Milk allergy

Definition

Milk allergy is an abnormal response by the body's immune system to milk and products containing milk. Cow's milk is the usual cause of milk allergy, but milk from sheep, goats and buffalo also can cause a reaction. Some children who are allergic to cow's milk are allergic to soy milk, too. Milk allergy is one of the most common food allergies in children.

A milk allergy usually occurs minutes to hours after consuming milk. Signs and symptoms of milk allergy range from mild to severe and can include wheezing, vomiting, hives and digestive problems. Rarely, milk allergy can cause anaphylaxis — a severe, life-threatening reaction.

Avoidance is the primary treatment for milk allergy. Fortunately, most children outgrow a milk allergy by age 3.

Symptoms

Milk allergy symptoms, which differ from person to person, occur a few minutes to a few hours after drinking milk or eating milk products.

Immediately after consuming milk, signs and symptoms of a milk allergy might include:

• Hives
• Wheezing
• Vomiting

Signs and symptoms that may take more time to develop include:

• Loose stools, which may contain blood
• Diarrhea
• Abdominal cramps
• Coughing or wheezing
• Runny nose
• Watery eyes
• Itchy skin rash, often around the mouth
• Colic, in babies

Milk allergy or milk intolerance?
It's important to differentiate a true milk allergy from milk protein intolerance or lactose intolerance. Unlike a milk allergy, intolerance doesn't involve the immune system. Milk intolerance causes different symptoms and requires different treatment from a true milk allergy. Common signs and symptoms of milk protein or lactose intolerance include digestive problems, such as bloating, gas or diarrhea, after consuming milk or products containing milk.

Anaphylaxis
Rarely, milk allergy can cause anaphylaxis, a life-threatening reaction that can narrow the airways and block breathing. If you or your child has a reaction to milk, tell your doctor about it no matter how mild the reaction was. Tests can help confirm a milk allergy, so you can take steps to avoid future and potentially worse reactions. Anaphylaxis is a medical emergency and requires treatment with an epinephrine (adrenaline) shot and a trip to the emergency room. Signs and symptoms start soon after consuming milk and can include:

• Constriction of airways, including a swollen throat that makes it difficult to breathe
• Facial flushing
• Itching
• Shock, with a marked drop in blood pressure

When to see doctor
See a doctor or allergist if you or your child experiences milk allergy symptoms shortly after consuming milk. If possible, see your doctor when the allergic reaction is occurring. This will help the doctor make a diagnosis. Seek emergency treatment if you or your child develops any signs or symptoms of anaphylaxis.

Causes

All true food allergies are caused by an immune system malfunction. Your immune system identifies certain milk proteins as harmful, triggering the production of immunoglobulin E (IgE) antibodies to neutralize the protein (allergen). The next time you come in contact with these proteins, these IgE antibodies recognize them and signal your immune system to release histamine and other chemicals. Histamine and other body chemicals cause a range of allergic signs and symptoms. Histamine is partly responsible for most allergic responses, including runny nose, itchy eyes, dry throat, rashes, hives, nausea, diarrhea, difficulty breathing and anaphylactic shock.

There are two main proteins in cow's milk that can cause an allergic reaction:

• Casein, which is found in the solid part (curd) of milk that curdles
• Whey, which is found in the liquid part of milk that remains after milk curdles

You or your child may be allergic to only one milk protein or allergic to both casein and whey. These proteins not only are present in milk, but they're also found in processed foods. Additionally, most people who react to cow's milk will also be allergic to sheep, goat and buffalo milk. Less commonly, people allergic to cow's milk are also allergic to soy milk.

Risk factors

Certain factors may increase the risk of developing a milk allergy:

• Other allergies. Many children allergic to milk also have other allergies. Often, however, milk allergy is the first to develop.
• Atopic dermatitis. Children who have atopic dermatitis — a common, chronic inflammation of the skin — are much more likely to develop a food allergy.
• Family history. A person's risk of a food allergy increases if one or both parents have a food allergy or another type of allergy — such as hay fever, asthma, hives or eczema.
• Age. Milk allergy is more common in children. As you grow older, your digestive system matures, and your body is less likely to react to milk.

