- Page 2
As discussed in the
previous newsletter, cow's milk can induce various types of adverse
reactions. This newsletter will continue the discussion of adverse reactions
that have been recorded in the literature, and will continue to focus
on allergic reactions (IgE as well as non-IgE-mediated reactions).
to cow's milk categorised by organ/bodily system involved:
Abdominal bloating, abdominal pain, diarrhoea, nausea and vomiting1,2,3,4,5
Esophagitis and eosinophilic esophagitis9,17,18,19
Food Protein-Induced Enterocolitis Syndrome, which generally presents
in the 1st year of life with diarrhea, emesis, and irritability. When
there is a delay in diagnosis, persistent exposure to cow's milk leads
to increasing enteric inflammation manifesting as bloody diarrhea, vomiting,
anemia, dehydration, and failure to thrive. The area in the gastrointestinal
tract that is affected generally determines the types of symptoms that
are experienced (because different regions of the intestinal mucosa
would show varying degrees of inflammation and villous atrophy). The
extent of enteric inflammation may be limited to mild proctitis, pancolitis,
or true enterocolitis with esophagitis, gastritis, enteropathy, and
colitis.20,21 Several studies have recorded an association
between cow's milk and colitis,22,23,24,25,26 proctocolitis,9,27,28,29,30,31,32
enterocolitis,9,33,34,35,36 necrotizing enterocolitis,37
cow's milk protein sensitive enteropathy,5,38 and intestinal
inflammation and malabsorption.5,39,40,41
Occult blood loss associated with cow's milk allergy can be a cause
of iron deficiency anemia in children.5,29,42,43,44,45
Regurgitation and vomiting are common manifestations of cow's milk
protein allergy in infants. This is usually ascribed to gastroesophageal
reflux (GER). In sensitized infants, cow's milk induces severe gastric
dysrhythmia and delayed gastric emptying, which may exacerbate GER and
induce reflex vomiting.46 In up to half of the cases of GER8
in infants younger than 1 year, there may be an association with cow's
milk allergy. In a high proportion of cases, GER is not only associated
with milk but also milk allergy-induced.9,47,48
Although colic associated with vomiting has mostly been attributed
to GER (itself often associated with milk ingestion: see immediately
above), a secondary form resulting from food hypersensitivity has been
eczema, atopic dermatitis, angioedema and erythematous rashes2,3,9,49,50,51,52,53,54,55,56,57,58
sinusitis and bronchitis54,67,68
syndrome (a very rare syndrome characterised by recurrent episodes of
pneumonia associated with pulmonary infiltrates, hemosiderosis, gastrointestinal
blood loss, iron deficiency anemia, and failure to thrive in infants
and young children)69,70,71,72,73,74
Nervous system:Inability to fall
asleep, restless and disturbed sleep75,76,77
A fairly common manifestation of cow's milk allergy:
Less common manifestations:
Milk has been found
to induce migraine as well as non-migrainous headache.78,79
In some studies,
it was shown that shaking of the head from side to side has been triggered
by milk (amongst other foods). It has been suggested that, in susceptible
individuals, foods can trigger movement disorders through acting on
dopamine and other neurotransmitter pathways in the brain.80
It has been suggested
that there is a relationship between cow's milk and mental disorders
such as infantile autism, schizophrenia and hyperactivity.39,81,82,83
It has been postulated
that cow's milk has a role in the onset of convulsive crises, even if
limited to certain types of epilepsy such as the cryptogenetic partial
Two groups of infants and young children with severe life-threatening
reactions can be identified: those with anaphylaxis within minutes of
ingestion of small volumes of milk, and those in whom 30-60ml of milk
elicit an anaphylactic response with bile-stained vomiting, hypotonia
and acidosis within 1-2 hours of milk ingestion.88 Food-dependant
exercise-induced anaphylaxis has also been recorded.89,90
to milk can induce glomerulopathy93 as well as immune complex
glomerulonephritis, which can result in a nephrotic syndrome.93,94,95
Another report has indicated milk to be the cause of steroid-resistant
nephrotic syndrome with mesangial proliferation.96
with or without TAR syndrome (a rare genetic congenital disorder that
is characterized by thrombocytopenia and other physical abnormalities)98
Other manifestations:Symptomatic exacerbations
of general inflammatory arthritis, rheumatoid arthritis and seronegative
monoarticular juvenile chronic arthritis in susceptible individuals.
Septic arthritis of the hip joint, secondary to the ingestion of raw
milk, has also been reported.99,100,101 Milk products have
also been found to cause episodic rheumatic pain, synovitis and changes
in immune complexes and IgE antibodies,102,103,104 whether
or not there was underlying arthritis.105
(a multisystem, inflammatory, relapsing chronic disorder that may include
mucocutaneous, ocular, genital, articular, vascular, central nervous
system or gastrointestinal involvement).106
syndrome (cheilitis granulomatosum, fissured tongue, facial nerve paralysis).111
||compiled by Karen du Plessis
Food & Allergy Consulting & Testing Services (FACTS)
PO Box 565
Comments by our editors
Prof Janice M. Joneja Ph. D., RDN
This case study and discussion strongly emphasise the fact that
although we believe we know quite a lot about IgE-mediated allergic
reactions, our knowledge of the non-IgE-mediated responses to food
components is very limited, and in some cases virtually non-existent.
