Milk Protein Intolerance
Milk Protein Intolerance: Excerpt from The 5-Minute Pediatric Consult
Rosalyn Diaz, MD
Milk Protein Intolerance - BASICS
Milk Protein Intolerance - description
A condition in which symptoms affecting the GI tract, skin, and respiratory tract result from ingestion of cow’s milk protein
Milk Protein Intolerance - epidemiology
Prevalence has been estimated at 2–7.5% of otherwise normal infants. It may rarely present for the 1st time in older children and recur in adults.
Milk Protein Intolerance - pathophysiology
- Unprocessed cow’s milk protein is 80% casein and 20% whey. The whey fraction contains >20 types of antigenic proteins, including β-lactoglobulin (the most allergenic of all), α-lactalbumin, bovine serum albumin, βExclusively breastfed infants may also develop milk protein intolerance through exposure to allergens that appear in breast milk.
- Although β-lactoglobulin is suspected to be an antigen, no single protein fraction has been proven. Most children appear to be allergic to multiple cow’s milk proteins; rarely are patients allergic to only one fraction.
- There is 25–30% cross-reactivity between milk proteins and soy proteins.
Milk Protein Intolerance - etiology
Predisposing factors include:
- Age (diagnosis usually <2 years)
- Immune deficiency (immaturity of the mucosal immune system, immaturity or damage of mucosal barrier function, low IgA)
- History or presence of atopy
- Early milk protein–based formula feeding
- Allergenic formula
- GI infection
Milk Protein Intolerance - DIAGNOSIS
Milk Protein Intolerance - signs & symptoms
- GI manifestations such as blood and mucus in the stool in a normal-appearing infant are the most common presentation.
- GI: Diarrhea, bloody stools, vomiting, feeding problems
- Dermatologic: Atopic dermatitis, urticaria, angioedema, eczema
- Respiratory: Allergic rhinitis, coughing, wheezing
- General: Anaphylaxis, failure to thrive (FTT), hypoproteinemia
Milk Protein Intolerance - history
- Diagnosis is implied if clinical symptoms resolve upon removal of cow’s milk protein–containing products.
- In some cases, no resolution is seen on soy-based formula, and hydrolyzed formula and even crystalline amino acid–based formulas are needed.
Milk Protein Intolerance - physical exam
- Usually healthy appearing child with normal physical exam
- Most patients will present in the 1st few months of life with:
- Occult blood loss (without anemia in most cases)
- Hematochezia
- Emesis/reflux symptoms
Some patients may present with:
Profuse watery diarrhea with signs of dehydration
Malabsorption (edema due to hypoalbuminemia, FTT, hemorrhage, rickets)
Abdominal distention
Milk Protein Intolerance - tests
- Clinical diagnosis
- No single laboratory test appears to have significant sensitivity for detecting this syndrome.
- Radioallergosorbent testing (RAST) and skin testing may be used with positive predictive value of only 50%.
- Occasionally, peripheral blood and stool eosinophilia may be documented.
- Infectious causes of enteropathy may mimic the disorder; therefore, infection should be ruled out with stool cultures and duodenal fluid cultures, if available.
- Rectosigmoid biopsies are not routinely performed.
- Histologic changes in bowel mucosa tend to be nonspecific.
- Grossly, the mucosa appears friable and inflamed, rarely with erosions or gross ulcerations.
- Pathologic findings may include:
- Partial villous atrophy with reduction in villous height on upper endoscopy
- Moderate increase in intraepithelial lymphocytes
- Prominent eosinophilic infiltrate
In the rare situation of severe food allergy with shocklike picture and acidosis, fluid resuscitation and refeeding should be done in the hospital.
Milk Protein Intolerance - differencial diagnosis
- GERD and colic are most often misdiagnosed in these infants.
- Diseases characterized by watery diarrhea, abdominal pain, and blood and mucous in the stool should be considered.
- Infectious causes (dysentery, Clostridium) and celiac disease should be excluded.
- Inflammatory bowel disease (IBD), celiac disease, autoimmune enteropathy, toddler diarrhea, anal fissures, and Meckel diverticulum (among others) should be considered, depending on the presentation.