Complications

Children who are allergic to milk are much more likely to develop certain other health problems, including:

• Allergies to other foods — such as eggs, soy, peanuts or even beef
• Hay fever — a reaction to pet dander, dust mites, grass pollen and other substances

Preparing for your appointment

You're likely to start by seeing your family doctor, a general practitioner or your child's pediatrician. However, you may then be referred to a doctor who specializes in allergic disorders (allergist-immunologist).

Here's some information to help you get ready for your appointment and to know what to expect from your doctor.

What you can do

• Be aware of any pre-appointment restrictions. When you make the appointment, ask if there's anything you need to do in advance. For example, if you're going to have allergy testing done, your doctor will want you or your child to stop taking antihistamine medications for a certain time period before the test.
• Write down any symptoms you or your child has experienced, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Make a list of any medications, vitamins and supplements that you or your child is taking, if applicable.
• Write down questions to ask your doctor.

Preparing a list of questions can help you make the most of your time with your doctor. For a milk allergy, some basic questions to ask your doctor include:

• Do you think this is a milk allergy or lactose intolerance?
• Are there tests to diagnose milk allergy? Do these tests require preparation?
• Is it possible to outgrow this allergy?
• Are there any treatments available?
• Is it necessary to avoid milk and milk products?
• Which foods are most likely to contain milk products?
• Is it necessary to stay away from other children drinking milk?
• What do I need to tell my child's school about this allergy?
• How can milk allergy best be managed with other conditions?
• Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?
• Do I need to have an epinephrine pen available at all times?

Don't hesitate to ask any other questions that occur to you.

What to expect from your doctor
Your doctor is likely to ask you a number of questions, including:

• When did you or your child first experience a reaction to milk?
• Can you describe the reaction?
• Does this happen every time milk or something made with milk is consumed?
• How soon after consuming milk or milk products do symptoms begin?
• How severe are the symptoms?
• Does anything seem to improve the symptoms, such as allergy medication or milk avoidance?
• What, if anything, appears to worsen the symptoms?
• Have you or your child tried any of the products made for people with lactose intolerance? If yes, did those help?
• Is anyone else in your family allergic to milk?

What you can do in the meantime
If you've eaten something containing milk, and you're experiencing mild allergy symptoms, taking an antihistamine medication may lessen your discomfort. But, be on the lookout for more-severe symptoms that might require medical attention. If you or your child has any symptoms of an anaphylactic reaction, seek emergency medical care immediately.

Tests and diagnosis

When food is the cause of an allergic reaction, it isn't always easy to pinpoint what food is to blame. To evaluate whether you or your child has a milk allergy, your doctor may:

• Ask detailed questions about signs and symptoms
• Perform a physical exam
• Have you keep a detailed diary of the foods you or your child eats
• Have you eliminate milk from your diet or your child's diet (elimination diet) — and then have you add back the food to see if it causes a reaction

He or she may also recommend one or both of the following tests:

• Skin test. In this test, your skin is pricked and exposed to small amounts of the proteins found in milk. If you're allergic, you develop a raised bump (hive) at the test location on your skin. Allergy specialists usually are best equipped to perform and interpret allergy skin tests. Be aware that this type of test isn't always accurate for detecting a milk allergy.
• Blood test. A blood test can measure your immune system's response to milk by measuring the amount of certain antibodies in your bloodstream, known as immunoglobulin E (IgE) antibodies. A blood sample is sent to a medical laboratory, where it can be tested for evidence of sensitivity to milk. However, this test isn't always accurate in correctly identifying a milk allergy.

If your examination and test results can't confirm a milk allergy, your doctor might administer an oral challenge, in which you are fed different foods that may or may not contain milk in increasing amounts to see if you react to the ones that contain milk.

If your doctor suspects your symptoms are caused by something other than a food allergy, you may need other tests to identify — or rule out — other medical problems.

Treatments and drugs

The only way to prevent an allergic reaction is to avoid milk and milk proteins altogether. This can be difficult because milk is a common ingredient in many foods.

Despite your best efforts, you or your child may still come into contact with milk. If this happens, medications, such as antihistamines, may reduce signs and symptoms of a mild milk allergic reaction. These drugs can be taken after exposure to milk to control an allergic reaction and help relieve discomfort. Talk with your doctor about which medications might work best for you.

