Allergies & food exclusions

If you think your child has an allergy it is important to speak to a GP, who may recommend a blood test, skin prick test, or exclusion of a particular food. A GP or pharmacist may recommend an antihistamine for your child. If your child is having a severe allergic reaction such as anaphylaxis, seek emergency medical attention.

With most food allergies, once the allergen is identified, children will be advised to avoid the food item. With immediate (IgE) reactions, this is a very strict avoidance. A health professional may recommend reintroduction of the food, as many children will grow out of their allergies before the age of 3.

Our paediatric dietitians do not regularly work with single allergy patients (except Cow's Milk Protein Allergy), as these families can usually manage safely at home under the care of their GP. Allergy UK and Beat Anaphylaxis provides lots of helpful information.

In the UK all pre-packaged foods must show a list of ingredients identifying the allergens. Restaurants and cafes are required to provide allergen information, which can help you make more informed decisions when your child has an allergy.

When weaning your baby it is important to introduce your child to small amounts of these allergens early on. If your family has a history of severe allergic reactions speak to your GP or health visitor in advance.

Breastfeeding: If breastfeeding and your baby is experiencing delayed allergy symptoms, we recommend that the mother removes cow's milk from their own diet. Breastfeeding is encouraged.

Formula Milk: If you are not breastfeeding, or using a combination of breast and formula milk, your GP may prescribe a hypoallergenic formula milk (extensively hydrolysed or amino acid based). These will be prescribed to babies up to 12-18 months of age.

Milk-Free Alternatives: When weaning your child onto foods, you should choose milk-free alternatives, like fortified plant-based milk drinks (e.g. soya, oat, pea, nut, coconut) and other milk-free alternative products (e.g. milk-free yoghurts and cheese). These foods can be introduced from 6 months and from 12 months, an alternative milk can be used as their main milk drink. It is important to always choose products fortified with calcium and other nutrients. By law, food companies must state cow's milk on food labels, usually in bold. When eating out, we recommend asking staff about ingredients and informing them of allergy requirements.

Note - soya milk is not recommended in babies under 6 months, and rice milk is not recommended in children under 4 and a half years.

To confirm diagnosis: You may be asked to re-introduce cow's milk protein into your babies diet via an at home challenge early on. This will only be recommended in babies with delayed (non-IgE) reactions. Do not challenge at home if your child has an immediate (IgE) allergy.

To build tolerance: At around 10-12 months of age, you may be advised to follow the milk ladder to re-introduce small amounts of cow's milk to establish how much milk your baby can tolerate, as most children outgrow CMPA. Do not do this at home if your child has an immediate (IgE) allergy unless advised to by a health professional.

The milk ladder consists of 6 steps. We recommend each step of the milk ladder is broken down into smaller portions and spending at least 2-3 days on each amount at each step, only progressing to the next amount once the previous portion is tolerated.

If your child reacts to step one we recommend waiting 3 months before re-trying. If your child reacts to a later step/portion, we advise waiting 6-8 weeks before re-trying this. It is important to continue to expose your child to the previous steps of the ladder, as your child can tolerate this quantity of milk protein. It's a good idea to have a suitable antihistamine at hand, should your child have a reaction (ask a pharmacist for advice).

Steps 1-3 are based on home-made recipes. Shop bought alternatives are as follows:

• Step 1: Malted milk biscuit starting with a third, then two-thirds and then a full biscuit as per the above process (as tolerated)
• Step 2: Mini muffin or fairy cake (without icing or chocolate chips) starting with a half and then a full one as per the above process (as tolerated)
• Step 3: Scotch pancake starting with a half and then a full one as per the above process (as tolerated)
• Step 4: Cheese
• Step 5: Yoghurt
• Step 6: Infant formula for under 1 year old, or whole cow's milk if over 1

Healthier Together North East and North Cumbria is a free website and app developed by local healthcare professionals to help parents keep their children safe and healthy, and includes more information about Cow's Milk Protein Allergy, including educational videos which may support you. Patient Webinars is a free website developed by Dietitians in Somerset which also provides educational videos on Cow's Milk Protein Allergy.

