Cow milk protein sensitivity in breast fed babies

What are the symptoms of cow milk protein sensitivity in breast fed babies?

Just as in babies on formula, symptoms are mainly of the gastrointestinal system, including restlessness, abdominal pain, mucus and blood in the stools. Babies are mostly in their first few months of life.
In most cases, the baby is thriving, developing and most of the day feels well. In many cases, there are only abdominal pain and mucus in the stools. See in the linked post about cow milk protein sensitivity, how these stools looks like and read about the significance (link).
In fact, symptoms are the same in babies being breast fed and those who are not, but my impression is that the severity of symptoms in cases of breast fed babies is lower, and that most cases are sub-clinical.

How is it possible to have cow milk protein sensitivity in exclusively breast fed baby?

This is the million dollar question.
There are a few sources for protein that cause the inflammation and sensitivity in the breast fed baby.
1- Proteins in the breast milk that are mimickers to cow milk protein, which cause similar reaction.
2- Milk products consumed by the mother – those are being metabolized in the mother’s gastrointestinal system, but there are remnants that can bring this sort of reaction in the baby.
3- Sensitivity to different kind of proteins – there are other antigens (proteins), that can pass to the baby in the breast milk, and can cause a similar clinical manifestations in the breast fed baby. Sometimes it is impossible to distinguish cow milk protein sensitivity and sensitivity to soy, eggs, nuts and more.
The first scenario – we cannot change. The 2 others can be altered in several ways, as you can read ahead.

How do you diagnose cow milk protein sensitivity in breast fed babies?

The physician will diagnose after through anamnesis and an appropriate clinical story, a picture of the stools (take pictures! One photo is worth a 1000 words), and subtle finding in a physical examination.
Allergy testing is usually not helpful. This is a sensitivity, not a ‘true’ allergy.

What is the treatment of cow milk protein sensitivity in breast fed babies?

Let’s start with a baby who is being fed with breast milk and milk-based formula. In this case, the first step would be to change the formula to semi-elemental formula. The options are diverse, and each has its advantages and disadvantages. Consult your pediatrician on the specific options. Relief of symptoms would usually be in a couple of days, but could take up to 2 weeks.
In cases with no relief in mucoid stools and abdominal pain after changing formula, you should read the next paragraph and consult your pediatrician.
In a baby exclusively breast fed, there is always a question of when to stop breast feeding and go for semi or fully elemental formula. The answer for that question is mostly no. the advantages of breast feeding (described in this post), are superior to the disadvantages of the sensitivity. In cases where the baby is experiencing severe symptoms (not just a mucoid stool now and then), there is room to discuss decreasing or even stop consuming milk products by the mother.
Two most important points:
1– How can you determine that this is cow milk protein sensitivity, and not sensitivity for another food the mother consumes?
Besides the fact that cow milk protein sensitivity is the most common one – you cannot tell with a 100% certainty that it is the cause for the symptoms, and no other antigens.
So do you need to stop consuming all allergic products, including nuts, peanuts, eggs and more? In my opinion, you need to reserve these extreme diets to the more severe cases, and not for 99% of cases which I see in my clinic. It can be difficult for the mother to avoid the morning coffee, so going through an extreme diet (which in most cases is not needed) is wrong.
I’m aware to the fact that many websites and some doctors recommended this extreme diet in every breast fed baby with abdominal pain. I think this is a mistake. If you choose to follow this method, note that the more updated literature is talking about eliminating one allergen each time (and not all at once) every 2-4 weeks, and following symptoms.
2– Stopping or decreasing milk products? In my opinion decreasing consumption of milk is usually enough and it is not necessary to eliminate all milk products (cheese, yogurts, pizza act.). I do agree that opinions are diverse, and each case must be examined separately. Remember that if you avoid milk and milk products, you should consider supplementing vitamin D and calcium to the mother.

What if the mother wants to stop or decrease breast feeding?

In those cases, the baby should start with elemental or semi-elemental formula. You may read here on all types of baby formulas.

What are the latest guidelines on developed by the ESPGHAN (European Society for Pediatric Gastroenterology and Nutrition) and what are their implications?

In July 2023 the European Society for Pediatric Gastroenterology and Nutrition published new guidelines on the investigation and treatment of infants with suspected cow’s milk protein allergy, both to those who are formula-fed and those who are breastfed.

The information previously published on my website with regards to this topic has not changed, but the society has released a major change to their guidelines.

Since there has been an over-diagnosis of this medical condition in recent years, and because this over-diagnosis may lead to problems in those infants who are falsely diagnosed, the society recommends a re-evaluation of the diagnosis 2-4 weeks following the mother’s introduction of a dairy-free diet.

If, after 2-4 weeks, the infant does not improve – a different diagnosis or different possible allergens in the mother’s diet are to be considered. Okay, well this part isn’t new.

If the infant does improve after 2-4 weeks – the mother is to return to a regular diet (including dairy products) in order to see whether the infant’s symptoms recur (abdominal pain and mucousy stool). If these symptoms do not recur, this suggests that the initial diagnosis was false. If the symptoms do recur, the initial diagnosis of cow’s milk allergy is confirmed, and the parents are to return to elemental or semi-elemental formola feedings.

So, what do I think about all of this? Do I agree that there is an over-diagnosis of cow’s milk allergy? I would assume so. But does it make sense to make more changes after the infant has already improved just to confirm the diagnosis? I am not so sure about that part…

Would I ask a mother to stop giving her child who has an ear infection their antibiotics 3 days later in order to see whether the pain recurs? Absolutely not. If I have diagnosed an ear infection the full course of treatment (7 days) should be completed.

I guess we will just have to wait and see whether or not parents and physicians accept this new, unusual guideline recommendation.

What about starting solids in breast fed babies and food sensitivity?

It is really important that you read the post about starting solids, and start and progress from an early age. In this way, you will lower the chance of sensitivity to other food types.

Will the baby always be sensitive to milk?

I am happy to say, that in most cases this sensitivity passes until the baby is 1 year old.
I would like to remind you of these two approaches:
1– Strict and meticulous: no exposer to milk until the baby is 1 year old, and that preforming skin prick test and examination by an allergy doctor.
2– Easy breezy: around the age of 9 months, start giving the baby milk products (not regular cow milk). In the beginning using baked milk (for example in baked goods, like muffins, cakes etc.), while monitoring abdominal pain and stools. Later on trying yogurts and milk based puddings. An allergic doctor consultation is required only if there are recurring symptoms.
I suggest that the decision on returning to cow milk based foods, as well as exposer to milk products ahead, will be done after consulting with your attending physician. In my opinion, an allergic doctor consult is not necessary in simple cases.

Thank you for your time, and for reading this post.