Cow Milk Allergy

All standard infant formula (eg SMA, Comfort milk, Cow & Gate, Aptamil) contains cow’s milk protein.

For children with mild to moderate delayed symptoms

It is important to try your baby with milk now. This is to make sure that any improvement in their symptoms is due to cutting out milk (and they have a cow's milk protein allergy) rather than for any other reason.

• Do NOT start this challenge if your child has had either immediate symptoms (within an hour of eating/drinking dairy) or a positive blood or skin test (specific IgE or Skin Prick Test) to cow's milk.
• Do NOT start this challenge if your child is unwell e.g.
  • Has a cold or any other lung infections or breathing problems
  • Any tummy/bowel problems e.g. tummy ache or loose nappies
  • Any 'teething' signs that are upsetting your child
  • Atopic dermatitis (eczema) has flared up
• Do NOT start this challenge if your child is having any medication which may upset their tummy, e.g. antibiotics
• Do NOT try any other new foods during this challenge

Try to write down what your child eats and drinks during the challenge. Also note any symptoms e.g. sickness, loose nappies, rashes or any other changes in their atopic dermatitis.

Home challenge for a formula fed baby (those taking formula with or without some breastfeeds):

Follow the advice in the table below: each day, increase the amount of cow's milk formula given in baby's FIRST bottle of the day - (use the scoop provided in each).

A Practical Example of a Reintroduction in a Formula Fed Child

If you have not seen any symptoms in your child by day 7 (when you have completely replaced one bottle a day with cow's milk formula) you can give your child cow's milk formula in all bottles.

Home challenge for an exclusively breastfed baby:

Simply start eating dairy products to the same levels as before starting on the diet.

All babies:

If you see any obvious symptoms e.g. sickness, tummy pains, a rash, itching, STOP the challenge. Go back to the previous formula your baby was taking or to a milk free diet if you are breastfeeding, and inform your GP.

If no symptoms occurs within 2 weeks of your child having more than 200ml (almost 7fl.oz.) of cow's milk formula per day, your child does not have cow's milk allergy.

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This dietary advice gives general information to help you make the recommended changes to your diet while you are breast feeding and while your child requires a cow’s milk free diet.  If you need more detailed advice, please ask your doctor to refer you to a Dietitian for advice on your diet.

Breast feeding is best for your baby.  Unfortunately, the cow’s milk protein you eat can pass through to your breast milk.  This means that your baby can be exposed to cow’s milk protein from your breast milk if you ingest cow’s milk and cow’s milk products.

Occasionally, breast fed babies can react to milk proteins transferred in breast milk from the mother’s diet. If your baby reacts to cow's milk proteins in your breast milk, you will be advised to avoid milk (dairy) whilst breastfeeding. This is usually done as a trial for between 4 to 6 weeks to see if your baby’s symptoms improve. If they do not, and you were following the diet strictly, you can return to your normal diet.  If your baby's symptoms improve whilst you are on a cow's milk free diet, you would be asked to reintroduce cow's milk back into diet after 4-6 weeks (Home challenge) to check for any return of symptoms.  Should there be return of symptoms on home challenge, non-IgE milk allergy is confirmed.

If your baby develops symptoms only on introduction of cow's milk in weaning/cow's milk containing feed (infant formulas), we encourage you to return to full breast feeding, and start milk free weaning. It is important to remember that if your baby does not have any symptoms on breast feed, while you (mother) are consuming cow's milk, you can continue to consume cow's milk containing foods in your diet, and initiate cow’s milk free weaning.

A small proportion of milk allergic children may also react to soya proteins in which case this also needs to be avoided in maternal milk.

If you have any other allergies or medical conditions, please seek further advice.

It is important for you to have a milk free diet- please check food labels and avoid products containing “Milk”.

Suitable alternatives to cow's milk are Calcium enriched soya milk, oat milk, nut milks (cashew, almond, hazelnuts), pea, coconut,  hemp milk etc.

Ingredients to watch out for on labels:

Milk and milk products will be indicated and 'milk' in bold on the ingredient list, check the labels.

