EP 30: Cow Milk Protein Allergy in Babies: Signs, Diagnosis, Formula Options, and When to Remove Dairy

Could your baby’s fussiness, spit-up, or unusual stools really be caused by cow milk protein allergy, or is dairy being blamed too quickly? In this episode, Dr. Liz Daniels explains what cow milk protein allergy, or CMPA, is, how it differs from a true IgE dairy allergy, and why normal newborn digestion can look like a food reaction. She shares the key signs parents should watch for, how CMPA is properly diagnosed through dairy removal and reintroduction, and why cutting dairy too soon may create more confusion. You’ll also learn about gentle, hydrolyzed, and amino acid formulas, when dairy may be safely reintroduced, the possible connection with soy, and what current research says about probiotics, gut health, and future food allergies. Most importantly, parents are reminded that babies with CMPA can heal, grow, and thrive.

What You’ll Learn:

• How to tell normal spit-up and fussiness from possible CMPA symptoms
• The difference between CMPA and a true IgE dairy allergy
• Why removing dairy too early may make diagnosis harder
• How dairy elimination and reintroduction help confirm CMPA
• Which formula options may be used for sensitive babies
• When parents may be able to try dairy again
• What CMPA may mean for gut health and future food allergies

Episode highlights: 
(4:06) When spit-up is normal and when CMPA may be suspected
(6:52) IgE dairy allergy vs. cow milk protein allergy
(10:37) How cow milk proteins may affect an immature gut
(13:46) How CMPA is properly diagnosed
(16:16) Why parents should not remove dairy too early
(17:48) Dairy elimination while breastfeeding
(21:29) Gentle formulas vs. hydrolyzed formulas
(23:33) Formula options for diagnosed CMPA
(24:30) When to try reintroducing dairy
(25:19) Soy sensitivity and amino acid formulas
(26:21) Probiotics, prebiotics, and long-term gut health
(28:48) CMPA and the risk of future food allergies

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Disclaimer: This podcast is for educational purposes only, not medical advice.

Transcript

SPEAKER_00 0:00

If you have a fussy baby who's spitting up all the time and you are thinking dairy needs to come out of the diet, before you eliminate dairy, listen to this whole podcast because I want you to understand what cow milk protein allergy is and is not, so that you can feel equipped and prepared if you really need that help. Welcome back to the Nutrition for the Earliers podcast with me, your host, Dr. Liz Daniels. I'm a nutrition first kind of pediatrician, and this podcast is for the parent who's second-guessing their grocery cart, worrying if their kid is gonna end up with the same food struggles that they once had. I love getting into the weeds of what kids actually need and then putting it into context of where they're at in growth and development so you can let go of the shame and guilt and focus on what actually moves the needle together. Let's get into it. Welcome back to the Nutrition for the Early Years podcast. I'm your host, Dr. Liz Daniels, the nutrition-focused pediatrician and your guilt-free guide for feeding your family well. Listen, I am pumped today because this is a topic I actually care so deeply about this particular topic. And I don't know that this, I don't think this is gonna be the only time I ever talk about this. So I feel I was feeling like hesitation and pressure before I jumped into this one, feeling like I needed to get everything in it and make it all complete. And I am taking a step back. And I'm just gonna say this is our first talk on calmic protein allergy. And my hope is actually that it generates questions and conversation because it's one that we probably need to have more conversations about. And it's one that I have a tremendous amount of respect for gastroneurologists, researchers, and the like who have helped us understand this better because it's still not fully clear. Like there's still gray out there, which is part of the reason that it is such a frustrating pain point for so many parents. And I um I just I'm really excited to share some some fun things with you. And my hope is, you know, I take care of a lot of families who um worry about this and we navigate this conversation. And when you're in that situation, you are so tired and so drained because your baby is like not sleeping and they're hardly eating and they're puking and they're pooping, and it's like it's really confusing, and you don't know if you're doing everything right or if you're doing everything wrong, if you're missing something, and you're so tired and drained that like when we talk about CMPA in the office, I don't think they're retaining much from the conversation because it's just like there's just overwhelm. You're so drained. When we're at the point of talking about dairy elimination, it's usually a month in and our babies are really tired, and our parents are even more tired. And so it feels like a lot of pressure, right? To like understand and go through everything. So today I want to talk with you about kind of what calmlic protein allergy is, what it's not, how we diagnose it, and sort of the loopholes there, that like the things that kind of get parents stuck in this worry cycle. And more importantly, what are the long-term implications for calmlic protein allergy? So the goal is that you can listen to this podcast and maybe come back to it if you're