Complete Guide to Cow’s Milk Protein Allergy and Baby Reflux

Both my babies had CMPA, and it was a difficult time for us as a family. Not only did we have the usual sleepless nights, at a time when time and energy were scant and precious, we suddenly had to change our diet completely, and restaurants became daunting. I’m pleased to say in the years since I had my second baby, there are so many more options which are readily available, and restaurants have had to up their game, but that doesn’t take away from the added anxiety CMPA causes. ⁠
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Cows’ Milk Protein Allergy (CMPA) is an allergy to the cows’ milk protein found in all dairy products such as milk, butter, cheese and yoghurt. CMPA is most commonly diagnosed because it leads to the symptoms of baby reflux.⁠

I first wrote this article for Dr Brook Vandermolen, and with permission have published it here as well.

Cow’s Milk Protein Allergy (CMPA)

The most common allergy that underpins reflux is due to a reaction to a protein in cows’ milk called Cow’s Milk Protein Allergy (CMPA). Babies with CMPA need to be assessed by a qualified medical practitioner. If your baby has CMPA then all items with cows’ milk protein need to be avoided and in 50% also soya.

Lactose Deficiency is different to Cow’s Milk Protein Allergy

CMPA is not the same as lactose intolerance, which is very rare in babies, where there is a lack of ‘lactase’, the enzyme needed in the gut to break down the naturally occurring lactose sugars which milk contains. Changing to lactose free products is helpful in lactose intolerance, since it removes the lactose, which cannot be digested and causes symptoms. Instead CMPA is an allergy to the actual protein in milk, so changing to lactose free products will not be helpful.⁠

Can you prevent Cow’s milk protein allergy?

Sadly, as yet, we don’t know how to prevent CMPA, but it is fine to consume dairy during your pregnancy. ⁠ If you have a family history of allergy, hay-fever, asthma, or eczema your baby will have a higher risk of developing CMPA. ⁠

When to see a doctor

• If you have concerns about your baby

• If the regurgitation becomes more forceful, and the vomit is expelled with such force that it lands some distance away.

• If your baby brings up milk that is green or yellowy green, or if it looks as though it has blood in it.

• If your baby has any new problems.

• If your baby is very distressed and you can’t soothe them.

• If you baby can’t feed.

• If you baby isn’t putting on weight.

What will the doctor do

Your doctor will take a history and find out more information about your baby, the vomiting, any additional symptoms and feeding. In some cases, they might arrange for your baby to have some investigations if there is doubt about the diagnosis, or additional concerns.

Can I change to goat’s milk instead?

Goats’ milk has proteins which are very similar to the cows’ milk protein and so changing to goat milk is very unlikely to help in a baby with CMPA. Approximately 50% of babies with CMPA will also have an allergy to soya as well, since the soya protein is very similar to the cows’ milk protein. Therefore exclusion of soya may well be required.⁠

What your doctor might prescribe

Previously when a baby was diagnosed with reflux they might have been treated first with anti-reflux medications. A few years ago, this changed and now first line treatment is to exclude an allergic cause. This will mean an exclusion diet for the mother while breastfeeding for at least 4-8 weeks to determine if the symptoms improve. In cases where there are still significant symptoms, your doctor might consider a trial of anti-acid medications such as ranitidine or a proton pump inhibitor such as lansoprazole or omeprazole; however, there is limited evidence that these work in children under 1 year of age.

If your baby has been diagnosed with CMPA, have a look at my blog about Plant Based Milks and what to look out for when you are choosing one.

What is reflux?

Reflux is the regurgitation of most commonly liquid back up the oesophagus/food pipe/gullet, from the stomach. There are two types of reflux, ‘physiological / functional’ and ‘non-physiological’. Up to 4 out of 10 babies will have reflux and 9 out of 10 of these will get better by themselves with time.

Physiological reflux

Most babies have a degree of physiological reflux, because they spend most of their time lying on their backs. They also have an under-developed muscle ring (sphincter) at the top of their stomach, which fails to prevent regurgitation. This type of reflux is very common, the baby is well, putting on weight appropriately and will naturally improve by their first birthday, as the sphincter muscle develops and the baby becomes more upright.

Non-physiological reflux

This refers to reflux which is impacting on the health of the baby and is frequently called Gastro-Oesphageal Reflux Disease (GORD). Recent evidence suggests that allergy, in particular to Cows’ Milk Protein, is the frequently the cause. Babies with this type of reflux may have a number of additional symptoms such as:

1. being difficult to settle
2. arching after feeds and drawing their legs up
3. explosive poos or constipation
4. blood in their poo
5. making rattling noises
6. poor weight gain
7. coughing or gagging during and after feeds
8. frequent vomiting after and between feeds
9. eczema before 6 months of age
10. cough

Since the regurgitated milk is also mixed with stomach acid, this can create discomfort for the baby. Some babies respond to this discomfort by being put off feeding (termed oral aversion), or want to feed all the time, in an attempt to keep down the acidic milk, and soothe their oesophagus/food pipe.

Most babies will vomit the regurgitated milk, but a minority do not, and this is termed ‘silent’ reflux. These babies often have milk in their mouth between feeds, from regurgitation even if they don’t vomit.

Simple tips to help Reflux

There are a number of really simples positional changes that can help your baby with the symptoms of reflux:

1. elevate the head end of the cot
2. avoid placing baby flat even for changing
3. hold baby upright after each feed for approximately 20 minutes
4. don’t bounce baby, as this is like ‘shaking a milk jug’, instead soothe by stroking, or swaying
5. try a dummy, which helps by drawing the milk down the oesophagus, because of the stimulation of sucking (non-nutritive sucking)
6. if you are breastfeeding and have very fast let down or very generous supply, try feeding against gravity by lying on your back, to slow the flow down

I found that a wedge, placed under the cot mattress was really helpful to elevate the head of my baby. Remember to abide by the Lullaby Trust Safer Sleep Advice.

See this blog for more information about the dos and don’ts of dummies.

Other Conditions That Can be Confused with Reflux

Regurgitation or vomiting can be the final common pathway for a number of other less common medical conditions, ranging from the benign to the more serious including: anatomical problems such as malrotation or hiatus hernia, and infections of both the gastrointestinal system and non-gastrointestinal system. Over supply of breast milk, while not a medical condition, can also mimic the regurgitation seen in reflux. Additionally, because of the discomfort associated with acid reflux, babies with reflux can be particularly unsettled. Babies with a tongue tie are at risk of ‘aerophagia’, which means swallowing air as they feed, leading to discomfort from wind, that can mimic the discomfort seen with reflux.

Colic

Colic is used as a catch all term for a baby who is unsettled between 6 weeks to 6 months old and they cry more than 3 hours a day, 3 days a week for at least 1 week. If you are concerned your baby is irritable, or you are unable to soothe them, you should seek medical advice.

Colic and reflux often start at a similar time and can be confused, but a baby with colic has none of the symptoms associated with reflux, and the diagnosis should only be made if your baby is otherwise well. There are some simple strategies you can try to soothe your baby with colic:

• Swaddle
• Rocking
• Cuddle them
• Winding them
• Giving them a warm bath
• White noise

There is very little evidence to support the use of anti-colic drops or manipulating the bones in your baby’s head (cranial osteopathy).

If your baby has been reviewed by a doctor and found to be otherwise well, you might find the purplecrying website useful.

Thanks to Brooke (@theOBGYNmum) who first posted my blog, and describes how she coped with her son who had reflux.

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