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Adverse food reactions: what’s the deal with Dairy? #003
THE DEAL WITH DAIRY
Adverse food reactions involving cow’s milk
Now that the major differences between the categories of adverse food reactions are clear we can dive into the nuances that make qualified healthcare professionals (HCP’s) so very important when discussing food allergies or intolerances.
Recently I read a comment in a social media post where the poster was asking the community for support in diagnosing/managing her daughter’s allergic reaction to cow’s milk. As I read through the comments, I was able to recognize that many of the community responses were about different diagnosis within one food allergen: cow’s milk.
As a healthcare provider that specializes in adverse food reactions, I was able to infer what the commenters diagnoses probably were and see how even the best of intentions may not provide the best support. There is a valuable space to learn from others in the community who are “walking the walk” but any health advice you’re considering implementing should always be reviewed with your trusted HCP prior to implementation.
The community can be a valuable resource to support patients with food allergies or intolerances, but it is not advised to implement advice without clarity from your healthcare provider.
This is incredibly important to ensure you are not acting inappropriately for your diagnosis. This brings me to my next VIP point – if you don’t know/ aren’t clear about your diagnosis (what your disease or condition is called) or if you don’t know/aren’t clear about your prognosis (time it will take to improve, likelihood of recovery or recurrence), ask.
ASK what your diagnosis is if you do not know or it isn’t clear.
Let’s compare a few adverse food reactions to cow’s milk
Food Allergy: Cow’s milk
A food allergy involves an immune system response.
Classic IgE-mediated food allergy
An immediate reaction (begins within minutes to 2 hours) typically involving one or more symptoms including hives, swelling, difficulty breathing etc. which has the potential to lead to anaphylaxis. Cow’s milk and other mammalian milk’s (and derivative products) are typically avoided 100%, with a few exceptions discussed with your HCP. This diagnosis requires an epinepherine autoinjector to be near the patient at all times in case of accidental ingestion. Trace amounts may lead to a reaction. It is impossible to predict the severity of reaction and reactions may range from mild to severe even within the same individual.
Subtype IgE-mediated food allergy: Alpha-gal Syndrome (AGS)
The main trigger for alpha-gal is actually meat, however many individuals with alpha-gal syndrome cannot tolerate milk products either. While the reaction is commonly delayed 2-6 hours after exposure the signs and symptoms can present as a classic IgE-mediated food allergy, with one or more symptoms including hives, swelling, difficulty breathing etc. and has the potential to lead to anaphylaxis. Alpha-gal reaction triggers are highly individualized, meaning trace exposure may severely impact some while not impacting others. Epinepherine autoinjectors are the first-line treatment for any anaphylactic reaction.
Non-IgE-mediated food allergy: Food Protein Induced Allergic Proctocolitis (FPIAP)
This is a common diagnosis in infancy and cow’s milk is one of the top triggers. There may be additional or different triggers for this diagnosis. The predominant symptoms are blood-tinged or mucous streaked stool which usually appears in the first few weeks-months of life. As cow’s milk is a top trigger, FPIAP is often initially managed by eliminating cow’s milk from the maternal diet if breastfed and switching to an appropriate formula if formula-fed. If symptoms resolve, consider (with MD) a reintroduction challenge to confirm cow’s milk as the trigger. If symptoms continue, discuss with your HCP which food may be appropriate to eliminate next. There are no medications prescribed.
Current allergy prevention recommendations advise patients not to delay infant introduction of the top 9 allergens and to continue to feed the allergen regularly. If an elimination of one of these allergens is necessary due to FPIAP in infants, discuss with your HCP when a reintroduction challenge should take place to prevent unnecessary delayed introduction and reduce the potential for other allergy development.
Mixed IgE/Non-Ige-mediated Food Allergy: Eosinophilic Esophagitis (EoE)
Cow’s milk is one of the top triggers. There may be additional or different triggers for this diagnosis. Signs & Symptoms may include difficulty swallowing and the feeling of food being “stuck.” Specific to children there may be increased food refusal, vomiting, abdominal pain, failure to thrive/weight loss, and/or malnutrition. Symptoms specific to adults may include regurgitation or chest pain. First the trigger must be identified. This requires an elimination diet and endoscopy, sometimes several, to determine if the correct food was eliminated. This is both an adult and pediatric disease. Depending on the number of food’s eliminated and the age and nutritional needs of the individual there may be a real risk for nutritional deficiencies and the support of a knowledgeable dietitian is advisable.
