Cow milk protein sensitivity

Which babies suffers from cow milk protein sensitivity?

Babies who are sensitive to the cow milk protein found in the babies’ formula.
In the classic form, it may happen in babies receiving regular milk-based formula. In the less common form it may happen to babies receiving other formulas, including soy-based and even babies who are being breast fed exclusively (about 0.5% of this population). As I mentioned before, the post about cow milk protein sensitivity in breast fed babies can be found here.

Is it cow milk protein sensitivity or allergy and what is the difference?

There are allergies or intolerance to many different types of foods. These may cause a range of reactions, from life threatening reactions, though Celiac (gluten sensitivity, read more here), and to the condition called cow milk protein sensitivity which is mostly presented with gastrointestinal symptoms.
In this post I’m going to discuss enteropathies (inflammatory state of the intestine), related to cow milk protein sensitivity, and not about immediate allergic reactions of shortness of breath, edema and rash which are more related to other allergies. The condition described in this post is different from that, and should be named (more accurately), sensitivity to cow milk protein, and not allergy.

What are the clinical manifestations of Cow milk protein sensitivity?

Most symptoms are of the gastrointestinal system, including abdominal pain, stools with blood and mucus, restlessness and sometimes failure of the baby to gain weight. Sometimes you may also see abdominal bloating and tenderness.
A rare manifestation is a baby with proctocolitis, means inflammation in the anal area. The anus look like it has been through a bad thermometer check (see a picture here). This condition is managed in the same way as cow milk protein sensitivity.
If I would have to give parents wondering if their baby is suffering from cow milk protein sensitivity one clue – it would be to look for mucus in the stools. In most cases in pediatrics, the color or smell of the stool does not have any significance, but the texture does. Mucus in the stools is a sign of colitis (inflammation in the intestine). The same with bloody stools.
In older children, stools with mucus or blood may indicate other etiologies such as bacterial infection (clinical dysentery, read more here). In younger infants or babies, who has lower incidence of bacterial infection, most cases indicate cow milk protein sensitivity.
Since I’ve learned throughout the years that even the most experienced parents are having trouble identifying mucus in the stools, I’ve attached one picture (not for the faint of hearts). This type of stools in a baby indicates an inflammatory process in the intestine and requires medical attention.

So who is the baby with cow milk protein sensitivity?

This is a baby in his first months of life, mostly fed with milk-based formula, and for a time period of days though weeks is suffering from restlessness, abdominal pain and mucus in his stools.
In most cases, babies are gaining weight and develop properly. They just suffer from abdominal pain (which is a little more severe than just colic or gas). It is important to remember that I’m not discussing babies with fever or vomiting, or those with a brother presenting with bloody stools and a new diagnosis of salmonella infection he got from the daycare. These babies require medical evaluation promptly.
So how can it be that yesterday everything went smoothly, and today is another day of abdominal pain and mucus in the stools? There is a spectrum of clinical symptoms. At one end, there are babies who suffer for a few straight weeks, and at the other – those with a few good days in the middle.
From my experience, there is a quantitative aspect in this equation. In days when the babies are consuming X amount of milk based formula, the symptoms are bearable. In days where he eats 2X formula, he will suffer more. That’s way symptoms will be apparent only when transitioning to larger amounts of milk-based formula (for example, after stopping breast feeding).

How do you diagnose cow milk protein sensitivity?

The physician will diagnose it after a relevant and characteristic anamnestic story, a photo (or live view) of the stools (take pictures! One photo is worth a 1000 words), and subtle findings in physical examination. Allergy testing is usually unhelpful, and they are reserved for different kind of allergies for different foods.

What is the treatment for cow milk protein sensitivity in babies?

Treatment is easy – elimination of cow milk protein. How to do so? Change the formula.
Changing the formula to elemental or semi-elemental proteins will bring a relief in symptoms in most cases. The relief will appear in a few days in simple cases, but may take longer (as much as a few weeks) in more severe cases. Changing for soy-based formula is less recommended since there is a high percentage of cross reactivity between cow milk protein and soy protein.
Consult with your physician about the options of formula available for your baby, each has it advantages and disadvantages.
In cases where symptoms continue after changing of formula, there is room for consulting with a pediatric gastroenterologist.
If the baby receives breast milk on top of formula, there is room to discuss reducing milk products from the mother’s diet (giving the fact that changing the formula alone did not do the trick).
Starting with solid foods – in every child with a “problem” regarding eating, I recommend early solid food introduction. Especially infants with cow milk protein sensitivity, an early start might lower the prevalence of sensitivity to other food types (read more here).

What are the latest guidelines on cow’s milk allergy developed by 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.

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 introduction of the elemental or semi-elemental formola.

If, after 2-4 weeks, the infant does not improve – a different diagnosis or a more extensively hydrolyzed formula are to be considered. Okay, well this part isn’t new.

If the infant does improve after 2-4 weeks – regular formula feedings are to be re-introduced 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 hydrolyzed formula 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 re-introduce regular formula feedings to an infant who has 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 will be in the future? Will my baby always be sensitive to milk?

Most of these cases will resolve until the age of one year.
There are 2 approaches:
1- Strict and meticulous: no exposer to milk until the baby is 1 year old, and that preforming a challenge 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’s milk based food, as well as later exposer to milk products will be made by your physicians (with each case considered individually). In my opinion, allergy doctor consultation is not required in most of the cases.

I hope this post will help you understand this matter. And most importantly, I hope you baby will grow and thrive and become as strong as Arnold Schwarzenegger.