Milk-free Meals:

When feeding children with a Cow's Milk Protein Allergy, you may not know which foods to try, and the child's diet may be repetitive and/or expensive.

Substitutions:

There are many products now available that are a substitute for a food which usually contains milk. Below we have listed a number of brands to look out for, but be aware that many supermarkets will also offer their own-brand alternative products too. When shopping, remember to check ingredient lists for milk. Look for products with a Vegan label as these will be cow's milk-free.

• Cow's Milk (including whole, semi-skimmed or skimmed): Swap to plant-based alternatives like oat, soya, pea, coconut, nut milks. (Some brands include Alpro, Oatly, and Koko).
• Yoghurt: Swap to yoghurts made with soya, oat or coconut. (Some brands include Alpro, Oatly, Coconut Collaborative, Almond-based Petits Filous).
• Butter: Swap to spreads made with plant oils. (Some brands include Flora, Pure and Vitalite).
• Cheese: Swap to cheese made with soya, oat or coconut. (Some brands include Plant-based Philadelphia, Plant-based Cathedral City, Sheese, Violife, Wicked Kitchen).
• Cream: Swap to creams made with soya, oat or coconut. (Some brands include Alpro, Oatly, Coconut Collaborative, and Elmlea Plant).
• Deserts: Swap to desserts like milk-free custards (Alpro and Oatly Vanilla Custard), cheesecakes (GU Plant and Over the Spoon) and ice creams (Ben & Jerry's Non-dairy, Coconut Collaborative and Wicked Kitchen).

Ways to use plant-based alternatives within meals:

Many recipes that contain cow's milk can be adapted by substituting ingredients, to make them suitable for your child. You may find it easier to make some of these foods milk-free for the whole family, rather than making a separate portion for your child with CMPA, or freezing in single portions for your child.

First foods (from 6 months):

• First foods tend to have a mashed or pureed texture like cooked vegetables (like carrots and broccoli) and soft/mashed fruits (like banana, and cooked apples). A small amount of a milk-alternative may be mixed into these foods.
• Baby cereals (like baby porridge or baby rice) can be made up using either your child's formula or a plant-based milk-alternative. When buying baby cereal, remember to check the ingredients to ensure it doesn't contain any milk.

Progressing to meals (from 9 months):

Breakfast:

• Porridge: Mix 20g porridge oats with 130ml plant-based milk-alternative and microwave until cooked. Optional: stir in a spoonful of plant-based yoghurt to cool the porridge and make it extra creamy, and add some soft fruits. Recipe for 1 child's portion.
• Pancake: Mix 150ml plant-based milk-alternative, with an egg and 50g plain flour to make a pancake batter. Mix all ingredients together until a batter is made, cook pancakes in a frying pan with a little oil, or milk-free spread. Recipe makes 6-10 pancakes depending on size.
• Toast: Choose a bread that does not contain milk, toast, and spread a little milk-free spread (butter substitute), or milk-free cheese, or cooked egg on top.
• Cereal: Choose a cereal that does not contain milk, serve with your choice of plant-based milk-alternative.

Main Meals:

Base main meals around the food groups by including a protein, a starchy carbohydrate and 1-2 vegetables. Example meals include; pasta bake, roast dinner, cottage pie, mild curry with rice, a sandwich etc…

• Sandwich: Choose a bread that does not contain milk and spread a little milk-free spread (butter substitute) on it. Add your choice of filling such as milk-free cheese, ham, chicken, tuna and salad.
• Omelette: Whisk an egg with 1tbsp (15ml) plant-based milk-alternative, fry chopped vegetables like onions or mushrooms until soft, then add the egg mixture. Sprinkle with 20g milk-free cheese, cook until completely set. Recipe for 1 child's portion.
• Mashed Potato: To one boiled & mashed potato, add 10g of dairy-free spread and 50ml plant-based milk-alternative. Great for using on top of a shepherd's pie. Recipe for 1 adult portion, or 2-3 child portions.
• White sauce (used in lasagne, or creamy pies): Use 25g milk-free spread, instead of butter, with 25g plain flour and a 250ml plant-based milk-alternative. Place all ingredients in a saucepan and mix continuously. To make a macaroni cheese, add your choice 50g milk-free cheese into the sauce, and mix into cooked pasta. Recipe suitable for a family of 4.

