Saturday, November 29, 2008

Which type of milk is best for my child with cow's milk allergy?

I get asked this question fairly frequently, so I want to apologize to some parents for taking too long to write this down.

First, I'd like to back track. Make sure your child has either an allergic reaction to cow's milk or an adverse reaction to cow's milk before you go through all this trouble. The former occurs in about 1-2% of the population during infancy usually. The latter can affect up to 15% of the population. Both are treated by avoiding cow's milk as much as possible. In my experience, both usually resolve without additional treatment in 2-3 years. If the allergic reaction was more severe and included asthma or anaphylaxis, I advise avoidance longer, of course an epinephrine auto-injector, repeat skin testing prior to reintroducing cow's milk into the diet, and possibly an observed challenge with cow's milk.

Second, how about substituting with another type of mammal's fresh milk? I saw goat's milk for sale in the Publix I shop. That would make substitution easy. Nope. There is extensive cross-reactivity between sheep's milk, goat's milk, and cow's milk. I expect the same thing between cow's milk and milk from other mammals, though I have no data.

At least four other types of milk for infants are available: soy milk, partially hydrolysed cow's milk, extensively hydrolysed cow's milk, and amino acid-based formula. Soy milk comes from a plant, and more specifically a legume. Here is a list of other milks made from plants. The number 2 most commonly available alternative is rice milk. Being Chinese, I have drank a lot of rice milk and soy milk. They do taste different than cow's milk, but not to me nauseating so. Frankly, I prefer the taste of soy milk over cow's milk. I do have to drink lactose-free soy milk, because I am highly lactose intolerant. I also select fat-free milk, because I do not think excess fat is good for my family's general health. We get plenty of fat in the rest of our diet thank you.

Hydrolyzed cow's milk means the milk has been digested by enzymes. The amount of digestion is roughly divided into either partially or extensively. Amino acid-based formula is basically a completely synthetic solution of amino acids, which are in relative quantities to mimic extensively hydrolysed cow's milk. This makes it expensive. Tangent: even in cases of food-induced anaphylaxis with written appeals and documentation, I have yet to see a case where the insurance company paid for the formula.

When do you give what? It depends on the amount of symptoms the baby has. Consider specifically the baby's: skin, gastrointestinal tract, and general happiness. Generally I recommend first switching from cow's milk to soy milk because the latter is usually palatable and less expensive than the next alternative. If soy milk is not tolerated, then I switch next to an extensively hydrolysed (EH) cow's milk formula. One well-written source and a guideline I found recommend EH cow's milk for infants 0 to 6 months of age and then switching to soy milk thereafter. I can live with that. If allergic disease is present, I see no role for partially hydrolysed cow's milk. Finally, comes amino-acid based formula.

If you suspect your baby may have an allergy to cow's milk, ask your doctor first. He or she should examine you baby and make a diagnosis. Then he refer you to a nutritionist. Having spoken to the Piedmont Dietetic Association, I know there are several manufacturers and many variations within each class. It can be confusing. Remember your fundamentals.

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