We can cite the four types of hypersensitivity reactions (Type I
(immediate IgE-mediated); Type II (IgG-mediated with involvement
of body cells); Type III (IgG-immune complex mediated), and Type
IV (delayed T-cell-mediated), and postulate one or more of these
mechanisms to explain some of the symptoms and phenomena discussed
in the section on symptoms. However, many of the conditions mentioned
are currently poorly defined in terms of the precise reaction mechanisms
responsible for the clinical signs, and it is clear that a great
deal of research will be needed before we can understand them. Once
the mechanisms are defined, it may be possible to develop laboratory
tests to identify each specific condition. In the meantime, the
message is loud and clear. The food components responsible for the
clinical conditions must be identified and avoided. At the present
time, our only method of achieving this is elimination of the suspect
food, and challenge of each food component by reintroducing it and
observing the patient's reactions, to determine it's effect on body
systems. A method for carrying out this process was briefly outlined
in the December Newsletter.
Spiesser B.Sc. Dip. Ther. Diet.
evaluating a child with failure to thrive, it is vital to determine
whether a child is not taking in, not being offered, or not retaining
adequate calories. The causes could be organic indicating malnutrition
due to a medical condition or non-organic due to social or behavioural
issues leading to insufficient dietary intake. Normally, one would
have expected weight gain acceleration on change from breast milk
to formula. The decreased weight gain should have been a concern
at this stage.
nutritional evaluation and social history should be obtained early
and patients with a failure to gain weight monitored closely.
Post diagnosis the family should be counselled with regards to
adequate energy intake to allow for catch-up growth. The toddler
should be monitored during the weaning period to allow early detection
and management of possible future food sensitivities.
This case report clearly demonstrates that one should listen closely
to a patient and strive to make a diagnosis using laboratory tests
as an adjunct to, and not in place of, one's clinical judgment.
Detection or non-detection of IgE does not equate with a diagnosis
or non-diagnosis of allergy.
For more information
on this subject and other allergy and intolerance related topics, visit:
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food allergy discussion list where this subject can be discussed further,
go to http://groups.yahoo.com/group/AllergyDietitian
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Questions (for South African dietitians only)
ALL THE QUESTIONS
1. True or false:
Cow's milk ingestion can cause constipation.
2. Which is true
regarding Milk Protein-Induced Enterocolitis Syndrome?
(a.) It generally presents in the 1st year of life with diarrhea, emesis,
(b.) It can present with more severe symptoms, such as bloody diarrhea,
vomiting, anemia, dehydration, and failure to thrive.
(c.) The area in the gastrointestinal tract that is affected generally
determines the types of symptoms that are experienced.
(d.) All of the above.
3. Which of the
following is not true regarding milk-induced gastroesophageal reflux:
(a.) It is characterised by regurgitation and vomiting.
(b.) Cow's milk induces severe gastric dysrhythmia and delayed gastric
emptying, which may exacerbate gastroesophageal reflux.
(c.) In almost all cases of gastroesophageal reflux in infants younger
than 1 year there may be an association with cow's milk allergy.
(d.) It may be associated with colic.
4. Can milk exacerbate
5. Which of the
following is a more common nervous system manifestation of cow's milk
(b.) Inability to fall asleep, restless and disturbed sleep.
(d.) Shaking the head from side to side.
6. Which of the
following has not been associated with cow's milk-induced anaphylaxis?
(a.) Anaphylaxis within minutes of ingestion of small volumes of milk
(b.) Anaphylaxis with bile-stained vomiting, hypotonia and acidosis
within 1-2 hours of ingestion of 30-60ml of milk
(c.) Lactose intolerance
(d.) Food-dependant exercise-induced anaphylaxis
7. Which of the
following has been associated with hypersensitivity to milk?
(b.) Nephrotic syndrome
(c.) Steroid-resistant nephrotic syndrome
(d.) All of the above
8. Can milk allergy
present as colic?
|1. a [X] b [ ]
||2. a [ ] b [ ] c [ ] d
||3. a [ ] b [ ] c [X] d
|4. a [X] b [ ]
||5. a [ ] b [X] c [ ] d
||6. a [ ] b [ ] c [X] d
|7. a [ ] b [ ] c [ ] d
||8. a [X] b [ ]
1. a. True
2. d. All of the above
3. c. In almost all cases of gastroesophageal reflux in infants younger
than 1 year there may be an association with cow's milk allergy
4. a. Yes
5. b. Inability to fall asleep, restless and disturbed sleep.
6. c. Lactose intolerance
7. d. All of the above
8. a. Yes
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