Calcium and Vitamin D

• When breast feeding, you require approximately 1250 mg of calcium per day.  This can be difficult to obtain from your diet when you are avoiding cow’s milk and cow’s milk products.
• To achieve a sufficient intake it is important that you try to use a calcium enriched cow’s milk substitute (for example soya drink, oat drink, rice drink, nut drink, hemp drink) and include non-dairy sources of calcium in your diet.
• Other mammalian milks such as goat milk and sheep milk and their products contain proteins similar to cow’s milk and should also be avoided.
• It may also be advisable for you to take a calcium supplement (1000 mg/day), please discuss this with your doctor.
• The Department of Health recommends that all breast-feeding mums take a 10µg Vitamin D supplement which can be obtained from pharmacies or health food shops.

Calcium content of foods

Example of how to meet 1250 mg Calcium per day

Why a milk free diet?

Around 3% of children develop non-IgE Cow's Milk Protein Allergy (CMPA). In most cases a strict cow's milk free diet is needed to manage the symptoms of  the allergy. This information will help you avoid cow's milk whilst making sure your child gets all the nutrition they need to grow and develop.

Which milk should be excluded?

Avoidance needs to include fresh, UHT, sterilised and dried cow’s milk. The diet should be free of cow's milk protein (casein and whey) and milk sugar (lactose). Other mammalian milks are not suitable alternatives to cow's milk as their protein structure is similar and may still cause an allergic response. Therefore, do not use milks such as goats, sheep, camel and buffalo milk.

Replacing cow's milk

Cow’s Milk is an important source of nutrition for babies and children.  If you breast feed your baby, continue to breast feed, while following a milk free diet. If your baby is taking an infant formula, it needs to be a milk free formula.

Important to remember - occasionally, breast fed babies can react to milk proteins transferred in breast milk from the mother’s diet. If your baby develops symptoms only on introduction of cow's milk in weaning/cow's milk containing feed (infant formulas), we encourage you to return to full breast feeding, and continue with milk free weaning. It is important to remember that if your baby does not have any symptoms on breast feed, while you (mother) are consuming cow's milk, you can continue to consume cow's milk containing foods in your diet.

Suitable infant formula free of cow's milk proteins

Your baby may have been prescribed a formula such a Alimentum, Althera, Nutramigen LGG, Aptamil Pepti (or more rarely Alfamino, Puramino, Neocate or Elecare). They should continue this until 12 months or as advised by your Health Care Professional.

Most babies aged 6-12 months need approximately 600ml (20oz) each day to ensure they are meeting their nutritional needs, especially Calcium.

Over 1 year this amount reduces to approximately 350ml (12oz).. Check with your Health Visitor or Dietitian if you have concerns about your child’s  calcium needs.

Other alternatives to cow's milk for cooking

A variety of plant based calcium enriched cow's milk substitutes fortified with calcium are available to buy from most supermarkets. They can be used in cooking from six months of age or as a main drink after one year old.

Examples include:

Oat milk

Soya milk – soya milk should not be given to babies under 6 months of age.  Soya can be introduced as part of weaning in the form of soya yogurts/pudding or cooking after 6 months if soya is safe for your child.  Some children with non-IgE milk allergy may also be allergic to soya.  Please be guided by your dietitian. Soya milk can be used as a main drink after 1 year of age.

Nut milk alternatives (almond, coconut, cashew, hazelnut),

Hemp milk/pea milk/coconut milk  

Rice milk should not be given to children under four and a half years old. This is due to concerns about arsenic content.

Babies with milk allergies can and should have nuts (in the form of nut butters) introduced into their diets to reduce the chance of allergies in later life. (as long as they have not had any allergic symptoms)

Always choose a milk alternative that is fortified or enriched with calcium - they should provide at least 120 mg of calcium/100mls. Organic versions do not usually have calcium added - check the label.

Foods to avoid

Look for the list of ingredients printed on the package and avoid foods which have 'milk' in bold on the label. When eating out, food outlets need to provide you with allergy information by law, so always ask.

Check with your pharmacist about tablets or medicines which may contain milk protein and/or lactose.

Introducing solids (weaning)

Starting solids for a baby who has Cow's Milk Allergy should be the same as for a non-allergic baby, however you must not give any foods that contain cow's milk or dairy products (example yogurt, fromage frais, cheese, cream or butter).  You should aim to start solid foods at around six months, but not before four months (17 weeks).  If your baby is premature, check with your dietitian about the best time to start.  For general information on introducing solids, check the NHS choice website page your baby's first solid foods - NHS (www.nhs.uk)

Adapting recipes

Many recipes can be adapted by using your chosen supermarket milk alternative. Use a milk free margarine instead of butter, milk alternatives in place of milk, and vegan cheese in place of  cheese. Try making up batches of milk free meals/puddings and freezing them.

