1) Dairy intolerances are commonly talked about these days, does intolerant mean allergic? 

No, intolerant does not mean allergic, but it is quite easy to confuse these.  Food intolerance and food allergies are two distinctly different conditions, although they can cause similar symptoms. 

A food allergy causes an abnormal response of the body’s immune system to the culprit food, causing a range of symptoms. Symptoms include; Diarrhoea, gas, bloating, abdominal cramps, rash, facial swelling, watery eyes, hives or a runny nose.

Intolerance is the body’s inability to digest a certain food.   With intolerances the immune system is not involved so no allergic reaction will take place.  Symptoms are mostly limited to gastrointestinal problems such as; abdominal pain, bloating, gas and diarrhoea.   

2) What is the difference between diary and lactose? 

Dairy is defined as any food or drink that is made from mammalian milk (cows, goat, sheep, donkey, camel etc.).  Dairy products are a good source of energy, protein and calcium.

Lactose is a sugar found in milk, including breast milk.  Lactose is often used in food, as a filler in pharmaceutical products and is readily added to infant formulas to match the composition to human milk.

3) How do I know if my baby is lactose intolerant / allergic to dairy?

Cow’s milk Protein Allergy (CMPA) is the most common food allergy reported in infants and children under the age of 3.  CMPA typically presents in early infancy and it can develop in both breastfed and formula fed infants.  CMPA results from the abnormal response of the body’s immune system to the proteins found in cow’s milk and other mammalian milks.  Although there is no cure for CMPA, the symptoms can easily be controlled through a dairy free diet. 

CMPA is more likely to develop in babies born into families where the mother, father or a sibling suffers from food allergies, asthma, eczema or hay fever but can also develop in those without a family history.

CMPA can preset in a number of different ways and symptoms are normally grouped (immediate / delayed) according to the time it takes for the symptoms to appear following intake. 

Immediate type:

Appear within seconds to two hours and include; lip swelling, itching or rashes, hives, red flushing on face or body, worsening of eczema or breathing difficulties.

Delayed type:

Appear within 24 – 48 hours after ingestion and include; nausea, vomiting or reflux, diarrhea, constipation, blood in stools and problems with gaining weight

Intolerance i.e. lactose intolerance is the body’s inability to digest the sugar (Lactose) found in milk due to a lack of the enzyme (lactase) that digest’s the lactose.  It can also occur following a gastrointestinal infection or the use of antibiotics and can co-exist with other gastrointestinal diseases. 

With intolerances the immune system is not involved so no allergic reaction will take place.  Symptoms are mostly limited to gastrointestinal problems such as; abdominal pain, bloating, gas and diarrhoea.  Lactose intolerance is usually temporary and the symptoms can only be managed by excluding lactose containing foods from the diet for approximately 2 – 6 weeks.

Symptoms of lactose intolerance include; spitting up or vomiting after a feed, diarrhea, bloating, abdominal cramps and irritability.  As feeding will cause discomfort, babies will naturally avoid feeding leading to poor weight gain.

4) Can a baby be intolerant of their mother’s breast milk? 

Breastfeeding is the preferred method of infant feeding and a baby cannot actually be allergic to their mother’s breast milk, but may develop an allergy or intolerance to components that pass through their mother’s milk from her diet e.g. dairy. However a few rare disorders do exist in which the infant cannot continue to breastfeed due to difficulty digesting parts of the mother’s milk. But it is important to not stop breastfeeding unless absolutely necessary.

Breastfeeding should be encouraged despite the diagnosis of CMPA as it is well tolerated by the majority of these infants.  When baby is symptomatic, mothers may be advised to exclude dairy from their diets.  This should always be done with the help of a dietician to ensure that the mother gets all the nutrients she needs during breastfeeding.  Symptoms usually clear up after 3 – 6 weeks on a diary free diet. 

If breastfeeding is not possible or top-up feeds are required a hypoallergenic formula will be suggested.   Two types of hypoallergenic formula’s are available; extensively hydrolysed formula’s (well tolerated, broken down milk proteins) and amino acid formula’s (contains no milk proteins).

5) Is dairy ALLERGY sometimes linked to Reflux?

Reflux is a common problem in infants and young children.  Although reflux and allergy are two different conditions, CMPA can often worsen the symptoms of the existing reflux.  See your GP or Paediatrician if reflux is suspected as medication, altered milk feeds and re-positioning are required to treat reflux.

