This article was first published in I CAN! newsletter June 2008 issue. Used with permission.
Food allergies in children have become common during the past decade, thus representing a major burden to our young. The term "food allergy" refers to adverse immunologic reactions to food, which primarily affects the skin and respiratory system (lungs, airways) and often the gastrointestinal (stomach, digestive) system too. However, there are gastrointestinal conditions that are non-allergic in nature, which can present with similar symptoms. Here we discussed with the gastroenterology specialists from the University Children's Medical Institute on some of the more common issues regarding the link between gastrointestinal and food allergies.
Prof Quak Seng Hock: On the basis of studies using cow's milk elimination and challenge, it is clear that a subset of infantile GERD is attributable to cow's milk allergy. The magnitude of the problem is not well-defined; it has been estimated that in 16% to 42% of infants, GERD is attributable to cow milk allergy.
A/Prof Marion Aw: Yes. It depends on the type of food and the type of "allergy". In young infants/babies, the symptoms of GERD and cow's milk protein allergy are very similar. In the former, it is acid refluxing into the food pipe that causes the inflammation (esophagitis) whilst in the latter; it is milk protein allergy that causes the esophagitis. In both cases, the symptoms could be vomiting/regurgitation, discomfort and arching.
Prof Quak: People often mistake lactose intolerance for milk allergy because they may cause the same reactions like stomach pains or bloatedness. But these conditions are not related. Cow's milk allergy is a true allergy to the protein found in cow's milk, which involves the immune system, while lactose intolerance is an inability of the digestive system to produce enough of the enzyme to break down the sugars in the milk. The mechanism whereby each occurs is entirely different, and a true allergy can result in potentially life-threatening conditions, whilst intolerance is very rarely life-threatening.
A/Prof Aw: Other ways that cow's milk allergy can manifest include acute onset of vomiting and diarrhoea, or more insidious/chronic conditions like persistent blood in the stool, GERD and chronic diarrhoea.
Lactose intolerance is by far more common than cow's milk allergy. Whilst many people may be lactose intolerant, it may be possible for them to still take a small amount of cow's milk without significant symptoms, whereas a person who has been diagnosed with cow's milk allergy should avoid it completely.
Fortunately, approximately 85% of young children often grow out their sensitivity to most of the common allergenic foods, including cow's milk, egg, wheat and soy, particularly with avoidance of the foods.
A/Prof Aw: Yes, it can be. However, the most common cause of colic is trapped wind, or a transient increase in intestinal motility. Food intolerance as opposed to food allergy is a more common cause of colic.
Prof Quak: The prevalence varies among the different racial groups. Local studies showed 2-3% of our children are found to be allergic to cow's milk.
A/Prof Aw: Yes. It is an allergy to "gluten", which is a protein primarily found in wheat, barley and rye. Gluten is found in post processed foods so it comes as no surprise that the symptoms of celiac disease become clear three to five months after a child first consumes these foods, typically between the ages of six months and two years (the common age for children to start eating processed foods). It presents over a period of months with fatty stools (steatorrhea), gassy stomach (flatulence), and weight loss.
Prof Quak: It is a life-long condition and those with coeliac disease would need to exclude gluten for the rest of their lives and be on long-term follow-up with their doctor.
Prof Quak: No. Although goat's milk casein is more similar to breast milk; cow's milk and goat's milk contain similar levels of the other allergenic protein and beta lactoglobulin, and can therefore still elicit the same allergenic reaction.
A/Prof Aw: Soy formula is ok. Occasionally, 20-30% of children with cow's milk protein (CMP) allergy are also allergic to soy protein. Lactose-free milk may still have traces of lactose and is still a cow's milk protein based formula. As such, it is ok for most lactose intolerant children, but not for children who are still allergic to cow's milk.
A/Prof Aw: We have to emphasise that there is more to eliminating cow's milk than just avoiding "liquid milk" in the child's diet. Milk and milk products lurk in common places like chocolates, processed meats, cheese, butter, cookies, ice cream, etc. Parents of patients must be instructed not only to avoid all obvious milk products but also to read food product ingredient labels for key words that may indicate the presence of cow's-milk protein, including "casein," "whey," "lactalbumin," "caramel colour" and "nougat."
Prof Quak: We cannot also undermine the role of breastfeeding in the prevention of allergic disorders. Studies have shown that prolonged exclusive breast feeding for at least 6 months compared to cow's milk feeding provides a long term allergy protective effect on the development of respiratory allergy during adolescence. Prospective studies on preterm neonates also demonstrated that early exposure to cow's milk formula compared with banked breast milk increases the risk of allergic disease by 18 months, particularly of eczema.
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