What about calcium?

Calcium is needed for strong teeth and healthy bones.  It is important that breast feeding mum's and children on a cow's milk free diet our meeting that calcium requirement.  The following table shows how much is needed for each age group:

Babies under 1 year of age – 525 mg calcium per day

1-3 year olds- 350 mg calcium per day

Breast feeding mothers – 1250 mg calcium per day

Sources of Calcium (portion size are not necessarily baby size!)

What about Vitamin D?

Vitamin D is needed by the body to absorb calcium/regulate calcium and phosphate in the body.  Our body creates Vitamin D from direct sunlight on the skin when outdoors.  Vitamin D is also found in a small number of foods.  Vitamin D is only found in a few foods  so a supplement is recommended for everyone

A supplement containing Vitamins A, C and D can be given from 6 months, (Healthy Start Vitamins) (Department of Health advice).  It is advised that breastfed babies take a vitamin D supplement from birth.

Supplements are available to purchase in pharmacies and supermarkets, or may be available online.

NB micrograms (mcg) can also be written as μg.

Formula feeding a baby with cow's milk protein allergy.

Milk free weaning for babies with cow’s milk protein allergy (video 5)

Why a milk and soya free diet?

Around 3% of children develop non-IgE Cow’s Milk Protein Allergy. Some children who are allergic to cow's milk protein are also allergic to soya protein so this may need to be excluded from the diet too. This information will help you avoid cow's milk protein and soya protein whilst making sure your baby gets all the nutrition they need to grow and develop

Cow's milk allergy in children | Health topics A to Z | CKS | NICE

Which milks should be excluded?

Avoidance needs to include fresh, UHT, sterilised and dried cow’s milk and soya milk options. The diet should be free of cow's milk protein (casein and whey), soya protein and milk sugar (lactose). Other mammalian milks are not suitable alternatives to cow's milk as their protein structure is similar and may still cause an allergic response -do not use milks such as goats, sheep, camel and buffalo milk.

Replacing cow's milk and soya

Cow’s Milk is an important source of nutrition for babies and children.  If you breast feed your baby, continue to breast feed your little one, while following a milk and soya free diet. If your baby is taking an infant formula, it needs to be a milk/soya free formula.

Important to remember- Occasionally, breast fed babies can react to milk proteins/soya proteins transferred in breast milk from the mother’s diet. It is important to remember that if your baby does not have any symptoms on breast feed, you can continue on normal diet without restrictions

Suitable infant formula free of cow's milk and soya proteins

Your baby may have been prescribed a formula such a Alimentum, Althera, Nutramigen LGG, Aptamil Pepti (or more rarely Alfamino, Puramino, Neocate or Elecare). They should continue this until 12 months or as advised by your Health Care Professional.

Most babies aged 6-12 months need approximately 600ml (20oz) each day to ensure they are meeting their nutritional needs, especially calcium.

Over 1 year this amount reduces to approximately 350ml (12oz). Check with your Health Visitor or Dietitian if you have concerns about your child’s  calcium needs.

Other alternatives to cow's milk and soya milk for cooking

Alternatives to milk that are fortified with calcium are available to buy from most supermarkets. They can be used in cooking from six months of age or as a main drink after one year old.

Examples include:

• Nut milk alternatives (almond, coconut, cashew, hazelnut),
• Oat milk
• Hemp, pea, coconut milk

Rice milk should not be given to children under four and half years old.

Always choose a milk alternative that is fortified or enriched with calcium - they should provide at least 120 mg of calcium/100mls. Organic versions do not usually have calcium added - check the label.

Foods to avoid

Look for the list of ingredients printed on the package and avoid foods which have 'milk' and/or 'soya' in bold on the label. When eating out, food outlets need to provide you with allergy information by law, so always ask.

Check with your pharmacist about tablets or medicines which may contain milk or soya proteins and/or lactose.

Introducing solids (weaning)

Starting solids for a baby who has non-IgE cow's milk and soya protein allergy should be the same as for a non-allergic baby,  however you must not give any foods that contain cow's milk or soya  products. Aim to start around six months, but not before four months (17 weeks). For general information on introducing solids, check the NHS choice website page - your baby's first solid foods - NHS (www.nhs.uk)

Adapting recipes

Many recipes can be adapted by using your chosen supermarket milk alternative. Use a milk and soya free margarine instead of butter and milk alternatives in place of milk. Try making up batches of milk and soya free meals/puddings and freezing them

Calcium and Vitamin D

For further information please see our what about calcium section on milk free diet for babies above for further information regarding calcium and vitamin D.

