Living with Cow’s Milk Allergy: A Guide for Parents and Carers

CMA is when the immune system responds to the proteins (casein and whey) in milk. Normally the immune system does not respond to these proteins, but in someone who is allergic, the immune system does not respond as it should and allergic symptoms may present. An allergy will always involve the immune system. Some people might get CMA and lactose intolerance mixed up. Lactose intolerance is not the same, this is when the body is not able to digest the sugars (lactose) in milk very well. This is because of a problem with the enzymes (lactase) which break down lactose and is very rare in infants.

Cow’s Milk Allergy (CMA) is one of the most common food allergies, affecting 1-7% of infants in the UK and typically develops in the first year of life (NICE, 2025).¹ Standard infant formulas contain cow’s milk proteins and therefore a baby with CMA will develop symptoms. There is also a very small percentage of breastfed/chestfed babies who will react to the milk proteins passed through breastmilk (human milk), from the mother’s/feeding parent’s diet.

Symptoms can either be immediate (develop within 2 hours) after consuming cow’s milk protein, known as an ‘IgE-mediated allergy’. Or they can be delayed (anything from 2 hours up to 72 hours later), known as a ‘non-IgE-mediated allergy’. You can also get a ‘mixed’ allergy, where you have both immediate and delayed symptoms.¹

Symptoms can be experienced in different body systems and can be as follows;¹

• Skin – persistent eczema, rashes or itching (persistent), hives swelling of the lips, eyes, face and/or throat
• Gastrointestinal (tummy related) – vomiting, diarrhoea, reflux, colic, constipation, blood and/or mucus in stools, abdominal discomfort or excessive wind
• Respiratory – wheeze, cough (persistent), breathing difficulties, rhinitis (sneezing, runny or blocked nose) or nasal congestion
• Other general symptoms – persistent Irritability or colic, food refusal or aversions, poor weight gain (or faltering growth in more severe cases)

Some of these symptoms can be especially distressing for parents, and it is important to seek medical help. These symptoms can be quite common in infancy, making CMA difficult to diagnose. CMA is more likely if symptoms occur in more than one body system.

Diagnosing CMA is not straightforward and can take time. Parents often ask for allergy testing, however, there are no validated allergy tests for delayed/non-IgE-mediated allergies. Tests are available for immediate/IgE-mediated allergies (skin prick and blood tests). However, this depends on local availability of allergy services. Tests are also not 100% reliable, and therefore it is important that a trained healthcare professional takes a detailed history of symptoms and family history. For instance, we know it is more likely to be CMA if there is a family history of allergies and other conditions such as asthma and hayfever. It is also more likely to be CMA, if symptoms are persistent or recurring with exposure to cow’s milk. Hence, the importance of having a healthcare professional who asks the right questions, when going through an allergy history.

When a delayed (non-IgE-mediated) CMA is suspected, you will be asked to remove cow’s milk from your child’s diet, or from the breastfeeding mother’s/feeding parent’s diet, usually for 4-6 weeks. If symptoms resolve, you will be asked to do a ‘milk challenge’, where either standard formula is gradually re-introduced, or milk is re-introduced in the breastfeeding mother’s/feeding parent’s diet. What foods and how much depends on the child’s symptoms. If symptoms return, this will provide a diagnosis of CMA and they should continue a milk-free diet. If symptoms do not return, it is unlikely to be CMA and they should continue a standard formula, or the feeding parent should continue to consume cow’s milk and not restrict. It is important to have guidance from a Dietitian or trained healthcare professional, who will give advice on how to ensure your child's or your own diet (if breastfeeding/chestfeeding) is adequate.

If you are breastfeeding/chest feeding and you suspect your baby might have CMA, you should never be asked to stop breastfeeding/chestfeeding. Breastmilk (human milk) is always best for you and your baby. You can continue your breastfeeding/chestfeeding journey, whilst resolving CMA symptoms, with the right support. You might be asked to remove milk from your diet because small amounts of milk proteins can pass through your milk to your baby and in very sensitive babies, this might cause symptoms.