If you or your child has a serious allergic reaction (anaphylaxis), you may need an emergency injection of epinephrine (adrenaline) and a trip to the emergency room. If you're at risk of having a severe reaction, you or your child may need to carry injectable epinephrine (such as an EpiPen) at all times. Have your doctor or pharmacist demonstrate how to use this device so you're prepared for an emergency.

Allergy shots, also sometimes called immunotherapy, haven't been proved effective for treating food allergies, but research is ongoing.

Prevention

There's no sure way to prevent a food allergy, but you can prevent signs and symptoms by avoiding the food that causes them. If you know you or your child is allergic to milk, the only sure way to avoid an allergic reaction is to avoid milk products. Know what you or your child is eating and drinking. Be sure to read food labels carefully. Look for casein, a milk derivative, which can be found in some unexpected places, such as in some canned tuna or other meats. Ask questions about ingredients when ordering in restaurants.

Sources of milk products
Obvious sources of allergy-causing milk proteins are found in dairy products, including:

• Whole milk, low-fat milk, skim milk, buttermilk
• Butter
• Yogurt
• Ice cream, gelato
• Cheese and anything that contains cheese
• Half-and-half

Milk can be harder to identify when it's used as an ingredient in processed food products, including baked goods, processed meats and breakfast cereals. Hidden sources of milk include:

• Whey
• Casein
• Ingredients spelled with the prefix "lact" — such as lactose and lactate
• Candies, such as chocolate, nougat and caramel
• Fat-replacement products, such as Simplesse
• Protein powders
• Artificial butter flavor
• Artificial cheese flavor
• Hydrosolate

Even if a food is labeled "milk-free" or "nondairy," it may still contain allergy-causing milk proteins — so you have to read the label carefully. When in doubt, contact the manufacturer to be sure a product doesn't contain milk ingredients.

When eating out, ask how foods have been prepared. Does your steak have melted butter on it? Was your seafood dipped in milk before being cooked?

While there's no sure way to prevent an allergic reaction to milk, reading labels, being cautious when eating out, and using hypoallergenic or milk-free products can help you or your child avoid an unpleasant or dangerous reaction.

If you're at risk of a serious allergic reaction, talk with your doctor about carrying and using emergency epinephrine (adrenaline). If you have already had a severe reaction, wear a medical alert bracelet or necklace that lets others know that you have a food allergy.

Milk alternatives for infants
Some research suggests that breast-feeding during the first four months of a baby's life instead of giving a standard cow's milk formula can help prevent milk allergy. In children who are allergic to milk, breast-feeding and use of hypoallergenic formula can prevent allergic reactions.

• Breast-feeding is the best source of nutrition for your child. Breast-feeding for at least the first four to six months of life if possible is recommended, especially if your infant is at high risk of developing a milk allergy.
• Hypoallergenic formulas are produced by using enzymes to break down (hydrolyze) milk proteins, such as casein or whey. Further processing can include heat and filtering. Depending on the level of processing, products are classified as either partially or extensively hydrolyzed. Or they may also be called elemental formulas. Some hypoallergenic formulas aren't milk based, but instead contain amino acids. Along with extensively hydrolyzed products, amino-acid-based formulas are the least likely to cause an allergic reaction.
• Soy-based formulas are based on soy protein instead of milk. Soy formulas are fortified to be nutritionally complete — but, unfortunately, some children with a milk allergy also develop an allergy to soy.

Milk from other animals, such as goats or sheep, isn't a good substitute for cow's milk, as these types of milk contain proteins similar to the allergy-causing proteins in cow's milk.

If you're breast-feeding and your child has a milk allergy, cow's milk proteins passed through your breast milk may cause an allergic reaction. If this is the case, you may need to exclude all products that contain milk from your diet. Talk to your doctor if you know — or suspect — your child has a milk allergy and has allergy signs and symptoms that occur after breast-feeding.

If you or your child is on a milk-free diet, your doctor or dietitian can help you plan nutritionally balanced meals. You or your child may need to take supplements to replace calcium and nutrients found in milk, such as vitamin D and riboflavin.

Coping and support

Having a serious allergy or being the parent of a child with a potentially life-threatening allergy can be stressful. Talking to others that share your situation can be helpful. Besides offering support and encouragement, they also may provide useful coping tips, such as how to deal effectively with school officials so that your child's medical needs are met. Ask your doctor if there are any support groups in your area, or contact the Asthma and Allergy Foundation of America.