in the middle of sort of sifting through is this you or not? And hopefully it can be a resource to encourage you that all is not lost, you are not broken, your baby is not broken, things are going to be okay. All right, so you might be in this category where your baby is fussy and spitty and irritable, and you are sleep deprived, maybe a month in, and you're trying to figure out is this dairy? Is this not? And your pediatrician's telling you one thing, your friend over there is telling you another lactation consultant's telling you a third thing, and you're just like exhausted. Just tell me what to do. Now, there's a lot of hype over this diagnosis, and there's actually some really important things to understand about it. So today is an honest take on CMPA so that you can know when you need to get help and when you don't need to worry about this. All right. So I want to kind of set the stage that if you were listening to the last week's episode, we were talking about spit up. This is the perfect segue for this conversation because um spit up is totally normal, totally physiologic. And when we are, when we have a baby who's growing really well, they don't have any of the red flags, they're doing great, they just spit up a lot. We don't enter this territory or camp of is it dairy or is it something else in our like do we need to change a formula? Do we need to do something like that? Like that's not us, okay. If you have a baby who is either having really obvious signs of CMPA, like our classic signs, which are blood in the stool, mucus and blood in the stool, usually, that usually shows up at like by one month of life for a lot of babies. And then that's an easy one. Yeah, you're in the CMPA camp. We need to talk about what to do. We need to talk about what it is, when we're gonna reintroduce, we're gonna talk about this process. And then there's that's the easy one too, right? Like those are the obvious, like, yes, you're in the camp, or no, you're not in the camp. But what about our babies who are just plain fussy and spit up a lot, or maybe don't even spit up a lot, but they're just like really fussy, or they have really weird poops. And you're like, I don't know, am I in that camp? Am I not? Like it's confusing. And then the problem here is that a lot of changes happen in your baby's digestive tract in the first month of life. And how many appointments do you actually have with your pediatrician in the first month of life? Sometimes just two, like one at the newborn and one at one month. And that's a lot of time in between where there's a huge transition in their gut maturity, huge transition in their gut motility, a lot of transition in your breast milk. And so there's a lot of changes every single day. And so as a result, your baby is kind of unpredictable, at least to you. And that is absolutely normal to me. But this is the situation that a lot of parents find themselves in researching at two in the morning. What formula do I need to switch to? Do I need to change my diet? Is it the onions that somebody, you know, gave me in a meal? And that is tricky, okay? And guess what? I've been there. So I know it really, really well. And I want to encourage you because, you know, you're not alone. You are so not alone. And this is also not going to be forever. Let me walk you through what CMPA is and what it's not. Okay, mamas, if you have a fussy baby who's spitting up all the time and you are thinking dairy needs to come out of the diet before you eliminate dairy, listen to this whole podcast because I want you to understand what cow milk protein allergy is and is not, so that you can feel equipped and prepared if you really need that help. All right, so in the last episode, you know, we talked about spit up, right? And um I'm not talking about that today. What I'm gonna talk more about is like the word allergy, what calmic protein allergy is, and like on the inside and what's actually happening. Now, there's sort of two types of dairy allergy. And I want to be really clear about the one that I'm talking about, okay, and the one I'm not talking about, which is a is a good one to understand, but they are really different. So, you know, when you have like a peanut allergy or, you know, a shellfish allergy, those are IgE-mediated allergies where, you know, lips swell and there's breathing and you know, all of that kind of stuff. You need an epipin, those are type one. There's four types of allergies. There's it's the type one IgE mediated allergy, and that means it's the type of antibody that it's kind of signaling through. And that particular pathway is one that dairy can be in that pathway too. So there are some babies, a small percentage, about one-ish percent worldwide, of babies will have true cow milk or dairy allergy. And this is diagnosed usually if they are, say, for example, mama is um breastfeeding, and then she introduces a bottle, and the baby has trouble with the bottle, and it's like they get a they get hives, they sometimes vomit with it. That's weird, right? And so we send the baby to the allergist, we do a skin prick test, and or they do the skin prick test, and they find that, yep, indeed, it's an IgE mediated allergy. Then we take it out of the diet, we don't do dairy until much later. Allergist manages that. That is very different from cow milk protein allergy that we're talking about, where it's the protein itself that's creating the response, because it's a different type