Cow’s milk protein allergy typically presents in the first year of life. It involves hypersensitivity to the protein in cow’s milk, which can be either:
- IgE-mediated, with rapid reactions to cow’s milk, occurring within 2 hours of ingestion
- Non-IgE mediated, with reactions occurring more slowly, hours to days after ingestion
Cow’s milk protein allergy is not the same as lactose intolerance. Lactose intolerance is not an allergic process.
Cow’s milk protein allergy is more common in formula-fed babies and those with a personal or family history of other atopic conditions.
Presentation
Cow’s milk protein allergy usually presents before 1 year of age. It may become apparent when weaned from breast milk to formula or to foods containing milk. It can present in breastfed babies when the mother is consuming dairy.
Symptoms and severity vary significantly among individuals.
Gastrointestinal symptoms may include:
- Bloating and wind
- Colicky abdominal pain
- Diarrhoea
- Vomiting
Skin symptoms may include:
- Angio-oedema (swelling to the face, lips or tongue)
- Urticarial rash (hives)
- Eczema
- Pruritus (itching)
Respiratory symptoms (mainly seen in IgE-mediated allergy) may include:
- Cough
- Wheeze
- Breathlessness
- Sneezing
- Watery eyes or nose
Rarely in severe cases anaphylaxis can occur.
Management
Skin prick testing or serum-specific IgE testing can be used to support a diagnosis of IgE-mediated cow’s milk protein allergy. Positive results indicate sensitisation, not necessarily allergy.
Diagnosis of non-IgE-mediated allergy involves a trial of strictly eliminating all cow’s milk-containing foods from the mother’s (if breastfeeding) and infant’s diets for 2-4 weeks. If the symptoms resolve, then cow’s milk is reintroduced:
- If symptoms return, the diagnosis can be confirmed
- If symptoms do not return, the diagnosis can be excluded
Specialist allergy clinic and dietician input may be required for diagnosis and management.
Management involves the elimination of cow’s milk-containing foods from the mother’s (if breastfeeding) and infant’s diets.
Hypoallergenic formulas are used in formula-fed infants:
- Extensively hydrolysed formulas (e.g., Aptamil Pepti or SMA Althéra) contain proteins that are broken down
- Amino acid formulas (e.g., Neocate) are made of individual amino acids (and are used in severe cases)
Milk Ladder
Most children will outgrow cow’s milk protein allergy by age 3, often earlier.
The milk ladder is a step-by-step plan for gradually reintroducing cow’s milk into a child’s diet, starting with foods containing very well-cooked milk and progressing to less processed forms.
Periodically, infants can be tried on the first step (e.g., well-baked biscuits) and then slowly progress up the ladder until they develop symptoms. Over time, they should gradually progress to a normal diet containing milk.
Last updated April 2026
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