Food Intolerance: Cow’s milk
A food intolerance does not involve an immune system response.
Lactose Intolerance: An overview
Lactose intolerance is dose-dependent and case-specific. Dose-dependent means the type (cheese, yogurt, milk etc.) and quantity (portion size) of lactose has an impact on the severity of reaction. Case-specific means it’s an individualized response. more specifically, what one individual who is lactose intolerant may tolerate another may not. Another influence on the severity of reaction includes what other foods were consumed with lactose foods. Treatment includes a reduction or elimination of lactose products. Some may consider l supplementation, of vitamins and minerals that are reduced/eliminated when removing cow’s milk/ lactose products from the diet. Accidental exposure to cow’s milk will not cause a serious reaction, either via direct ingestion (took a bite and then realized it was a cheeseburger not a hamburger) or cross-contact (a spoon used to serve the mac-n-cheese was then used to serve your mashed potatoes.)
Lactose Intolerance: Primary
An intolerance to cow’s milk is a type of metabolic intolerance often related to an age-related progressive loss of the enzyme lactase, which breaks down the carbohydrate (sugar) lactose. This is a genetic, natural, and progressive reduction beginning in childhood which some individuals are more genetically predisposed towards. This is more commonly seen in adolescence and adults. This is not common for infants and in the early years. Lactose can be found in cow’s milk, as well as other mammalian milks (goat milk, etc.).. T
Lactose Intolerance: (Secondary/Acquired/Transient)
This type of lactose intolerance is secondary, to a primary diagnosis. Some examples are acute gastroenteritis, celiac disease, Chron’s disease, or any other illness, surgery, or injury causing mucosal damage to the small intestines. Once the primary diagnosis is managed often the lining of the small intestine heals and individuals begin producing lactase again, which leads to resuming tolerance of lactose containing foods.
Q&A?
What happens if you ignore lactose intolerance?
If you have a primary lactose intolerance your symptoms will continue when you eat or drink anything with lactose in it. If your lactose intolerance is secondary, once you resolve the primary diagnosis (acute gastroenteritis, controlled celiac disease, etc.) your gut mucosa has the opportunity to heal, and potentially you can resume consumption of lactose containing products as tolerated. Chronic symptoms that are ignored do have the potential to lead to other complications and a poorer quality of life. For example, chronic diarrhea can lead to malnutrition including dehydration, anemia, and unintentional weight loss.
Can I take lactose intolerance pills or lactose intolerance medication?
Yes, when taken as directed, some people find the lactose intolerance supplement to adequately provide the missing enzyme needed to digest lactose which relieves symptoms. This may not work for all individuals or in all circumstances. Lactaid pills are one example of a digestive enzymes supplement. (Not a sponsored post.)
Why is my baby so fussy? Can it be milk in my diet?
Is short, yes, it’s possible. To be more detailed, we don’t advise removing food unnecessarily from maternal (breastfeeding mom’s) diet or from an infant’s diet without just cause. I have often seen an unsupervised elimination diet in a breastfeeding mother spiral from milk to multiple other “possible irritants” in an attempt to soothe baby’s fussiness. This can lead to a serious decrease in quality of life as well as impact mom’s health. When you are concerned, ask your HCP for guidance instead of uncertain elimination diets. Consulting your HCP can also help you understand where the food source is in your diet, as there are times individuals believe they have eliminated a suspected irritant when in fact it is still regularly being consumed.
Nutrients of concern when eliminating cow’s milk
General Recommendations
For any restriction of cow’s milk, especially in pediatrics, calcium intake via non-dairy food sources or supplements should be considered. Plant-based milk alternatives are not nutritionally equal, and you should speak with your HCP to determine which is the best fit for you. Vitamin D should also be evaluated.
Unnecessary elimination of cow’s milk may impact a child or adult’s health and quality of life. If you need to avoid cow’s milk and/or milk products and have any questions please reach out.
At Weston Nutrition & Wellness Eva Weston RDN, LD, NBC-HWC is a registered dietitian nutritionist and national board-certified- health and wellness coach (NBC-HWC).
Eva has additional certificates of training in Adult Weight Management from the Commission for Dietetic Registration (CDR) & in Pediatric Food Allergy from Food Allergy Research & Education (FARE).
WNW is here to help individuals living with a food allergy or intolerance.