Breastfeeding offers numerous health, social, economic, and environmental benefits, providing optimal nutrition and antibodies that protect against various communicable diseases while also offering long-term advantages for both mother and child. For infants diagnosed with cow's milk allergy (CMA), supporting the continuation of breastfeeding requires a careful examination of the evidence surrounding maternal cow's milk elimination diets.
Understanding Milk Protein Allergy
It's crucial to distinguish between lactose intolerance and milk protein allergy. While human milk is rich in lactose, most babies and toddlers can digest it without issue. The problem usually arises from the large protein molecules in cow's milk that can pass into human milk and potentially affect sensitive babies.
A milk allergy is an abnormal immune response to the proteins found in cow's milk, most commonly affecting infants and young children. This allergy necessitates careful dietary management to avoid triggering adverse reactions.
Identifying and Managing Cow's Milk Protein Allergy (CMPA)
If you suspect your breastfed baby is sensitive to cow's milk protein in your diet, removing dairy products is a common first step to see if it makes a difference. It's important to note that it can take up to 21 days for all traces of cow's milk protein to leave your system, so allow two to three weeks to evaluate the results. Many babies outgrow this sensitivity, potentially allowing you to reintroduce dairy into your diet as your baby gets older. However, some babies may show no improvement, indicating that other elements in your diet could be causing the problem.
The Elimination Diet: A Diagnostic and Therapeutic Tool
The elimination diet involves completely removing cow's milk protein (CMP) from the infant's diet (or the mother's diet if breastfeeding) for 2-6 weeks. If symptoms do not improve after this period, CMPA is unlikely. If symptoms do improve, an oral food challenge is usually performed to confirm the diagnosis. Once CMPA is confirmed, a therapeutic elimination diet entirely free from CMP (dairy) will be required.
Read also: Safety of Low-Carb Diets During Lactation
A specialist dietician or nutritionist should provide the parent/caregiver with comprehensive information, including a complete list of foods containing the proteins the child (or mother) should avoid.
Maternal Diet and Breast Milk Composition
Current clinical practice recommendations advise a 2-4 week trial of maternal cow's milk dietary elimination in specific cases:
- IgE-mediated cow's milk allergy only if the infant is symptomatic on breastfeeding alone.
- Non-IgE-mediated associated symptoms only if the history and examination strongly suggest cow's milk allergy.
- Infants with moderate to severe eczema/atopic dermatitis, unresponsive to topical steroids and sensitized to cow's milk protein.
A plan for home reintroduction of cow's milk into the maternal diet for a period of 1 week is crucial to determine if the cow's milk elimination is responsible for the resolution of symptoms and subsequent reoccurrence upon reintroduction.
Considerations for Maternal Cow's Milk Avoidance
It is important to consider the potential consequences of maternal cow's milk avoidance, including reducing immune-enhancing factors in breast milk and the potential nutritional and quality of life impacts on the mother. Referral to a dietitian is advised for dietary education, along with calcium and vitamin D supplementation according to local recommendations. A maternal substitute milk should also be considered.
Navigating a Dairy-Free and Soy-Free Diet
For breastfeeding mothers, a dairy-free and soy-free diet might seem overwhelming but is manageable with the right resources and support. Cow's milk protein is a common reason for food sensitivity in babies, with soy being the second most common. Many babies with milk sensitivities also have soy sensitivities.
Read also: Optimal Nutrition: Vegetarian Breastfeeding
Foods and Drinks to Avoid
Eliminating dairy and soy requires careful attention to food labels and ingredients. Begin by looking at food label warnings, as products containing milk or soy must include it in the ingredient list or state "may contain," "processed in a facility that processes," or "processed on equipment with."
Dairy/Milk Products to Avoid:
- Milk (all types)
- Yogurt
- Cheese (including cottage cheese)
- Sour cream
- Cream
- Ghee
- Custard
- Pudding
- Half and half
- Nonfat dry milk
- Whey products (including whey protein and whey powder)
- Casein/Caseinate
- Milk chocolate and most other chocolates
- Butter products
- Lactalbumin
Soy Products to Avoid:
- Soy products (including soy protein and soy protein isolate)
- Soy milk
- Soy flour
- Soy yogurt
- Soy beans
- Soy nuts
- Soy caseinate
- Soy sauce and teriyaki sauce
- Vegetable protein, broth, gum, and starch
- Tofu
- Miso
- Edamame
- Soy oil and Soy lecithin are generally considered okay
Dairy-Free and Soy-Free Options
Despite the restrictions, many options remain available for breastfeeding mothers on a dairy-free and soy-free diet.
