Interview with Carl Bauer

What to do in case of a cow’s milk allergy?

A conversation with Prof. Carl PeterBauer, long-standing Medical Director at
the Specialist Clinic of Gaißach and the Chairman of the Gesellschaft
für Pädiatrische Allergologie und Umweltmedizin (Society of Paediatric Allergology and Environmental Medicine) and member of important expert associations, including the European Academy of Allergology and Clinical Immunology (EAACI).

Prof. Bauer, cow milk’s allergy (CMA) is currently the most frequently occurring food allergies in babies and small children. But its diagnosis is not very simple. What are its typical characteristics?
The symptoms of a CMA can be extremely varied and less specific. They can affect the skin, the gastrointestinal tract as well as the respiratory tract. In such a case, the immune system reacts to the foreign protein (immunogen) from the cow’s milk. In case of a reliable diagnosis, the elimination of cow’s milk protein from one’s diet
is necessary.

The symptoms of a CMA can affect the skin, the gastrointestinal tract as well as
the respiratory tract.

Can the reaction to the foreign protein occur at all if the baby is being exclusively breastfed?
Fully breast-fed infants only seldom develop aCMA. If that is still the case, the mothers should continue to breastfeed, but exclude milk and milk products from their diet. In order to avoid nutritional deficiencies in the mother, however, nutrition counselling and, if necessary, the intake of food supplements, especially calcium, is advisable.

And if the breastfeeding is discontinued? Conventional infant formula still based on cow’s milk, right?
Amino acid formulas (AAF) should be reserved for infants, who do not tolerate an extensive hydrolysate formula (eHF), which affects less than 10 per cent of all infants with CMA. In case of severe anaphylactic reactions and severe enteropathy, however, an AAF must be taken into account.

There are different eHF variants. What must particularly be taken into account when choosing formula?
Every eHF should be tested in clinical trials and must prove that it is tolerated by more than 90 per cent of all infants with CMA. Generally, eHFs with lactose must be preferred
to eHFs without lactose, unless a gastrointestinal manifestation with transitory lactose intolerance exists. At approximately 70 g/l, lactose is the largest solid component of breast milk.

Every eHF should be tested in clinical trials and must prove that it is tolerated by more than 90 per cent of all infants with CMA.

Special lactose-free formulas have negative effects on the gut microbiota of infants with CMA. Infants affected with CMA, who were fed an eHF with lactose, showed more bifidobacteria and lactobacilli as well as higher concentrations of short chain fatty acids (SCFA) in the stool than those who were fed a lactose-free eHF. SCFA stimulate the production of regulatory T-cells in the body, which enhance the immunotolerance. Apart from that, eHFs with lactose taste better than eHFs without lactose.

Are there other diet possibilities as well?
Partially hydrolysed infant formulas as well as sleep or goat milk are not suited for the dietary treatment of CMA. Soya milk for infants below the age of 12 months is not recommended either, even if it is tolerated by around 80-90 per cent of babies
with CMA, especially those older than 6 months.

For how long should a diet free of cow’s milk protein generally be continued?
It should not be continued for longer than necessary. This means that for infants, a provocation test should generally be carried out not earlier than 6 months to check whether the infant tolerates cow’s milk protein. For infants and young children with severe anaphylaxis, however, it must be decided individually as to whether and when a
re-provocation can be carried out, depending on the allergological re-evaluation (e.g. molecular IgE diagnosis).

A diet free of cow’s milk protein should not be continued for longer than necessary.

Is there any hope for the affected infants and their parents?
With the exception of severe anaphylaxis, a tolerance develops around in half the children with CMA at the age of 1 year and in over 90 per cent at the age of 6 years. With this perspective, it might probably be easier to cope with the symptoms of
the ailment and limitations during the treatment.