Cow’s milk protein sensitivity

Which babies suffer from cow’s milk protein sensitivity?

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

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

There are allergies or intolerances to many different types of foods, which can cause a range of reactions, from life-threatening responses to conditions like Celiac disease (gluten sensitivity, read more here), and to a condition called cow’s milk protein sensitivity, which is mostly characterized by gastrointestinal symptoms.
In this post, I’m going to discuss enteropathies (inflammatory conditions of the intestine) related to cow’s milk protein sensitivity, not the immediate allergic reactions such as shortness of breath, edema, and rash, which are more commonly associated with other allergies. The condition described in this post is different from those and should more accurately be called sensitivity to cow’s milk protein, not allergy.

What are the clinical manifestations of cow’s milk protein sensitivity?

Most symptoms affect the gastrointestinal system, including abdominal pain, stools with blood and mucus, restlessness, and sometimes failure to gain weight. Occasionally, you may also observe abdominal bloating and tenderness.
A rare manifestation is proctocolitis, which means inflammation in the anal area. The anus may appear as if it has been subjected to a rough thermometer check.(see a picture here). This condition is managed in the same way as cow’s milk protein sensitivity.
If I had to give parents wondering whether their baby is suffering from cow’s 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 significant meaning, but the texture does. Mucus in the stools is a sign of colitis (inflammation of the intestine), as is blood in the stools.
In older children, stools with mucus or blood may indicate other causes, such as bacterial infection (clinical dysentery, read more here). In younger infants or babies, who have a lower incidence of bacterial infection, most cases indicate cow’s milk protein sensitivity.
Since I’ve learned over the years that even the most experienced parents have trouble identifying mucus in the stools, I’ve attached one picture (not for the faint of heart). This type of stool in a baby indicates an inflammatory process in the intestine and requires medical attention.

So, who is a baby with cow’s 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 why 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’s milk protein sensitivity?

The physician will diagnose it after taking a relevant and characteristic medical history, reviewing a photo (or live view) of the stools (take pictures! A picture is worth a thousand words), and noting subtle findings during the physical examination. Allergy testing is usually unhelpful and is reserved for different types of food allergies.

What is the treatment for cow’s 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 regarding this topic has not changed, but the society has introduced a significant update to their guidelines.

Since there has been an overdiagnosis of this medical condition in recent years, and because this overdiagnosis may lead to issues for infants who are falsely diagnosed, the society recommends a re-evaluation of the diagnosis 2-4 weeks after the introduction of the elemental or semi-elemental formula.

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

If the infant does improve after 2-4 weeks, regular formula feedings should be reintroduced 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 incorrect. If the symptoms do recur, the initial diagnosis of cow’s milk allergy is confirmed, and the parents should return to hydrolyzed formula feedings.

So, what do I think about all of this? Do I agree that there is an overdiagnosis of cow’s milk allergy? I would assume so. But does it make sense to reintroduce regular formula feedings to an infant who has improved just to confirm the diagnosis? I’m not so sure about that part…

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

I guess we’ll just have to wait and see whether parents and physicians accept this new, unusual guideline recommendation.

What will the future hold? Will my baby always be sensitive to milk?

Most of these cases will resolve by the age of one year.
There are two approaches:

1- Strict and meticulous: No exposure to milk until the baby is one year old, followed by 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’s milk). Begin with baked milk (e.g., in baked goods like muffins, cakes, etc.), while monitoring for abdominal pain and stools. Later, introduce yogurt and milk-based puddings. Consultation with an allergy doctor is only required if recurring symptoms appear.
I suggest that the decision on reintroducing cow’s milk-based foods, as well as later exposure to milk products, be made by your physicians, with each case considered individually. In my opinion, consultation with an allergy doctor is not necessary in most cases.

I hope this post helps you understand this matter. And most importantly, I hope your baby grows and thrives, becoming as strong as Arnold Schwarzenegger!