Snacks (from 12 months):

• Milk-free yoghurt served with soft fruit.
• Milk-free soft cheese (like plant-based Philadelphia) spread onto a cracker, or served with veggie sticks to dip in.
• Other snacks that are naturally free from milk such as sliced fruits (banana, melon, strawberries) or veggies (avocado, cucumber, carrot).
• If buying pre-made snacks for babies/children, remember to check the ingredient list to ensure it does not contain milk.

Common symptoms of Coeliac Disease include:

• Diarrhoea, abdominal pain, bloating, wind, indigestion, constipation, vomiting, fatigue, weight-loss, itchy rash, numbness or swelling of hands and feet.
• Note: sometimes there are no symptoms present

In children these symptoms can often be confused with other illnesses such as a stomach bug, so Coeliac UK have produced a handy self-assessment for families.

When testing for Coeliac Disease, gluten must be present in the child's diet in order to get a diagnosis, therefore it's important to continue eating gluten until advised by a health professional to stop.

If Coeliac Disease is not treated this may lead to malnutrition, as the body is not able to digest food in a normal way leading to a lack of energy and nutrients. People with Coeliac Disease must follow a strict, life-long gluten free diet as even tiny amounts can cause damage to the body.

Treatment: The only way to treat Coeliac Disease is eating a gluten free diet. Your dietitian can give you practical tips and information to help.

If you have Coeliac Disease and gluten is eaten it can cause damage to the gut lining which can cause nutritional deficiencies and long term health complications. Therefore, it is very important that you have a gluten free diet, whether you do or don't have symptoms.

• If your child has  IgE-mediated (immediate) symptoms, skin prick tests, blood tests, or food challenge in hospital may be used to diagnose these allergies. These are done by an allergy specialist. If you are concerned about IgE allergies, speak to your child's GP or Paediatrician.
• Most CMPA allergies are  non-IgE-mediated (delayed). If your child has these symptoms, there are no specific tests to confirm. Diagnosis is made by excluding the food (in this case cow's milk protein) from the diet, to see if symptoms improve. If they do, cow's milk protein is then re-introduced to check that symptoms return.
• We do not recommend patch testing, hair strand testing, kinesiology, and/or vega testing as there is no scientific evidence for these.

• All breastfed babies should take vitamin drops/liquid from birth, containing vitamin D. Speak to a pharmacist about choosing an over the counter age appropriate supplement.
• Babies who are fed solely or partially from formula, do not need vitamin drops/liquid, unless they are taking less than 500-600ml of formula per 24 hours.
• Once your child is weaned off formula, and their intake of this is below 500-600ml per 24 hours, a vitamin supplement should be started. Speak to a pharmacist about choosing an age appropriate supplement.

• Speak to your child's GP or Paediatrician, as a trial of an amino-acid formula may be required.

• If your child has begun weaning, they could be reacting to another food. Keep a food and symptom diary, and speak to your child's GP or Paediatrician.

• Some brands have a stage 2 formula (suitable for use from 6 months), and others don't. Speak to your child's GP about this. Brands without a stage 2 are suitable for continued use.
• Brands with a stage 2: Nutramigen with LGG and Aptamil Pepti

• Up to 10-12 months, we recommend continuing to exclude milk from your child's diet. From 6 months, you may want to use a shop-bought milk substitute like soya or oat milk in meals such as on cereal, in white sauces or in mash potato.
• We recommend following typical weaning advice for a child of that age, including advice around when to start, textures of foods, and portion sizes. See NHS Start4Life for more guidance. NHS Start4Life have lots of very good weaning recipes, but remember to look out for ingredients containing cow's milk (like milk, cheese and yoghurt) and substitute these for milk-free alternatives.
• By law, food companies must state cow's milk on food labels, usually in bold, which is helpful when shopping and looking for which products to avoid.
• If your child has an IgE-mediated allergy, do not try dairy or the milk ladder until advised by your healthcare professional.

