I want to ask about breastfeeding an infant with suspected

Patient

Q: I want to ask about breastfeeding an infant with suspected cow's milk protein allergy. My 7 month old came out in nettle rash all over his face within minutes of eating cheese. He did not have other symptoms. He is breastfed & started solids at 6 months. However he has had eczema for many months & I have now cut out dairy (& soy) completely from my own diet as well as his to see if the eczema would improve. I have been dairy free for 4 weeks and it has not improved (it is also being treated with prescribed creams). Today I tried step one on the milk ladder with him - giving him a malted milk biscuit & he had no reaction to it. I am wondering if I should continue to be dairy free in my own diet for breastfeeding? To be clear about his symptoms - he has never had stomach upsets just the nettle rash after he ate cheese (& eczema of unknown causes)

Doctor

A:   Hello,
Thanks for the query to ATD for an opinion,

Cow milk protein allergy (CMPA)usually develops in early infancy, following the first exposure to cows’ milk which, for the majority of infants, occurs through first use of formula milk or first taste of weaning foods. For a small percentage however, this can occur through exposure to the cows’ milk proteins present in breast milk which originate from the mothers’ diet.

Symptoms can take minutes to hours to develop, and can vary considerably between infants, but may include:
Vomiting
Reflux (sometimes called ‘spitting up’)
Rash
Urticaria (hives)
Anaphylaxis

Treatment/Management
If a baby shows symptoms of CMPA on an exclusively breastfed diet, the mother should continue breastfeeding but follow an elimination diet for two weeks to remove all sources of cows’ milk protein in her diet, to prevent proteins transferring to the breast milk. She must avoid accidental exposure and cross-contamination (through shared cutlery or crockery for example).
Cows’ milk should be clearly labelled on all packaged food products within the UK in accordance with food labelling laws; however it can be useful for parents to know what words to look out for on ingredients list (see below):

(Please note, the following is not an exhaustive list): butter, buttermilk, casein, caseinates, cheese, cream cheese, lactose, milk (evaporated, dried, powder, condensed), cream, sour cream, ghee, curd, lactoglobulin, whey solids, milk solids, quark, whey, hydrolyzed whey, whey powder, yogurt, fromage frais.

It is important that a calcium supplement is taken during any period of cows’ milk exclusion from the diet (1000mg/day); as dairy foods are the best source of calcium within the diet. Taking a supplement ensures a good supply of calcium to both the mother and the baby (through the breastmilk). A vitamin D supplement of 10mcg/day should also be taken throughout this time. If the mother is taking these supplements the baby should not need any additional supplementation themselves.

If an improvement in symptoms is noted after the two weeks, cows’ milk should be reintroduced into the diet. This should see the symptoms return, and is used as a positive diagnosis of CMPA. Following a positive diagnosis, the mother should be encouraged and supported to adopt a cows’ milk free diet for the duration of the breastfeeding period. It is important that the difficulty of this is acknowledged and supported, as failure to do so can result in early cessation of breastfeeding to provide dietary relief for the mother; requiring use of a modified milk formula for the infant.

An amino-acid formula can be used to provide ‘top-up’ feeds if required.
If there has been no improvement in symptoms during the elimination diet then the mother can resume a normal diet and further diagnostic tests should be carried out to establish the cause.
As with all babies, breastfeeding is the preferred way to feed. With a CMPA infant, the maternal diet needs to be free of cows’ milk for this to continue. If top-up fees are required, an amino-acid formula should be used.

Amino Acid Formula
This is a formula where the proteins have been broken down into their amino acid parts. Amino acid formulas on the market in the UK are: Neocate LCP or Nutramigen AA, both suitable from birth. Neocate Advance or Neocate Active are amino-acid formulas which are suitable for babies over 12 months of age.

Extensively Hydrolysed Formula
These are formulas where the protein chains are broken down into shorter strands, making them easier to digest. This can be used as a first line treatment in infants with mild to moderate symptoms of CMPA including colic, reflux or eczema without faltering growth. It should be noted that some babies may still react to this and go on to need an amino acid formula. The most common formulas in the UK are:

Alimentum (casein-based, suitable from birth onwards)
Nutramigen LIPIL 1 (casein-based, suitable from birth onwards)
Nutramigen LIPIL 2 (casein-based, suitable from 6 months onwards)
Aptamil Pepti 1 (whey-based, suitable from birth onwards)
Aptamil Pepti 2 (whey-based, suitable from 6 months onwards)
Althera (whey-based, suitable from birth onwards.

Other animals milk such as sheep or goat milks are not recommended as infants with an allergy to cows’ milk are more likely to be allergic to other animals milk too.
Nut milks or rice/oat milks are not recommended as they are not nutritionally suitable for this age group.

Parents should reassure themselves that almost 90% of infants grow out of CMPA by their third birthday so for the majority these alterations will not be a permanent change. Over time, healthcare professionals may suggest ‘re-challenges’ with cows’ milk or cows’ milk products under close supervision to see if this has occurred.

So, in your case as its already been 4 weeks but still the eczema and rash has been present, still it is advisable that you be patient and omit all sources of cow's milk or any other milk source from your and your child's diet. You may use formula amino acids as the supplement as advised above and continue breast feeding. The rash shall subside in due course of time. As the other accompanied symptoms of vomiting, diarrhoea, coughing, breathlessness are not present, there is at present not much need to be worried. Just be patient and wait for few more weeks and get a check from a paediatrician at the same time and discuss your options in detail.

I hope I have answered your query in detail,
Wishing you good health and your child too,
Regards

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