It is estimated that 1 in 14 children under the age of three will have some sort of food allergy, with the most common allergies to milk, eggs, peanuts, tree nuts, soya, fish and wheat.
Did you know that 2-3% of babies have an allergy to milk or Cows Milk Protein Allergy (CMPA)? It’s the most common nutritional issue that babies have and it’s on the rise. Research hasn’t yet found a reason why, but as a paediatric dietitian, I am coming across more and more babies and children with CMPA.
What is CMPA?
Cow’s milk naturally contains a variety of nutrients, including protein. The proteins found in cow’s milk are called casein and whey. When some babies consume cow’s milk, their bodies react to these proteins and trigger an immune response releasing antibodies. These allergic reactions can happen immediately after eating any cows milk products - called an IgE mediated response, or can be delayed - called a non-IgE mediated response.
Does my baby need to avoid all foods containing milk?
Whatever type of milk allergy your baby has it is very important that they follow a dairy free diet. This doesn’t just mean avoiding cows milk but any foods that contain any cows milk products, such as butter, yoghurt, cheese, custard and ice-cream.
What about goats milk?
As the proteins in cow’s milk are quite similar to the proteins of other mammalian milks, your child will also need to avoid milk from other animals too like goat’s milk, sheep milk and buffalo milk, which includes cheeses made from these milks.
What about traces of milk in manufactured foods?
Milk or milk products are often used as an ingredient in lots of processed foods, like bread or flavourings, so it’s really important to check all food labels on any food products. By law, if food contains any products in any form, they have to declare it prominently on the label. For example, many manufacturers display allergens in bold so it is easy to spot.
What are the symptoms of CMPA?
Symptoms of an allergic reaction can be immediate or delayed. Immediate means that they come on typically within 30 minutes after eating a food containing the allergen. Delayed symptoms can occur from two hours to several days later! Symptoms can include (but not limited to):
Swelling of the lips, tongue, mouth or body
An itchy, runny nose
Tummy troubles such as vomiting, constipation or diarrhoea
Anaphylaxis (in extreme cases)
What should I do if I think my baby has CMPA?
If your baby shows any of the symptoms of CMPA, it is really important that they are seen by a healthcare professional such as your GP as soon as possible. If it’s an IgE reaction you will be referred to a paediatrician in your local hospital to confirm the diagnosis.
Immediate onset reactions
IgE allergies are diagnosed in a hospital under the guidance of a Paediatrician. Your child may have skin prick tests where a small amount of the suspected allergen food is put on your baby’s skin. The surface of the skin is then scratched and the size of the ‘wheel’ it creates is measured.
They are notoriously inaccurate in babies under 1 where skin is sensitive and false positives are common.
Alternatively, a blood sample can be taken and sent off for further analysis, the results take several days to come back.
A very detailed allergen focussed history will be taken from you so it’s good to have a food diary and symptom record if possible. It is this coupled with the tests that will confirm the diagnosis.
Delayed onset reactions
If it’s a non-IgE reaction your GP will take an allergen focussed history and may suggest an ‘exclusion diet and challenge.’ Essentially this is a 2-4 week trial of a milk free diet to see if this improves their symptoms.
If you are breastfeeding, this will involve you avoiding dairy foods in your diet and if your baby is weaning they will need to avoid them too.
Your GP should organise a referral to a Registered Dietitian too as the diagnosis is only confirmed when your baby is ‘challenged’ i.e. when the food is reintroduced producing a return of their symptoms.
This can be carried out at home for most non-IgE babies, and best practice is to do this alongside a Registered Dietitian. You should be aware that access to an NHS dietitian can be scarce in some areas and an appointment may not be offered in time.
I’ve seen other tests I can buy online. Are these any good?
There are lots of alternative tests marketed to diagnose allergies such as IgG, vega testing, iridology, hair analysis, kinesiology or cytotoxic testing. These are widely available online and the costs can vary.
However, none have scientific evidence for their use and can’t diagnose an allergy or intolerance.
The only evidence based methods of diagnoses are the ones outlined above.
Hurrah! My baby is better, what happens next?