6) What are the other options? Is soya or goat’s milk easier to digest? 

CMPA symptoms are only managed by eliminating cows’ milk protein form your baby’s diet.  You can either continue with breastfeeding whilst following a dairy free diet or opt for a hypoallergenic infant formula.

Extensively Hydrolysed Formulas (EHF)

EHF’s are classified as food for special medical purposes.  They can be prescribed by your doctor for certain types of CMPA.  In these formula’s cows’ milk proteins are broken down into small fragments that are well tolerated by allergic infants.

Amino Acid Formulas

These do not contain any cow’s milk proteins as they are based on amino acids.  Also only available on prescription for certain types of CMPA.

In the case of lactose intolerance – a lacto-free infant formula will be prescribed and should be used for a minimum of 2 – 6 weeks.

Other mammalian milks are not suitable to be used as infant feeds.  The proteins structure found in goat, sheep and donkey etc. milks are similar to those found in cow’s milk and can easily lead to cross-reactions.

Soy formulas are not recommended to use in infants under the age of 6 months due to the phytoestrogen content (similar to oestrogen hormone) and potential cross-reactivity.

Other milks including soya, rice, oat, pea and almond milks are not recommended in children younger than 2 years due to their lack in nutritional adequacy.

7) If my baby is allergic to dairy is it more likely that they will be allergic to other things, like wheat? 

A dairy allergy can increase the risk of developing other food allergies (eggs, nuts etc.) and allergic reactions (hay fever). However, dairy allergy is often the first to develop as the digestive system in babies is still immature.   Children with Atopic Dermatitis (chronic inflammation of the skin) are much more likely to develop a food allergy.  The risk increases in an Atopic family, where one or both parents suffer from a food allergy or any other type of allergic reaction – hay fever, asthma, eczema etc.

8) Will my baby be able to get the right amount of calcium elsewhere? 

The prescribed hypo-allergenic infant formula and weaning foods will ensure that all baby’s nutritional requirements, including calcium requirements are met.  These infant formulas are nutritionally complete and in most cases no additional supplementation is required.  Once baby is weaned, recipes can easily be adjusted to be dairy-free.  Ask your dietitian to discuss dairy-free recipes and creative cooking with you.

9) Will my baby grow out of a CMPA? 

Yes, fortunately most children outgrow their CMPA by the age of 3 and almost all by the age of 5 years.  As children get older their digestive system matures, which means that milk is better tolerated.

10) What is the most commonly asked question on the subject and what can I do to help?

The most commonly asked question is the one about which alternative milks can be used if baby is allergic to dairy.  I see a lot of mum’s that have tried various formulae that have been suggested by other mothers who’s babies have been going through something similar.  Parents should be careful not to believe everything they read on forums and avoid self-diagnosing, as every child is an individual and secondary conditions might co-exist with either dairy allergy or lactose intolerance. 

If you suspect an allergy or intolerance, speak to your GP or Paediatrician to ensure the most accurate treatment and care is given to your child.

Also bear in mind that babies on hypoallergenic formulas will often struggle to take this new formula due to the taste difference.  It is important to persevere and not give up after only being on the new formula for one or two days.  These formulas or a dairy free diet needs time to work (3 – 6 weeks), try to be patient.  Speak to your dietitian if baby continues to refuse the new formula as she will be able to make suggestions and offer practical tips.

It is also useful to keep a food-symptom diary if you suspect a food intolerance or allergy.

About Biana Parau:

I am registered paediatric dietitian with a Bachelors degree in Human Nutrition obtained from the University of the Free State in South Africa. Since moving to the UK, I have worked in various community and acute NHS hospital settings. I currently work as a Senior Paediatric Dietitian at BUPA Cromwell Hospital. Being part of a multidisciplinary team, I work closely with general paediatricians, paediatric gastroenterologists and paediatric allergists providing practical, evidence based advice that is easy to follow. I have experience in all aspects of paediatric diet and nutrition, with specific interest in gastroenterology and allergies.

Bianca Parau, Senior Paediatric Dietitian, Bupa Cromwell Hospital, Cromwell Road, London, SW5 0TU

T: 020 7460 5566 | F: 020 7835 2518 | E: bianca.parau@cromwellhospital.com