Drinks:
- Water (including seltzer waters)
- Milk substitutes (such as rice, coconut, or almond milk)
- Fruit and vegetable juice
- Soda
- Tea
- Coffee
- Milk-free hot cocoa
Breakfasts, Lunches, and Dinners:
- Eggs
- Fruits and vegetables
- Non-breaded meat
- Grains and starches (such as potatoes, rice, quinoa, and most pastas, ensuring no soy fillers)
- Beans (including hummus)
- Natural peanut butter and sun butter
- Chia seeds
Snacks:
- Salsa and guacamole
- Pretzels, popcorn, plain potato chips, corn chips
- Most cereals
- Gummies and hard candies
- Most sorbets
- Specific brands of snacks, such as LaraBar snack bars, HyVee wheat crackers, Nabisco’s triscuits and Wheat Thins, Eat Smart veggie chips, and Keebler and HyVee animal crackers
Condiments:
- Ketchup
- Mustard
- Miracle Whip
- Buttery spreads (a plant-based product that tastes like butter)
- Hershey’s chocolate syrup
Baking Ingredients:
- Butter flavored Crisco
- Guittard semi-sweet chocolate chips and Enjoy Life chocolate chips
- HyVee white cake mix
- Certain brands, such as Enjoy Life and Kinnikinnick, also make products for dairy- and soy-free diets.
Tips for Eating Out
When eating out, always inform your server about your dietary restrictions. Cross-contamination with milk is a risk in restaurants, so always inquire about ingredients, even if you have eaten the food or at the restaurant before. Avoid buffets where milk-containing items are present.
Reading Food Labels: Hidden Sources of Milk
Milk and milk products can be found in obvious forms like cream, cheese, butter, ice cream, and yogurt, but they may also be hidden in commonly eaten foods. The words "nondairy" on a product label indicate it does not contain butter, cream, or milk. Kosher foods labeled "pareve" or "parve" almost always indicate the food is free of milk and milk products. A "D" on a product label next to the circled "K" or "U" indicates the presence of milk protein. Processed meats, including hot dogs, sausages, and luncheon meats, frequently contain milk or are processed on milk-containing lines.
Lactose-free milk still contains milk protein, so always read the entire ingredient label to look for milk. Milk ingredients may be listed in the ingredient list or in a "Contains: milk" statement after the ingredient list. Advisory statements like "processed in a facility that also processed milk" or "made on shared equipment" are voluntary and not regulated by the FDA. Consult your healthcare provider about consuming foods with these labels.
Read also: Losing Weight Safely While Nursing
Cow's Milk Proteins in Breast Milk: What the Evidence Says
Cow's milk-derived proteins have been detected in human milk samples in various studies across different countries. Beta-lactoglobulin (BLG) is the most commonly measured CM protein, with bovine casein levels measured in fewer studies. Detectable quantities of these CM proteins are typically found in very small concentrations (nanograms per milliliter), significantly lower than the levels in fresh cow's milk.
Concentrations of CM proteins detected in breast milk vary widely, regardless of the mother's consumption and timing. BLG has been detected in only 42% of samples collected in observational studies and 52% of samples in interventional studies. Inter-women variations in BLG concentrations were found even within the same study after ingestion of the same amount of cow's milk, suggesting that physiological differences in food protein absorption and secretion into breast milk may influence these results.
A recent systematic review estimated that the probability of an IgE-mediated allergic reaction in a food-allergic infant breastfed by a woman consuming the relevant food allergen is less than 1 in 1000 infants. Specifically for CM, the probability of having sufficient quantities of CM proteins within a single breastfeed to elicit an IgE-mediated allergic reaction in a breastfed infant was estimated at one in 2893 infants. The probability of non-IgE-mediated reactions to food proteins in breastmilk is still unclear due to a lack of evidence.
Specific Considerations for Different Types of CMA
IgE-Mediated CMA
Current clinical practice guidelines do not recommend routine maternal CM protein avoidance for infant IgE-mediated CMA unless symptoms are evident whilst the infant is exclusively breastfeeding. However, practices vary.
Non-IgE-Mediated CMA
Some gastrointestinal manifestations of non-IgE-mediated allergies triggered by CM protein may be experienced by exclusively breastfed infants. The most common presentation is food protein-induced allergic proctocolitis, where symptoms usually start within the first month of life and include blood (sometimes seen with mucous) in bowel movements. Diagnosis relies on the resolution of infant symptoms upon exclusion of CM from the maternal diet for 2-4 weeks and symptom reoccurrence upon CM reintroduction.
CMA and Colic/Eczema
Colic and eczema are common in infants, but the role of food allergens in eliciting and maintaining symptoms remains unclear. If a maternal CM elimination diet is commenced for suspected CMA in an infant with eczematous symptoms, maternal CM challenge reintroduction is essential, as spontaneous resolution of eczema often occurs.
Emergency Preparedness
Always carry two doses of epinephrine medicine, such as epinephrine autoinjectors or nasal sprays. If you don't have epinephrine, talk with your healthcare provider.
A Note on Beef Allergy
A small number of people with cow's milk allergy may also develop a reaction to beef. Discuss this possibility with your healthcare provider.
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