Once the diagnosis is confirmed you will be advised to continue following the dairy free diet. You must be immediately referred to a Registered Dietitian with paediatric expertise if you haven't already because by cutting out milk you are cutting out a key food group from your growing baby which if not appropriately replaced can result in failure to thrive and nutritional deficiencies leading to health problems. It is essential that those missing nutrients are replaced with other foods in your little one's diet.
What is cows milk protein intolerance?
You might have heard people use the phrase ‘cow’s milk protein intolerance’, however, this doesn’t actually exist. It’s a term that healthcare professionals have previously used to describe the delayed onset or non-IgE milk allergy, but it sometimes is still used today.
What about lactose intolerance, is that different?
This is not an allergy to dairy foods and is a separate condition. Lactose is the sugar that is found naturally in milk. Children with lactose intolerance have trouble breaking down the lactose in foods because they are missing the ‘lactase’ enzyme.
Often this is temporary following a nasty tummy bug as the ‘lactase’ has been washed away. In rare cases, it is a genetic disorder where lactase isn’t produced by the body in sufficient amounts.
Lactose doesn’t cause an allergic reaction and there is no need for your baby to follow a dairy free diet, you can buy lactose free versions of milk and yoghurt and cheese is naturally low in lactose so fine to have. Alternatively, you can add a couple of drops of the ‘lactase’ enzyme to normal milk.
Again, if you think your baby has lactose intolerance, it is really important to go see your healthcare professional for further advice.
I suspect my baby has CMPA, can I trial a milk free weaning diet without seeing my GP?
Milk and dairy foods are one of the five main food groups and contribute to a significant amount of your baby’s nutrition.
If your baby is breastfed, they will receive small amounts of dairy protein through breast milk and if formula fed, all of their nutrition comes from dairy as the majority of infant formula are derived from animal milks.
Once weaning starts, the amount of milk (and the nutrition coming from milk) gradually decreases as food intake goes up. However, milk and dairy foods still play a significant role in nourishing your little one right through their childhood.
If you suspect that your baby/child has CMPA, you have to be very careful as by cutting out milk, your baby is at risk of being deficient in lots of nutrients, which will affect their growth and development. Below is a list of just some of the key nutrients a dairy free diet is at risk of being deficient in:
Calcium (affecting their bone health)
Vitamin B (Riboflavin)
Always seek the advice of a healthcare professional before you try a diet that avoids a whole food group as babies can become deficient in nutrients quite quickly which can impact on their future health and development.
Here is a quick list of foods a CMPA baby can have to replace some of those key nutrients:
Foods containing calcium:
Fish with soft edible bones e.g. tinned sardines, tinned salmon and anchovies – it’s the bones that contain calcium so blend / mash them up well rather than picking them out
Dried apricots, currants and figs
Nut butters such as peanut butter and almond butter
Tahini and houmous
Fortified non-dairy breakfast cereals such as Ready-Brek
Soya milks and yoghurts that have calcium added
Green veg such as kale and broccoli – however, it’s not so well absorbed by the body
Foods containing protein:
Meat – particularly red meat such as beef or lamb for its iron content
Poultry – the darker meat is more nutritious
Beans and other pulses
Tofu and soya (if tolerated)
Foods containing iodine:
White fish & tuna
Chicken & Turkey
Bread ( contains a little)
Nut butters (contains a little)
People often think that egg is a dairy food and therefore has to be avoided if your baby has CMPA. The good news is that unless your baby has a specific egg allergy, egg does not contain the same proteins as milk so your CMPA baby can enjoy eggs as part of their diet which are an excellent source of nutrition.
The waiting list for a dietitian appointment is so long. Is there anything else I can do?
Seeing a Registered Dietitian is crucial because dietitians are the only nutrition professionals regulated by law that can advise you on how to manage a free-from diet without risks to your baby’s health.
Unfortunately, NHS dietitians are scarce in some areas and so it’s important to make arrangements to attend either a group or one-to-one appointment when it’s offered.
If you feel the waiting list is too long, you can also self-refer to a Registered Dietitian in private practice – look for one who is experienced in paediatrics and allergies.
What will the dietitian do?