• When weaning your child onto foods, you should choose milk-free alternatives, like calcium fortified plant-based milk drinks (e.g. soya, oat, pea, nut, coconut) in their meals from 6 months and be used as their main milk drink from 12 months.
• Other milk-free alternative products (e.g. milk-free yoghurts and cheese) can be introduced from 6 months. 
• There is no recommendations for particular brands, and many supermarkets will sell their own-brand of milk-alternatives. However, it is important to always choose products fortified with calcium and other nutrients. There are 'growing up' versions of some alternative milks like oat and soya available. These are fortified with extra nutrients suitable for children.
• Note - soya milk is not recommended in babies under 6 months, and rice milk is not recommended in children under 4 and a half years.

• There is evidence that it is beneficial to introduce potentially allergenic foods early on (from 6 months) once weaning is established.
• Once general weaning is established, you can introduce wheat, egg, fish, nuts (smooth nut butter) and beans/pulses one at a time, ensuring 3 days with no new foods to spot any reactions. If your child has a reaction, seek medical advice as appropriate.
• Some children who react to cow's milk protein do react to soya and so we advise introduction of soya around 7-8 months starting with soya lecithin/soya flour and if tolerated, to then try soya yoghurts and then soya milk in meals. If your child reacts at a step of introduction, exclude those forms of soya.

• If your child has an immediate reaction that affects their breathing we would advise avoiding foods that have 'may contain' or 'made in a factory' with relation to cow's milk protein, unless advised otherwise by your child's GP or paediatrician.
• If your child has less severe symptoms, they can try these foods in their diet. If they do have a reaction to these foods, avoid from their diet.

• Lactose intolerance is not the same as a CMPA. Lactose intolerance is when the body cannot digest lactose (a sugar in milk) whereas CMPA is where the body reacts to the protein in dairy. In children with CMPA, avoiding just lactose will not help symptoms and full dairy exclusion is needed.
• Lactose intolerance most commonly occurs after gastroenteritis and is temporary. Babies are very rarely born with a permanent lactose intolerance. Lactose intolerance is treated with a lactose free formula and diet. Very often children will be able to tolerate some low lactose foods and even some small amounts of normal milk without symptoms.

• From 1 year, if a child is eating a generally well balanced diet and is growing well, we recommend weaning onto a calcium fortified plant-based milk drink (e.g. soya, oat, pea, nut, coconut). Rice milk is not safe to use in children under the age of four and a half.
• Goat, sheep and other animal milks are not suitable as they have similar proteins to cow's milk.
• The main purpose of milk over 1 is to meet calcium requirements and if 300ml of calcium fortified alternative milk was consumed per day (can be included in meals), this would meet requirements. If your child was having other calcium fortified alternative products (e.g. yoghurts/milky desserts/certain cereals and breads), even less milk will be needed. 
• If taste acceptance is an issue, you can replace one ounce of your child's prescription formula, with one ounce of the calcium fortified alternative milk. Once this is accepted, you can continue to replace ounce by ounce, until fully accepted. If needed you can use small amount of no added sugar milkshake flavouring, added to the alternative milk to improve the taste, and encourage acceptance.

• Most GPs will stop prescribing the formula from 12-18 months, as from 12 months most children can transition onto a shop-bought milk substitute like soya, oat, almond or coconut milk, as their main milk drink. GP practices differ between surgeries.

• Most children will grow out of their Cow's Milk Protein Allergy. For children with a non-IgE mediated allergy, we recommend starting the milk ladder from 10-12 months, to help your child build tolerance.