of an allergic response. And I want to make sure this is very clear and very distinct because in a dairy allergy, like a true dairy allergy, IgE-mediated dairy allergy, sometimes those kids don't get diagnosed until they're a little bit older. And especially in exclusively breastfed babies, this is hard to pick up on because I think a lot of parents will think, well, I've had it in my diet, therefore the baby should, you know, have shown me that they had symptoms of it. And that's actually not how that one works. That's like a really different process. And our breast milk, it's so tricky because um what's in maternal breast milk is not the same. Like the part of the allergenic component in true dairy allergy is not really coming out in the breast milk in the same way. So it has to come from the dairy food, meaning it has to be introduced in formula in order to elicit that response. And there's some really interesting research that it suggests that there's maybe an important window of exposure for dairy, just like there is for peanuts and eggs. I'm not going into that too much today, but just as a little like carrot to dangle that like really cool things coming. Again, thank you to the researchers who are spending their lives, work, and energy trying to understand this to protect us. And it's so cool. But I just think that this conversation is why I find this so fascinating. And it's taken me 20-something episodes when it was like I wanted it to be one of my first ones, because I just like there's so much to this, right? And it it gets me all excited. Anyway, um, the that is different, right? That is you need an allergist, and we need to have a, you know, that's a whole different thing. For the baby who's fussy and irritable, and mom is like, I think I need to eliminate dairy, according to my friends and Google, then, or ChatGPT, then um, that's who we're gonna talk about, right? So this is different. This is where the dairy that mom is consuming in her diet gets broken down by her gut. But some of the peptides, which are like if you have an intact protein, it's a whole globulin, like a whole, like think of it like a rubber band of a bunch of different, like a rubber band ball, kind of all together. And peptides would be if you were to trim sort of parts of the external rubber bands, like clip just a couple of rubber bands off, and you get these like little pieces of elastic, that would be like a representation of a peptide. And the peptide actually, there's a couple of them that will end up in the maternal breast milk. And they have sort of a like a cow origin, like they're the sh some of the amino acid sequence is that of cows. And um, that's not bad. That's not wrong. Okay, that's just that's that's okay. But the point here is that because it's bovine, because it's from a cow, when it comes through the intestinal wall of the very immature baby's gut, the immature baby's gut actually sees it as a foreign material. And thinking that it's foreign, it needs to evacuate it so it's not at the wrong place at the wrong time. And so the baby starts having diarrhea and/or vomit, and it kind of will go in both directions. Sometimes this is expressed in spitting up, being really fussy, being really irritable, having frequent bowel movements. Sometimes this is expressed in our skin looking really um bumpy and red and not just like normal newborn rash, but like it's a distinct kind of papillar, almost eczema-like look. Sometimes it is a chronic cough that doesn't want to go away. Sometimes it is just plain irritability in a baby without a lot of vomit or a lot of diarrhea, it can kind of vary. And this is why it becomes a really stressful thing. Because it's different day to day and it's not always predictable, but there's always something that you're like, this doesn't, there's you just feel it like as a parent, like something's not right. And so when I have a parent who comes to me like that and they're worried, and you know, for what it's worth, a lot of the time this is happening pretty early, like in the first month of life, or this is happening and maybe our growth is going really, really well. But I am especially worried about this if our growth is not going really well. Um, and I want to test and see if this is calmic protein allergy. The key here in understanding is that this type of allergy isn't really, it's not the same kind of allergy. And so there's not this like scary, immediate risk carried. Meaning, I'm not worried that if it's a holiday weekend and the baby is having these symptoms and we're worried about it, it's okay to wait until like that next opportunity to get into the office in a couple of days or a few days within the week. It's it's okay to wait to get seen and get the right kind of care instead of just jumping the gun and trying to change everything. Because we as pediatricians, we really need that objective information. And it's really helpful because there's this gap between in the literature, like what's truly diagnosed calmic proteinology and what's parental reported. And this isn't because parents are doing something wrong or lying or embellishing or being extra. That's not it. The reason I want to bring this up is because, and I've been in this camp, right? But like to actually diagnose calmic proteinology, it's not easy. We have to remove dairy from the diet fully and then put it back in and see if it helped. That's annoying. That's like two to three weeks of trial