If you are breastfeeding the dietitian will advise on the dietary changes you’ll need to make to your own diet. You don’t need to stop breastfeeding. As well as excluding dairy foods you will need to add in other foods in order to ensure your milk supply and milk quality isn’t affected. The dietitian will also be considering how your diet needs to look so that your own health is optimised.
If you are formula feeding the dietitian will assess your baby’s diet, growth, and allergy symptoms and advise the GP on which of the prescription formula would be best for your baby. There are currently 11 variants, all with their own unique formulation.
I’m breastfeeding and my baby has CMPA - Do I need to cut milk out of my diet too?
The short answer is maybe...We aren’t sure why, but CMPA is rare in breastfed babies by comparison to those on formula. One of the potential explanations is the immune benefits that breast milk contains, as well as the ‘microbiome’ or healthy gut bacteria that breastfed babies have.
It is important to note here that whilst CMPA is more commonly seen in formula fed babies, it can still occur in breastfed babies. Cow’s milk passes through breast milk at 100,000 times lower than that which is in cow’s milk.
What this means is that the amount of cow’s milk that gets to the baby through their mother’s milk is a lot lower than if they were to directly consume cows milk. Therefore most allergic babies are able to tolerate their mother’s milk. It also means that the vast majority of mums don’t need to follow a milk-free diet either.
However, if your baby is one of the rare ones who does react to your breastmilk, then you can try a milk free diet for a period of time (usually around 2-6 weeks) to see if the symptoms improve.
It’s essential to see a dietitian, as it is important the quality of mum’s diet doesn’t suffer, particularly their calcium intake, and also to ensure that the quality of the breast milk isn’t impacted.
It’s crucial that breastfeeding mums meet their daily calcium and vitamin D requirements. Did you know that as a breastfeeding mum, your calcium requirements increase from 700mg/day to 1250 mg/day whilst you are nursing?
You will need approximately a litre of calcium enriched plant-based milk each day as well as a 10mcg vitamin D supplement just to meet your requirements.
If you don’t get enough calcium and vitamin D, it’s likely your own bone health will suffer as your baby will take the calcium and vitamin D they need from your stores instead.
If after a milk free diet the babies symptoms don’t improve then your dietitian will be able to advise on what you need to do next.
Weaning on a Dairy Free Diet
Stage 1 (around 6 months)
Research has shown that at the start of weaning it is best to start with single vegetables then fruits but progressing on to iron rich foods quite quickly. You can read more about this in my blog called ‘Why Food Before One is Just for Fun is Not True’. You don’t need to do anything differently at the start of weaning if your baby has CMPA as fruits, vegetables and all my suggested iron rich foods are dairy free.
If you need to thin down purees that are too thick, you can use expressed breast milk or some of the prescribed formula you have been given. If your dietitian has advised that your baby can have soya, you could use a little calcium fortified soya milk providing they are over 6 months old. Soya isn’t suitable for babies under 6 months.
Stage 2 onwards (7 months +)
As weaning progresses and your baby is taking 3 meals a day, you will start to try and balance their meals by including protein foods such as eggs, meat, fish, beans and pulses and starchy carbohydrate foods alongside their fruits and vegetables.
However, you will need to ensure that your baby avoids all forms of milk, butter, cheese and yoghurt, and any foods that contain milk by checking all food labels to ensure foods do not contain milk.
Cross contamination can be a real problem when eating outside the home or at nursery. For example, when foods containing milk have been prepared in the same area, the milk proteins can occasionally contaminate dairy free foods and cause an allergic reaction if eaten. Do let restaurants know before you order and have a good long chat with your childcare provider before they start nursery.
As weaning progresses and your baby starts to drop milk feeds, you need to be in close contact with your dietitian as most babies who follow a dairy-free diet need to take more breastmilk or formula than non-allergic babies in order to meet their nutritional requirements.
The dietitian will also advise on how best to balance your infant's diet depending on what known allergies they have and also whether they require any supplements.
The limiting nutrients protein, fat, energy, calcium, iodine, vitamin A and certain B vitamins will be considered alongside your typical routine and family meals to help you plan a way of eating that meets your baby’s nutritional needs. The nutrients that your baby receives in the first two years of life affects their growth and development including their brain development and intellect.