Milk Protein Intolerance - TREATMENT
Milk Protein Intolerance - general measures
- Removal of cow’s milk protein–containing products from the diet is the cornerstone of treatment.
- ~10–30% of children with cow’s milk protein intolerance will also be intolerant to soy protein. For this reason, soy-based formulas are rarely recommended.
- Casein hydrolysate formulas (Pregestimil, Nutramigen, Alimentum) are the formulas of choice for infants with cow’s milk protein intolerance.
- Resolution of grossly bloody stools usually occurs within 24–72 hours, but guaiac-positive stools may continue for 2–6 weeks.
- Neocate and EleCare formulas are amino acid, simple carbohydrate, and fat-based formulas that have been more effective in recalcitrant cases of intolerance.
- Epinephrine may be needed in cases of severe milk protein allergy and anaphylaxis.
Milk Protein Intolerance - FOLLOW UP
- It is important to restrict the diet completely for milk and soy protein during the 1st year of life.
- With the introduction of solids, it is important to read labels carefully for the presence of any milk or soy proteins.
- In most cases, tolerance to cow’s milk protein develops at age 1–2 years, and a normal diet can be safely reintroduced.
- Occasionally, symptoms of intolerance may persist past the 3rd year of life; ~10% will have symptoms that persist at 6 years of age.
- Cow’s milk protein challenge with RAST, skin testing, and possible GI biopsies can help to monitor the degree of allergic response in these older children.
- In cases of severe anaphylactic reactions or acute urticaria, the cow’s milk challenge should be performed in a hospital under medical supervision.
- GI intolerance seems to persist in a certain proportion of subjects, with intestinal symptoms and increased prevalence of lactose intolerance.
Milk Protein Intolerance - bibliography
- Crittenden RG, Bennett LE. Cow’s milk allergy: A complex disorder. J. Am Coll Nutr. 2005;24(6 suppl):582S–591S.
- Ewing WM, Allen PJ. The diagnosis and management of cow milk protein intolerance in the primary care setting. Pediatr Nurs. 2005;31(6):586–593.
- Host A. Frequency of cow’s milk allergy in childhood. Ann Allergy Asthma Immunol. 2002;89(6 suppl 1):33–37.
- Host A, Jacobsen HP, Halken S, et al. The natural history of cow’s milk protein allergy/intolerance. Eur J Clin Nutr. 1995;49(suppl 1):S13–S18.
- Kokkonen J, Tikkanen S, Savilahti E. Residual intestinal disease after milk allergy in infancy. J Pediatr Gastroenterol Nutr. 2001;32:156–161.
- Sampson HA, Anderson JA. Summary and recommendation: Classification of gastrointestinal manifestations due to immunologic reactions to foods in infants and young children. J Pediatr Gastroenterol Nutr. 2000;30:S87–S94.
- Vanto T, Helppila S, Juntunen-Backman K, et al. Prediction of the development of tolerance to milk in children with cow’s milk hypersensitivity. J Pediatr. 2004;144(2):218–222.
- Walker-Smith J. Cow’s milk allergy: A new understanding from immunology. Ann Allergy Asthma Immunol. 2003;90(6 suppl 3):81–83.
- Walker-Smith J. Hypoallergenic formulas: Are they really hypoallergenic? Ann Allergy Asthma Immunol. 2003;90(6 suppl 3):112–114.
Milk Protein Intolerance - CODES
Milk Protein Intolerance - icd9
579.8 Milk protein allergies
Milk Protein Intolerance - FAQ
- Q: Can a fully breastfed infant develop milk protein intolerance?
- A: Fully breastfed infants rarely develop milk protein intolerance because there are fewer cow’s milk protein antigens in breast milk, but it may still occur. To continue to nurse, the mother needs to follow a strict elimination diet.
- Q: When does this problem usually resolve?
- A: In most infants who develop minimal symptoms, the problem will resolve by the 1st year of life, but the range can be several years. Some reports of residual GI disease exist.
- Q: When should a patient be referred to an allergist?
- A: Infants with severe symptoms, persistence of symptoms despite a strict elimination diet, and/or those older than 12 months of age, should be referred to an allergist.
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Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
More About Lactose Intolerance
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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