and error of this, which is a long time when you're already not sleeping really well. And that's frustrating. And I totally get that. So sometimes parents, you know, for whatever reason, maybe we don't have access, but there can be reasons that parents will switch the formulas. And without some of the information ahead of time of like knowing our growth and what's really going on, it can be hard to really be confident in a diagnosis. And in calmic protein allergy, you remove dairy and then that irritated lining heals, heals quickly. And then once you reintroduce dairy back again, the symptoms come right back and it's really obvious. So I say that just to say that with calmic protein allergy or calmic protein sensitivity, it is usually pretty clear that yes, this made a difference, and yes, this was the problem. If you are in that gray territory, it's probably not calmic protein allergy. And we want to call that out and name it, and not just hang out on a hydrolyzed formula or hang out on a dairy-free diet forever without really being confident in that diagnosis because those carry risks. So, what I mean here is that if you're in that, and we're talking lots and lots of parents whose babies, you know, we think might have chalmic proteinology, but we're not really sure. We're in this sort of gray zone. I'm talking to you because I want you to feel confident in that diagnosis. And the reason is that it gives us good direction on when to reintroduce dairy back. And it gives you confidence to take care of yourself. I remember when my babies were doing this, like my first two, especially. I ended up doing a dairy elimination with both of them and with my pediatrician's guidance because we were trying to decide what the reason for the issues were in the spit up. And so we eliminated dairy. It didn't really get better. And so we knew it wasn't calmic protein allergy. Second time around, we did the same thing. Didn't really get better. Okay. It's helpful to know. But, you know, often I'll have families who will ask me, like, well, my first baby had calmic protein allergy, or I think that they had calmic protein allergy. So I want to start out with a dairy-free diet right away. And I really like to caution you, please don't do that unless your pediatrician really feels strongly that you need to. And let me let me tell you why. Because Kelmic protein allergy is essentially like a safe, frustrating, uncomfortable, but it's like a safe situation. We want to understand. And it's not because we want to put your baby through unnecessary struggle, but we want to be clear. Because if we cut dairy before we have symptoms, then it actually can make it really confusing if as they're growing, they're starting to have symptoms for other reasons. And the problem here is that a lot of symptoms get blamed on CMPA that actually aren't it. And we want to take the right kind of care for you. And I think that most parents would agree you really deserve good care, right? Like we want parents to have that. And so it's okay to be curious and advocate if you're needing the support you need. But be a partner and make sure that you're getting understood because there's a reason in the thought process for this. There's actually a tool that's pretty helpful that we can use for screening for these symptoms, and we can actually sort of quantify how severe are those symptoms. And that tool can really help guide us on how significant the crying, the fussiness, the spit-up, the stooling changes, and all of those things can be attributed to CMPA. And if you're the right kind of candidate for a dairy removal. If you are, then we do a dairy removal. There's two ways to do this. So, number one, if we're going to remove dairy and mom is breastfeeding exclusively, then it takes a couple of weeks, really about a week, and you want to have the, you want to have time for then the gut to heal the next week. But it takes a while for the the dairy proteins to be fully evacuated from the breast milk. And so I will typically recommend that a mom either pump during that time and consider offering a hypoallergenic formula, if she wants to, you know, just like essentially switch right away, assuming breastfeeding is well established, while we're waiting to see and then go back to breast milk once we have made it to two weeks of dairy-free diet and see how that worked. So that can sort of be a fast track. And when we do that, if it truly is CalMut protein allergy, babies will often feel better pretty much right away, like within a few days. They're feeling like, oh, this is a noticeable difference. And then by two weeks, you're like, oh yeah, I think this is good. And then you really know when you give them a bottle of a regular formula or breast milk that has dairy in it and they're fussy six hours later. Then you know, right? Like, oh, okay, yeah, definitely. And that's a really great place to land. Okay. Here's the other thing I want families to understand is that that protein that's in there isn't like damaging the gut. I think a lot of parents get worried and they think inflammation and it's bad. And so there's going to be all these gut health problems forever. And it's it's really not like we don't have any literature to really and a home run say that these babies who have calmic protein allergy, when they're treated properly with the right either formula or breast milk changes, they actually recover beautifully and they can be just fine and