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CMPA and Lactose Intolerance - what are they and how to handle them?

CMPA and Lactose Intolerance - what are they and how to handle them?

A glass of milk morning and evening - isn’t that how most Indian children grow up? I know I did! But there are many children out there who are unable to drink milk or consume milk products due to allergies and intolerances.

In this article we will cover both Cow Milk Protein Allergy (CMPA) and Lactose Intolerance, both of which are quite common in infants and children and often confused with each other. We want to break them down and explain them to you, so here is what we will discuss:

  1. Does my child have CMPA?
  2. Is my child Lactose Intolerant?
  3. What is the difference between CMPA and Lactose Intolerance?
  4. Precautions to be taken with CMPA/Lactose Intolerance

WHAT IS CMPA? Does my child have CMPA?

CMPA is a cow’s milk protein allergy that occurs when the body’s immune system reacts to the proteins found in cow’s milk, casein and whey or both. It is one of the most common allergies in children. 2-5% of all children have CMPA.

There are two types of reactions to cow’s milk proteins -

  1.  Immunoglobulin E (IgE) mediated - IgE-mediated reactions are immediate.
  2.  Non-IgE mediated - The non IgE-mediated reactions are delayed and therefore, it is more difficult to diagnose).

Common symptoms of both types of CMPA include:

  • Gas
  • Bloating
  • Diarrhoea
  • Vomiting
  • Skin reactions like eczema and urticaria (hives)
  • Coughing
  • Wheezing
  • A runny nose
  • Vomiting
  • Chronic constipation
  • If it is very severe, it can also cause anaphylaxis or breathing difficulties in which case immediate attention is required.

If these symptoms appear immediately after consuming dairy (IgE), allergy testing can be done via a blood test. For delayed (non IgE) symptoms, an elimination diet is recommended to see if the symptoms are resolved after eliminating dairy for 2-4 weeks and then reintroducing dairy to see if the same symptoms return. For infants, a formula with cow’s milk proteins can be introduced and for older children, dairy based products. Then the parents can watch out for late reactions to the dairy consumption. If the symptoms reappear, then the CMPA diagnosis can be confirmed.

There is no treatment for CMPA. However, it can be avoided in some cases by breastfeeding. Studies show that exclusive breastfeeding between 4-6 months of an infant’s life reduces the risk of CMPA. But if your child does have CMPA, it can be managed. All traces of milk and milk protein have to be removed from the child’s diet. So if the child is breastfed, the mother needs to stop consuming dairy products as well. If the child is formula fed, they can be given extremely hydrolysed formula where the whey and casein proteins in milk are broken down. Hydrolysed formulas in India include Neocate and Zerolac.

In more severe cases, amino-acid formula is prescribed, where the milk proteins are broken down even further. Doctors do not usually prescribe soy-based formula, because babies with CMPA may have soy allergies as well.

There are several things other things apart from milk that need to be removed from the child’s diet:

  • All mammalian milk including goat milk, sheep milk etc.,
  • Cheese, cream, butter, milk based over-the-counter milk-based formula.
  • All labels need to be read thoroughly for foods purchased from outside
  • Medicines, cosmetics, washing powder, toothpaste too etc.

WHAT IS LACTOSE INTOLERANCE? IS MY CHILD LACTOSE INTOLERANT?

When a child is Lactose Intolerant, their body does not have an enzyme called lactase (or have less lactase) in their body. So the body cannot tolerate sugar in the milk called lactose.The lactose could be metabolised by bacteria to create discomfort in the gut.  

Being born with lactose intolerance is rare but it develops after 3 years of age as the lactase levels in the body drop. This is very common in Asians (including Indians) and Africans. It generally occurs from toddlerhood 3-5 years of age) but is more common in adolescents and adults as lactase levels drop. In fact, 40% of humans stop producing the lactase enzyme between the ages of 2 and 5.

Lactose intolerance can be primary or secondary. 

Primary Lactose Intolerance is when the lactose intolerance is long-lasting. 

Secondary Lactose Intolerance is when lactose intolerance occurs due to a gastrointestinal infection and goes away after a certain period of time. Lactose and lactose products can be consumed when the child gets better. The World Health Organization (WHO) suggests an infection should have lasted for 2 weeks before consideration of lactose intolerance. Your child will typically feel lactose intolerance symptoms between 30 minutes and two hours after ingesting milk or a dairy food.

Symptoms of Lactose Intolerance include:

  • Loose stools
  • Gas
  • Stomach pain
  • Bloating
  • Nausea and vomiting
  • Vomiting and diarrhoea can also cause the body to lose other nutrients, leading to malnutrition

Lactose Intolerance can be solved by simple steps which are similar to those for CMPA.

  • Breastfeeding mothers should remove dairy from their diets.
  • Lactose free formula should be given to formula fed children. These include the brands Isomil, Nan Lo-Lac, Nusobee and L-Free which are available in India.
  • All dairy products should be avoided for children who are on solid foods, so labels have to be scrutinised carefully.

At the same time, some Lactose Intolerant children are able to tolerate small quantities of cheese or yogurt but that is something to be tried with great caution. 

WHAT ARE THE DIFFERENCES BETWEEN CMPA AND LACTOSE INTOLERANCE

Both CMPA and Lactose Intolerance are milk-related and their gastrointestinal symptoms are often similar. So, as parents and caregivers, how do you differentiate between the two conditions?

  • CMPA is an allergic reaction to protein in cow’s milk while people who are Lactose Intolerant cannot tolerate lactose.
  • CMPA affects the immune system, while Lactose Intolerance does not
  • CMPA can affect the gastrointestinal system, skin and respiratory system while Lactose Intolerance only affect the gastrointestinal system.
  • CMPA usually starts in infants below 1 and is outgrown by age 3 in most cases while Lactose Intolerance starts later (after age 2) and affects even teens and adults
  • Formula fed children use hydrolysed or amino-acid formula if they CMPA while Lactose Intolerant children need lactose-free formula.

PRECAUTIONS TO TAKE IF YOUR CHILD HAS CMPA/LACTOSE INTOLERANCE

  • Make sure your doctor prescribes hydrolysed formula or amino acid formula or lactose free formula for an infant.
  • Make a diet plan for toddlers and children with their condition in mind. Avoid all forms of dairy.
  • Make sure you start reading labels on products before you purchase them to check for dairy.
  • When you travel or go out to eat, make sure the food is dairy free, even if you have to explain it to the staff repeatedly.
  • Explain the condition to your child’s school and their friends’ parents to make sure they don’t eat food or have drinks in dairy with them. Make sure they don’t eat the food other children bring.
  • Assess with your doctor every 6-12 months to check if your child has outgrown the allergy.
  • Worried about calcium? Talk to your doctor about calcium supplementation but remember that a lot of other foods have a lot of calcium - chia seeds, spinach and other leafy greens, almonds, sunflower and sesame seeds, broccoli, oranges, okra etc.

Remember that old Amul ad? “Doodh doodh doodh wonderful dooooodh…” Well if doodh aka milk is not that wonderful for your child due to allergies and intolerances, we hope the information in this article is helpful. Do share it with other families struggling with CMPA or Lactose Intolerance.

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