Introducing other allergenic foods during weaning
When your baby has a food allergy, they are more likely to have another. This also includes little ones with severe eczema requiring regular steroid cream.
The advice is to introduce the other allergenic foods, one at a time between 4 months and 12 months of age. Delaying introduction of these foods beyond 12 months can actually make the likelihood of having an allergy greater.
It is advisable to start with egg and then peanut, after that the other allergens detailed on the list below can be offered.
Choose british red lion stamped eggs and offer both the white and the yolk together. Something like scrambled egg or omelette strips work well.
You mustn’t give your baby whole nuts due to the risk of choking, and peanut butter on a spoon can also pose the same risk. Puffed peanut snacks, peanut powder mixed into food or a small amount of smooth peanut butter warmed and thinned down with some of your baby’s usual milk or hot water are better options. You can add this thinned peanut butter to pureed fruits or vegetables.
If your baby tolerates these foods without a reaction, continue offering them regularly as part of their normal diet. This repeated exposure has a protective effect.
Other allergenic foods
You can then start to offer the other common allergenic foods alongside other tolerated foods. Just offer one at a time (no more frequently than one new food per day) and just ¼ to ½ teaspoons worth, so that if your baby does react you know which one was the culprit.
Tree-nuts - almond, cashew, walnuts, brazil nuts, pecans, hazelnuts etc prepared in the same way as peanuts above.
Wheat - breakfast cereals, pasta, bread, couscous, breadsticks
Sesame - such as houmous which contains tahini (sesame paste)
Fish & seafood - cod, haddock, salmon, trout, tuna, prawns, crab, mussels
Again if your baby tolerates them continue offering them regularly as part of their normal diet to capitalise on the protective effect of repeated exposure.
I’ve heard that there are lots of other foods that people can be allergic to. What about those?
There are other foods that can cause allergic reactions when eaten, the Food Standards Agency (FSA) recognises 14 common allergens, which by Law must be declared prominently when they are an ingredient in any food.
It is possible that anyone can develop an allergy to anything, so it is very important to be aware of the symptoms of an allergic reaction.
If you are concerned that a certain food is causing a reaction to your baby, stop offering that food and seek medical advice from a health professional.
For more information on the 14 allergens please visit the FSA website.
The Food Standards Agency’s 14 allergens
Whilst the list below is not exhaustive of all allergens (it is possible for anyone to be allergic to anything), this is the list of the 14 most common allergenic foods, that must be legally declared when they are used as an ingredient in food in the UK:
Cereals containing gluten - the protein found in wheat
Crustaceans - a type of seafood like prawns, crab and lobster
Lupin - a flower that’s found in flour
Molluscs - shelled foods like mussels, whelks, snails
Sulphur dioxide - used as a preservative in dried fruits
A note about soya
If your baby has IgE or immediate onset CMPA, there is no need to be concerned about them being allergic to soya.
There is a link however between non-IgE or delayed onset CMPA where as many as 60% of babies/children may also show a similar allergic reaction to the proteins found in soya. The current advice would be to try introducing a small amount of soya once weaning is well established and use a stepwise soya ladder to increase quantities. Your dietitian will go through what this looks like with you.
I heard that soya was bad for babies and they should avoid it, is this true?
It is recommended that babies under 6 months don’t have soya infant formula but this has nothing to do with allergies. Soya also contains phyto-oestrogens which are similar to female hormones. An old study in male marmoset monkeys found changes in male monkeys fertility when they were fed soya.
As a precaution, the NHS advises that babies should not have soya infant formula under 6 months of age but this can be given after 6 months when weaning has started and milk is no longer the sole source of nutrition.
How do I know if my baby has outgrown her milk allergy?
If your baby has been symptom-free for 6 months and is older than 9 months of age they can undergo a stepwise challenge to see if they are still allergic. The Milk Ladder is a step by step approach that is carried out under the supervision of a dietitian if your baby has non-IgE delayed onset type of allergy.
For those who have an IgE or immediate onset milk allergy, the milk ladder is carried out in hospital under close medical supervision.
What is the milk ladder?
The milk ladder is a six-step approach to re-introducing milk, initially in a baked form alongside other proteins as this is less allergenic and moving stepwise in increasing amounts, other proteins and less baking time as it progresses.
