Cow’s Milk  Allergy (CMA) in infants: Skin-related symptoms

Eczema is a condition where the skin’s barrier does not work as well as it should. People do not develop eczema because of an allergy, but sometimes allergies can cause eczema to flare.^3,4

 A helpful way to describe eczema, is thinking of the skin as a well-built brick wall.^5,6

The ‘mortar’ is holding everything together. This keeps the moisture in and the ‘irritants’ out. For those with eczema, the ‘mortar’ is weak, which means it can’t do its ‘job’ as effectively. The skin can become dry and irritated.^5,6

Eczema can show up for many reasons, including temperature changes, stress, illness and environmental contact reactions (e.g. perfume, washing detergents, etc).

Eczema is a common condition in young children. In the UK it affects around 1 in 5 infants and typically develops before their 1^st birthday. It is very often unrelated to CMA. If it is not resolving with conventional treatments, flares occur consistently and repeatedly after dairy exposure, and particularly if it flares alongside other symptoms (described later in this article) it could be a sign of CMA. Often an eczema flare can take a couple of days to show in response to exposure.⁷

Hives are itchy, raised welts on the skin. You may have noticed these if you have ever had a nettle rash. They can appear suddenly and change rapidly. 

They can be identified as:

• Raised bumps – they appear in different shapes and sizes
• Appear anywhere on the body
• Feel itchy/sting or burn
• They may be pink or red when affecting someone with pale skin; the colour of the rash may not be as visible when on those with brown or black skin⁸

Hives can occur for many reasons. If they occur immediately after the consumption of dairy (usually within minutes to a couple of hours) then this could indicate an allergy.⁹

Infants can get ‘contact reactions’ to foods or substances, which are not related to allergy.¹⁰ You might notice the skin on their face gets a little red when they eat, or eczema may be more difficult to manage. This could be because the food is acidic (for example) and is irritating their skin. Applying a barrier cream to the face during eating (e.g. petroleum jelly), can help reduce the food-to-skin contact.⁶

Angioedema can occur for reasons unrelated to food allergy. If it occurs after your infant consumes dairy (within minutes to a couple of hours), this may indicate an allergic response.⁹

Some other common infant rashes that are not related to CMA include:

• Heat rash
• Cradle cap
• Nappy rash
• Teething/ dribble rash
• General dry skin

This is not an exhaustive list. Further details on rashes can be found at www.nhs.uk.¹¹  Always consult a healthcare professional if you are not sure.

It is rare for eczema/hives to be the only symptom in relation to a food allergy. When looking at symptoms of CMA it is important to note that there are different types of CMPA.

The two main types are:

The symptoms are delayed (occur 2-72 hours after exposure) and include:

• Reflux
• Loose stools (they may be more mucousy or contain blood)
• Persistent constipation
• Abdominal pain
• Excessive wind
• Persistent irritability
• Persistent eczema
• Food refusal or aversions
• Poor weight gain (in combination with above symptoms)⁹

These symptoms are immediate (usually occur within minutes and up to 2 hours after exposure) and include:

Mild to moderate signs:

• Skin & Mucosal: Hives, swelling of the face, lips and eye or itchy mouth
• Gastrointestinal (tummy-related): Stomach pain, vomiting and diarrhoea
• Respiratory (breathing-related):  Rhinitis (sneezing, runny or blocked nose) or nasal congestion

Life-threatening signs:

Anaphylaxis is a sudden, severe, and potentially life-threatening allergic reaction.⁹ Symptoms tend to appear within minutes and progress rapidly.

Anaphylaxis can affect:

• Airway: (swollen tongue, persistent cough, hoarse voice and difficulty swallowing
• Breathing: Difficult or noisy breathing and wheezing
• Consciousness: Dizziness, light-headedness, floppiness/collapse, or loss of consciousness

These will likely be in combination with some of the mild symptoms described above.⁹

It is important not to self-diagnose, and to seek healthcare support if you recognise any of the symptoms above.

Please note that if you suspect anaphylaxis call emergency services immediately.^9,12

Management of skin symptoms is individual.

If a healthcare professional recommends long-term dairy elimination for an infant, guidance from a specialist dietitian is essential.

For breastfed/chestfed infants suspected of reacting to dairy, the mother/feeding parent must exclude dairy from their own diet. For formula fed infants, a switch to a dairy-free formula may be required.¹²

Options include:

• Extensively Hydrolysed Formulas
• Amino Acid-based Formulas

Beyond clinical guidance, several UK-based organisations and resources are available to help families navigate this condition.

Nutricia Support Resources

Nutricia offers a range of additional resources that you may find helpful. These can be accessed via the Nutricia website, where you'll find dedicated sections providing further practical information and support. If you'd like any additional guidance, the Nutricia Resource Centre team is always happy to help on 03457 623653.

• For further practical help, patient stories, and detailed articles on managing daily life, visit Nutricia's "Living with" section
   

External Support & Advocacy Groups

Several UK organizations provide independent education, research, and support for allergy and eczema management:

Allergy UK: www.allergyuk.org

Anaphylaxis UK: www.anaphylaxis.org.uk

British Skin Foundation www.britishskinfoundation.org.uk

BSACI: https://www.bsaci.org

Eczema care online: www.eczemacareonline.org.uk

Eczema UK www.eczema.org

Food Standards Agency: www.food.gov.uk

Natasha Foundation: www.narf.org.uk  

NHS website www.nhs.uk

Primary Care Dermatology Society www.pcds.org.uk

Written by Sara Dawson BSc (Hons) RD, Advanced Allergy & Eczema Dietitian

Owner & Founder of ‘Sara Dawson Dietitian Ltd’. Sara has been a dietitian for 12 years. She has taught on MSc Allergy and Dietetic degree programmes in London and Southcoast Universities. She helped set up the first adult allergy dietitian service, at an Allergy Centre of Excellence, as well as the first Paediatric Allergy Eczema dietetic service at a specialist teaching hospital on the south coast. She continues to work for the NHS and owns her own private dietetic practice.