All standard infant formula (eg SMA, Comfort milk, Cow & Gate, Aptamil) contains cow’s milk protein.

An assessment of your child’s allergy, medical history and/or results indicate that it is time to see if they have outgrown their food allergy. This can be done by adding milk into the diet gradually at home.

Milk is introduced into the diet by following a ‘milk ladder’ where each food contains increasing levels of milk protein. It is important to start with well-cooked/processed milk first before progressing to ‘uncooked’ dairy products. This ‘milk ladder’ is based on scientific research.

Remember, these foods are part of a mixed diet and are not expected to be a significant part of the child’s diet. The Milk Ladder should only be used:

• In children with mild to moderate delayed (non-IgE) cow’s milk protein allergy symptoms (watch the film cow’s milk allergy explained if you are unsure of the type of reaction your baby has had)
• Baby/child has been milk free for 6 months and can manage to eat foods on the milk ladder
• Your child is well

Do NOT start this challenge if:

• Your child has had either immediate symptoms (within an hour of eating/drinking dairy) or a positive blood or skin test (specific IgE or Skin Prick Test) to cow's milk
• Your child is unwell, e.g. cold or  chest infection etc
• Your child has any tummy/bowel problems e.g. tummy ache or loose nappies
• Your child has any ‘teething’ signs that are upsetting your child
• Atopic dermatitis (eczema) has flared up
• Your child is having any medication which may upset their tummy, e.g. antibiotics.

Throughout the challenge, it is useful to keep a record of the foods tried/the amounts eaten and any reaction (including how long after the food was eaten did the reaction occur). Each of the foods listed contain progressively more milk protein. The time spent in each step will vary for one child to another depending on how they presented. Each step will take at least 3 days to a week but it is fine to go slower than this if needed.

The Milk Ladder

Click image to download or print

The lower steps of the milk ladder are designed to be used with homemade recipes to ensure that each step has the appropriate milk intake. You can ask your health professional (dietician) for further guidance on the steps or for recipes if needed.  

Step 1:

Start with ¼ of biscuit on the first morning, if no symptoms, give half a biscuit the next day and gradually increase till they can have 3 biscuits a day without any problems. If using store-bought biscuits rather than homemade look for a biscuit that contains milk powder as one of its ingredients.

Step 2:

Start with ¼ to ½ a muffin and build up to one muffin.

Step 3:

Start with ¼ to ½ a pancake and build up to one. If using store-bought pancakes, they should contain milk protein as one of its ingredients. (Pancakes contain less milk than muffins but are cooked for a shorter time).

Step 4:

Start with a thin slice of hard cheese such as cheddar or parmesan. Increase the amount gradually until your child is eating 15g baked cheese e.g. on a pizza or lasagne.

Step 5:

Start with one small teaspoon of yoghurt and increase daily until eating 125 mls (4.5 oz) yoghurt. Once your child tolerates yogurt you can include butter, chocolate buttons and cream cheese. Once your child tolerates yoghurt, butter, spread, chocolate buttons, fromage frais, petit filous (be careful of the sugar content), you can introduce softer cheese like cream cheese and camembert/brie –remember to use pasteurised soft cheese for children.

Step 6:

Pasteurised milk (or suitable infant formula). Introduce 100ml (3.5 oz) pasteurised cow’s milk or infant formula (powder) and mix with current milk replacement. Build up to 200 mls. (7 fl oz.) If this is tolerated switch all current milk replacements to pasteurised milk or suitable infant formula. UHT and sterilised milk will be tolerated as well.

Some children may be able to tolerate a certain amount of cow’s milk in their diet If they have more than the amount that they are able to tolerate then they may develop symptoms (up to 48 hours later). If this is the case it is sensible to include dairy products and cow’s milk up to the  amount they can tolerate while remaining symptom free.

If the food at any step of the ladder is tolerated, your child should continue to consume this (as well as all foods in the previous steps) and then try the food in the next agreed step.

If the child does not tolerate the food in a particular step, simply go back to the previous step. Re-try again in 2-3 months to check if able to progress.