There are specific recipes to accompany the first 3 steps on the milk ladder and it's important not to alter these recipes which have been created in a specific way to measure tolerance.
If your child doesn’t tolerate a certain step, they remain on the step before and include these foods in their diet until a date is arranged to try again.
Balanced meal ideas for CMPA child:
Here are my top 10 recipes for each stage of weaning:
Baby’s 1st Birthday Cake (Made with plant milk)
Frequently asked questions
I’m formula feeding, what formula can by CMPA baby have?
For younger babies there are 11 different variants and the one your baby needs will be determined by the dietitian, Essentially there are two main differences:
Extensively Hydrolysed Formula
These are processed so that the protein within the cow's milk is broken down into smaller parts so that they become hypoallergenic and are able to pass by the immune system without causing symptoms.
Examples include Althera, Nutramigen 1&2, Pregestamil, Aptamil Pepti 1&2, Pepti Junior and Simlac Alimentum.
Amino Acid Formula
These are only prescribed in the most severe cases of food allergy. The proteins are completely broken down to amino acids and so are unrecognisable to your baby’s immune system.
Examples include Alfamino, Puramino or Neocate.
Both extensively hydrolysed formula and amino acid formula will taste and smell differently to standard baby formula. For young babies, such as under 4 months, they tend to just get used to this and accept it. However, older babies who are used to the taste and smell of standard formula, are likely to struggle to accept the new formula.
Your dietitian can work with you to make this transition easier and increase the chances of your baby accepting the new milk.
If your baby is over 6 months of age
A soya based infant formula may be a suitable alternative to standard formula assuming your baby can tolerate soya.
It’s important not to give soya formula to babies under 6 months as the levels of oestrogens are too high for developing babies. You should also be aware that soya infant formula contains a type of sugar which isn’t good for your babies teeth.
How long should my baby stay on their special formula?
In order to ensure your baby is getting all the nutrition they need, it is likely they will likely stay on their infant formula until around 2 years of age which is the current World Health Organisation Guideline, however if they eat a balanced and varied diet and are not fussy, your dietitian may suggest certain plant based milk alternatives, it’s important to follow their advice as not all plant milks are nutritionally equal.
If this is the case it’s likely that additional calcium and vitamin D in the form of a supplement will be needed.
Could I not just give my CMPA plant milk to drink instead of formula?
There are lots of plant based milk available on the market such as almond milk, oat milk, hemp milk and pea milk. Whilst these do not contain any milk, they are a poor source of nutrition for your baby as they do not contain the right balance of nutrients, particularly calories, fat and protein as well as lots of other nutrients.
Calcium fortified unsweetened soya milk can be used in cooking, but should not replace breastmilk or formula or be given as a drink until at least 2 years of age. Your dietitian will advise if the other plant based milks can be used in cooking with your individual baby. Again it’s not a one size fits all approach as the context of the rest of their diet has to be considered.
Rice milk is not suitable for children under 5 due to the naturally occurring high levels of inorganic arsenic.
How long does CMPA last?
Research shows that most babies with CMPA will have outgrown their allergy by the age of three. However, it can last throughout childhood and even into adulthood in some rare cases. It is possible to desensitise the body to milk using the milk ladder described above, so including milk containing foods at the level your baby reached on the milk ladder as part of their normal diet is important.
As eliminating milk from the diet is associated with nutritional risks, challenging your little one at regular intervals in encouraged.
How do I access a dietitian?
Your health visitor or GP can refer you to an NHS dietitian or you can find a private practice one here. Make sure your dietitian is a paediatric dietitian with experience in food allergies in order to support you fully.
How can I find out about more about CMPA?
There is information available on CMPA on the British Dietetic Association website
Are there any alerts I should sign up to?
I would recommend signing up to the Food Standards Agency (FSA) allergy food alerts. You can receive email/text reminders whenever there is a food safety recall due to an allergen not being present on a food label and therefore a risk to anyone with a food allergy.
How can I find out more about Baby Nutrition & Weaning?
You can follow me on Instagram and Facebook for daily tips and advice or you can join me on my Baby Nutrition & Weaning Digital Course where I will guide you every step of the way along your baby’s weaning journey.