Cow's Milk Protein Allergy (CMPA)

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

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.