Calcium needs of any mother / parent producing breastmilk (human milk) are high (1250mg per day)² and additional calories are also needed (approximately 330kcal).³ It is therefore important to include calcium-fortified alternative products or non-dairy sources of calcium such as bread, fortified cereals or to take a calcium supplement. Iodine is another important mineral, which breastfeeding mothers /parent producing breastmilk (human milk) need more of (200mcg per day) and is most commonly found in dairy products. You can also get it from fish, eggs and nuts. Vegetarian or Vegan breastfeeding mother's /feeding parents need to be especially mindful of choosing dairy alternatives which are fortified with Iodine.²

Formula fed babies will be changed to a ‘hypoallergenic formula’. Don’t be concerned when cow’s milk is still listed as an ingredient, the proteins are broken down, which means the immune system does not recognise them anymore. There are two main types of formula;

1. Extensively Hydrolysed Formulas (EHF) The cow’s milk proteins in these formulas have been broken into smaller molecules. Some of these formulas may or may not contain lactose. The majority of CMA children will tolerate these formulas.
2. Amino Acid Formulas (AAF) are when the proteins have been fully broken down into single amino acids. These are generally given to babies with severe allergies or who have tried and not tolerated EHFs or if growth is not as expected.

Practical tips for parents and carers

It can feel overwhelming when your child is diagnosed with CMA. All the new information, explaining to everyone else, label checking, second guessing symptoms. It does get easier over time. Here are 5 top tips to help things feel more manageable;

1. Check every label every time - get used to reading food labels. Manufacturers change ingredients, so even if it’s a staple, still check. Milk should be listed in bold but also look out for ‘casein’ and ‘whey’ which are the milk proteins.
2. Simplify food shopping - shop online and use a filter (usually under diet and lifestyle - choose ‘milk-free’), bulk buy and freeze (you can even freeze dairy-free cheese/yogurts), download apps or follow qualitified Dietitians’ social media accounts, for recipe ideas.
3. Keeping the cost down - meal plan for the week, ask AI the cheapest place to shop for ingredients, batch cook and freeze. Not all snacks need to be in a packet (more expensive), think fruit, home-made oat bars, hummus and age-appropriate veg sticks.
4. Plan ahead - eating out? Call ahead and check they can cater for milk-free, going on holiday? Call the hotel, check what they can provide. Bring snacks with you
5. Focus on what they CAN have, there are lots of whole, fresh foods which children can have with CMA. Particularly during weaning, home-cooked foods are best and you know exactly what’s going in them. Vegetables, fruits, pasta, rice, meat, fish, eggs are ALL naturally milk-free.

As a Dietitian, one of the most important things we discuss is how your child can still get all the nutrients they need, on a milk-free diet. Key nutrients to think about are total calories, protein, calcium (Vitamin D, to help absorb calcium), Iodine, Vitamin B12 and riboflavin.

There is a growing number of milk-free alternatives on the market, which is really positive, being able to have more options but parents can find it difficult knowing which to choose. A few key things to remember are: Alternative milk drinks such as soya, oat, coconut ‘milks’ can be used in cooking/added to cereals but not to be used as their main milk drink <12 months of age. Milk-free yogurts, cheeses, creams (generally soya, oat, coconut based) can be an excellent source of nutrition, if they are fortified. Read labels and choose ones with added Calcium, Vit B12, Vit D, Riboflavin and ideally Iodine.

Avoid products with too many added sugars and ideally aim for no added sugar options.

Finally, weaning and mealtimes are moments for families to connect and to be enjoyed. Try to be patient and persistent with new foods during weaning, eating is a new difficult skill to learn, and it takes time. Maintain routines and regular mealtimes as best you can. Offer choices and encourage self-feeding. Make mealtimes positive and playful (and embrace the mess!).

Nutricia’s support for families

Nutricia also has a number of other resources which can be accessed:

We appreciated that there is often a lot of information to read online and sometimes it is easier to talk to someone over the phone.

The Nutricia Resource Centre can be reached at 03457 623 653

Allergy UK has excellent resources, including an Allergy Weaning Pack which is free to download on their website. Weaning Support Pack | Allergy UK | National Charity

When to seek professional help guidance

Having a child with suspected CMA can be very stressful. As a parent, you will always know your child best. If you suspect your child has any of the following;

• CMA symptoms/allergic reactions
• Feeding issues
• Poor weight gain

Always seek advice from a healthcare professional, the sooner you raise your concerns, the sooner we can get your baby settled and on the right track.

Bio: Aimee McEvilly works at a large Children’s Hospital in the Midlands, as the lead for the Coeliac Service. She also provides care to those needing nutrition support and who have intestinal failure, as well as other gastro conditions. She has 15 years experience working as a Dietitian, 12 of which are working in Paediatrics. She has a passion for supporting families who have children with allergies and continues to do this in her freelance capacity and also working for the charity Allergy UK. Aimee is a member of the British Dietetic Association and is on the Paediatric Specialist Group Committee.