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milk intolerance

Intolerance to cow milk in infants is fairly common. The hallmark of cow milk intolerance in the very young infant is an inflammation of the digestive tract leading to various symptoms from mild rashes to vomiting, diarrhea, and ultimately bloody stools. Babies intolerant of cow milk may be very uncomfortable and cry excessively, mimicing true colic. Other symptoms related to the respiratory tract such as nasal congestion or wheezy breathing can occur less frequently.

Milk intolerance is usually diagnosed clinically - that is without true laboratory testing - by history of typical symptoms, presence of blood in the stool, and by therapeutic challenge with hypoallergenic (pre-digested) formula (Alimentum®, Nutramigen®). Sometimes it is necessary to confirm the diagnosis by skin testing, which is both reliable and predicts the long term outlook for tolerance of milk products.

There are several forms of cow milk intolerance that are recognised in human babies.

The first is true milk allergy, which involves an abnormal antibody to the proteins in milk that triggers urticaria (hives) or repiratory symptoms in the child. This allergy ranges from mild to quite severe. The levels in the bloodstream of abnormal antibody are fairly predictive of the severity of allergy - the more antibody, the worse the symptoms. About one in 25 children has some degree of this allergy, but severely allergic children are luckily rare.

The least allergic patients break out where milk touches the skin but don't have major reactions. The most allergic children have generalised (the whole body) hives and systemic symptoms such as wheezing, vomiting, and runny nose. Children may outgrow milk allergy if it is mild, however some severely allergic individuals never outgrow it and must avoid milk protein all their lives.

Then there is non-allergic type cow milk protein intolerance. While children with this problem have digestive tract symptoms - vomiting, diarrhea, and cramps - they don't get the hives and respiratory symptoms. This type of intolerance is an intolerance to the protein in the milk, and gets worse as the amount of cow milk in the diet is increased. These children generally do very well and will be able to tolerate a reasonable amount of milk protein in the diet as they get older.

Babies with milk allergy or intolerance symptoms will usually need to stay on special formula until they are 12-18 months old. The majority can be successfully introduced to soy formula once the original bout of gastrointestinal inflammation is over.

The final category of milk intolerance is factitious¹. The human mind seems to grasp for easy answers to every problem. In the newborn period, normal post-delivery spitting and vomiting which have nothing at all to do with the type of formula used are sometimes erroneously labelled as "formula intolerance" or "milk allergy." Soy formula is substituted for cow milk formula, and presto! the baby does better. The fact is that babies' digestive tracts are often a bit squeamish after the stressful experience of delivery, and a little vomiting will occur regardless of the formula offered. This type of spitting is transient and temporary; there is no need to change formula as the first response. But the formula is switched, the baby seems to improve, and the parents and doctor are convinced it was the formula change that caused improvement. Often the baby is never again tried on cow milk formula, and the parents are convinced the child is "allergic to milk." This is usually not the case, of course. But the child has been labelled, often for several years.

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