they outgrow this in time. So they're not that fragile. It's not that we're going to hurt the baby by doing that elimination diet. The purpose is actually understanding so we have the right diagnosis. The other part here is that formula is expensive. And so if you're in a situation where you're using formula and you don't need to be using one of the hydrolyzed formulas, I wouldn't want you to because it's super expensive and it can be really hard to find sometimes, especially if your baby is really particular about which one they need to be. We're going to talk a little bit about those in just a second, but just know that there's a reason for that. Okay. Couple of other things I like families to understand and what's kind of like some myths here. You know, I think a long time ago, it wasn't uncommon to see, you know, pediatricians or family practice doctors who are, you know, taking care of babies do like a blood test in the poop. There can be some help in using that as a tool in building the case for calmic protein allergy, but it's not how we diagnose calmic protein allergy. So if your doctor doesn't do that, that's okay. It's not something that I routinely do when I'm diagnosing calmic protein allergy either. Sometimes it's there as a useful tool to kind of understand what's going on in the diaper, but it's not a regular indicator and it's not the most reliable indicator for true calmic protein allergy. The other thing I like coming to understand is that, you know, you're kind of in a mix of a lot of information that has accumulated over the years and can pass down from some of it, you know, old studies that we found maybe aren't totally true, and some from maybe marketing that it's going to be better if they're on a hypoallergenic formula. And this is kind of where there's a little bit of um gray area. So hear me when I say there is so much in the way of like understanding what's working well for your baby, being like a relationship with your pediatrician. And that is the key. Like the key to having a good outcome here is having a good relationship with your pediatrician so they know what you're feeling, what you're seeing, what you're feeding them. And that feedback is really, really helpful. If your baby's super fussy and you wanted to, for example, try out a gentle formula, you don't need permission to do that. That's totally fine. The gentle formulas, in case you're curious, are things like um goat milk formulas. They are called gentle or partially hydrolyzed formulas. And there's pretty much every brand, every manufacturer for formula is going to have a gentle product on their line. The key here is knowing what it is and what it's not. Okay. I mentioned that an intact protein. Which is what's kind of triggering some of this response in a baby is from a peptide that's in the intact protein when they have KalMic proteinology. And it's like this rubber band ball, like a multicolor rubber band ball. And the gentle formulas have done the same kind of thing where they've partially broken up little bits of the rubber band on the outside. So you have peptide chains, plus they like piece of the protein structure. When different formula companies do that, there are different recipes, right? Like we don't all like Doritos and Tostitos have to be different chips. They have different recipes. Different formula companies, I kind of look joke that the formulas are like the chip aisle, where like they have to have their own flavor in their own recipe, but they're all really good. And there's reason for them. Okay. So this is not a one is better than the other. This is a understand that the ingredients and the process of getting there are purposefully different. So sometimes families will tell me, well, they did really well on this one brand and not on that one brand. And I used to be like, that doesn't make any scientific sense. But really, it probably does. And it's okay. So if that's your observation and your baby does really well on a gentle formula, that's not calm up protein allergy. And it's also not lactose intolerance. Okay. But a lot of the products that are gentle will have a lower lactose uh formulation. So just be mindful of that. Now, if you've tried a gentle formula and it's not working really well, and it's like, okay, now it's time to go to the next layer and we want to figure out if it needs to be hydrolyzed, then there are sort of three primary products, and I'm going to use the brand names. None of this is sponsored, but none of I want you to understand like these names because they do matter for this particular diagnosis. It would be um Similax Alamentum, infamil's neutramogen, and nutritia's pepticate. Those are three different products that have different ratios of casein to whey. They have different formulations. They're all equally safe and all appropriate for calm protein allergy, but they are different. And again, I will have babies that sometimes really do well on one product over another. And you don't always know until you try. So it's okay if your experience is your experience. You don't have to have a reason or justification for that's the one that works, but if it does, it does. And then you know, okay, we tried it and it was much better. And then we did a day of the regular formula and it was awful, and nobody wants to go back to that. And then you know. So then the next question becomes well, how long do we stay on this product for? And that's where the literature