis, and angioedema, with vomiting and/or wheezing also suggestive of CMA.1 The majority of children with CMA have one or more symptoms involving one or more organ systems, mainly the skin, gastrointestinal tract, and, less frequently, the respiratory or cardiovascular systems.1 Reactions can range from mild to moderate, but life-threatening anaphylaxis can occur.1

2% to 3% of children

The prevalence of cow's milk allergy in children living in the developed world is approximately 2 percent to 3 percent.1

Common cow's milk allergy symptoms include:1

  • Acute urticaria
  • Atopic dermatitis
  • Angioedema

 

  • Vomiting
  • Wheezing
  • Anaphylaxis

Symptoms generally occur within minutes of cow’s milk ingestion, but can take up to two hours to manifest.1

Cow's milk allergy and lactose intolerance

Due to the similarities in the clinical symptoms of cow’s milk allergy and lactose intolerance, there is ongoing diagnostic confusion between the two.4,5 This confusion may lead to a delayed cow’s milk allergy diagnosis as well as inappropriate dietary interventions, as the treatment of lactose intolerance involves the reduction, but not complete elimination, of lactose-containing foods.5,6

Cow's milk allergy: Refining differential diagnosis through testing

Like all food allergies, diagnosing a cow’s milk allergy starts with a physical examination and, of critical importance, a food-allergy-focused patient history.7,8

The findings of this milk-allergy-focused patient history can then be used to guide testing decisions and results interpretation. This systematic approach can help determine whether the reported history of food allergy, combined with laboratory data, is sufficient to diagnose food allergy, or if an oral food challenge (OFC) should be considered.8

Who should be tested?

The European Society for Pediatric Gastroenterology Hepatology and Nutrition has developed an algorithm for the evaluation of infants and children with symptoms compatible with the diagnosis of CMA.9
 

Click to View Algorithm10

As the majority of children outgrow their milk allergy, periodic re-evaluation—including testing—is recommended.3

What is component testing?

What is component testing?

When a patient asks, “Do I have a milk allergy?,” it’s tempting to get a “yes” or “no” answer and leave it at that. But what if there was a way to uncover even more information about an allergic sensitization, such as the specific protein that’s triggering your patient’s reaction?

Testing with allergen components helps you assess your patient’s potential to tolerate baked milk products. So, instead of just answering the question of “Do I have a milk allergy?,” you can know exactly which protein triggers their reaction, the risk of reaction severity associated with that protein, as well as their likelihood of outgrowing the allergy.

Specific IgE blood testing for milk components can also be used to find out whether the allergy is to a protein that can be broken down when exposed to extensive heat, such as in muffins, cakes, or other baked foods. Allergen component testing can also help determine whether an oral food challenge (OFC) test is recommended. An OFC test can be used to confirm a food allergy or to see if a patient has outgrown a food allergy.

By detecting sensitization with milk component testing you can create a personalized management plan that can help provide answers for questions such as:

"Will cookies trigger my symptoms?"

"Is there the potential that I’ll outgrow my milk allergy?"

 

It’s not just knowledge you’ll be giving them, but peace of mind, too.

Cow's milk allergy and quality of life

Food allergy, including cow’s milk allergy, can have a dramatic effect on quality of life.10 Many studies have detailed the negative affect of food allergy on health-related quality of life (HRQoL), as well as the financial and emotional toll a food allergy takes.9 Identified issues include feeling different because of the diet, worrying about foods, the presence of physical and emotional distress, increased responsibility, effect on social activities (e.g., social restrictions, school, travel, and dining out), anxiety, stress, bullying, and having to consistently exercise greater caution.8

Cow’s milk allergy patients and their families must be educated to avoid accidentally ingesting food allergens (e.g., by reading food labels), to recognize early symptoms of an allergic reaction, and to initiate early management of an anaphylactic reaction.2

Common foods containing cow’s milk

Cow’s milk can be an ingredient in many foods, making it integral for healthcare providers to educate patients on the importance of reading food labels. A high level of patient education is needed to maintain safety when it comes to allergy avoidance.8

Cow’s milk can be hidden in a variety of foods including:12

  • Biscuits
  • Baked goods
  • Pastry
  • Batter
  • Processed meat
  • Savory snacks
  • Soups
  • Gravies

Cross-reactivity

There is a high degree of cross-reactivity between cow’s milk and the milk from other mammals.  In studies, the risk of an allergic reaction to goat’s milk or sheep’s milk in a person with a cow’s milk allergy is about 90 percent.6 Therefore, it is important for healthcare providers to advise patients with cow’s milk allergy to also avoid milk from other domestic animals such as sheep, goats, and buffalo.1

Testing Confidence

Testing Increases Diagnostic Confidence

Adding diagnostic testing to aid in a differential diagnosis has been shown to increase confidence in diagnosis to 90 percent.i,ii Conventionally, a diagnosis of allergic or autoimmune disease relies on the case history and a physical examination. However, adding diagnostic testing to aid in a differential diagnosis has been shown to increase confidence in diagnosis.i,ii Diagnostic testing can also help to improve the patient’s quality of life and productivity, reduce costs associated with absenteeism, and optimize use of medication, in addition to decreasing unscheduled healthcare visits.iii,iv 

i. Duran-Tauleria E, Vignati G, Guedan MJ, et al. The utility of specific immunoglobulin E measurements in primary care. Allergy. 2004;59 (Suppl78):35-41.
ii. NiggemannB, Nilsson M, Friedrichs F. Paediatric allergy diagnosis in primary care is improved by in vitro allergen specific IgE testing. Pediatr Allergy Immunol. 2008;19:325-331
iii. Welsh N, et al. The Benefits of Specific Immunoglobulin E Testing in the Primary Care Setting. J Am Pharm Assoc. 2006;46:627.
iv. Szeinbach SL, Williams B, Muntendam P, et al. Identification of allergic disease among users of antihistamines. J Manag Care Pharm. 2004; 10 (3): 234-238

See which labs in your region have the tests you need

Learn how to interpret test results and decide on a management plan

Management and care of patients with cow's milk allergy

Avoidance of cow’s milk protein in any form is currently the only available treatment for CMA.1,2 Effective management of food allergy requires avoidance of ingestion and prompt treatment in the event of an allergic reaction.9

Strict avoidance of cow’s milk is usually advised, however, some children with milk allergy can tolerate it when extensively heated in baked goods.9 Studies have shown that 75 percent of children with a milk allergy can actually tolerate baked foods containing milk, such as a muffin or cake.12,13 A specific IgE blood test can help you determine if your patient is a good candidate for an oral food challenge to see if they’re likely to tolerate baked milk.

Practice parameters have been developed to help guide the management and treatment of patients with milk and food allergies.

 

References
  1. Lifschitz, C and Szajewska H. Cow’s milk allergy: evidence-based diagnosis and management for the practitioner. Eur J Pediatr 2015; 174:141-15..
  2. Sampson, HA. 9. Food Allergy.J Allergy Clin Immunol;2003; 111(2Suppl): S540-7.
  3. Johns Hopkins Medicine, Milk And Egg Allergies Harder To Outgrow https://www.sciencedaily.com/releases/2007/12/071215205437.htm. Accessed May 2019.
  4. Heine et al. Lactose intolerance and gastrointestinal cow’s milk allergy in infants and children – common misconceptions revisited. World Allergy Org J. 2017; 10:41
  5. Rangel, A et al. Lactose intolerance and cow’s milk protein allergy. Food Sci. Technol, Campinas. 2016;36(2): 179-187.
  6. Kurowski K, Boxer RW. Food allergies: detection and management. Am Fam Physician. 2008;77:1678-1688. 
  7. Burks AW, Tank M, Sicherer S, et al. ICON: Food allergy. J Allergy Clin Immunol. 2012;129:906-920. 
  8. Sicherer SH, Sampson HA. Food allergy: A review and update on epidemiology, pathogenesis, diagnosis, prevention, and management. J Allergy Clin Immunol. 2018 Jan;141(1):41-58
  9. Koletzko S et al. Diagnostic approach and management of cow’s-milk protein allergy in infants and children: ESPGHAN GI Committee practical guidelines. J Pediatr Gastroenterol Nutr 55:221–229.
  10. Antolín‐Amérigo et al. Quality of life in patients with food allergy. Clin Mol Allergy (2016) 14:4
  11. Luyt D et al. BSACI guideline for the diagnosis and management of cow's milk allergy. Clin Exp Allergy. 2014;44(5):642-72. 
  12. Nowak-Wegrzyn A, et al. Tolerance to extensively heated milk in children with cow’s milk allergy. J Allergy Clin Immunol. 2008;122:342-7.
  13. Caubet JC, et al. Utility of casein-specific IgE levels in predicting reactivity to baked milk. J Allergy Clin Immunol. 2013;131:222-4.