is truly changing. There are a lot of traditionally, we would say you reintroduce dairy at a year because that's the time that the gut maturity has sort of gotten to a place where it no longer recognizes that peptide as a foreign substance anymore. Well, I think that you can do that probably a little earlier. Some people start as early as six months as a trial of reintroduction. Some people start as early as nine months. And I'm saying this to you because inevitably, at some point, either somebody buys the wrong formula, the daycare gives the wrong bottle, or you accidentally eat dairy at a wedding and you come home and realize after your baby's really fussy, if something accidentally happens, your baby's okay. It's okay. Totally okay. It's safe and take it as information. Don't feel blame and don't feel like you ruined them. It's gonna be okay. Now, there are some babies that are extra sensitive. And in that category, they also have a little cross-reactivity with soy. So notice that when I suggested if your baby's really fussy and you go to a gentle formula, I didn't say soy products. And this is why. Because if your baby has an allergy to dairy, there's actually a pretty good chance that they're gonna be sensitive to the same peptides that are in soy products. So I don't recommend soy as an alternative when we are looking at a calm protein allergy. Now, as your baby gets older, you know, well, let me say one more thing about the sensitive kiddos. Sometimes those babies need to go on to um like an amino acid formula. And if that's the case, then we're pulling in our gastroneurologist, we're making sure that we're gaining weight appropriately. It's a little bit more involved because sometimes we need a prescription for some of those formulas because they're so, so specialized. And thank goodness that we have products to do that with that babies can still grow and thrive and be amazing humans with. Now, the other question I'll often get is gosh, if there's all that inflammation there, don't I need to be worried about their gut health long term? And I love that question. But I think that that one's a little bit of, I wouldn't quite call it hype, because there's a lot of value in our early microbiome. There really is. It's not that there's hype, it's that we really don't have a great answer. You see, a lot of the formulas that have prebiotics will actually use some of the components from the dairy to create those very nice little prebiotics. And when you're on a hydrolyzed formula, most of the time you're not gonna be able to get that. So if you have the option to breastfeed and you can and you can be dairy free, then that is typically our preference because you're still gonna be receiving some of those prebiotics from the breast milk. Whereas in the formulas, you're not gonna be able to do that. That's not a don't do it. It's more of just a like when families ask me this question, I think it's a little nuanced. And so I like to go there with the nuance. Now, can you do external pre and probiotics? Yes, but you need to be thoughtful because some of those pre and probiotics have also used the same substrates that might trigger a little bit of that CMPA in your baby. So it's important to understand if it's safe for your baby or not. That's pretty product specific. And it's worth either reaching out to the manufacturer or like really making sure checking with your doctor and seeing if you can find out. But um, the broader question is do these babies benefit from probiotics, like externally added? Unfortunately, we don't have any data that really confirms that. Do we think there's possibly a role? I'm sure there probably is, but it comes down to knowing what strain at what dose and how is that delivery method? Because, you know, probiotics have to survive the whole GI tract before they get down to where they need to live and thrive, and they need the prebiotics to help support them. So it's not an easy question to answer or an easy question to study to get the research to tell us the answer. And I hope that someday we are there. But I just like to remind families that no, your kid's gonna grow. And by the time we're able to introduce solids, we can think about those probiotics and prebiotics when we're introducing solids then. So don't worry about it right now. Heal their gut, just make sure we have the right formula, right breast milk, and love them and know that you are doing everything you can to support your baby and everything is going to be okay. They are going to grow and they're going to be beautiful and amazing, and it's all gonna work out. And my last little myth that I just want to kind of offer you is that, you know, families will sometimes ask me, if my kid had Kelmate protein allergy, are they gonna be at greater risk for food allergies? No, is the short answer. But if your baby has eczema or has other reasons that they're at higher risk for food allergies, we want to make sure we're capturing that window. So it's worthwhile to have those conversations about early exposure, early introduction with our other allergenic foods. So definitely encourage that and want to support you in your own journey along this way. Thank you so much for listening all the way to the end. I really appreciate you. If you have questions, please reach out. I'd love to hear from you, hear what you think, hear your stories of success, or some of the challenges you've had along the way. See you guys next week.