Managing cows’ milk allergy in childrenBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5424 (Published 16 September 2013) Cite this as: BMJ 2013;347:f5424
All rapid responses
MARE'S MILK, CAMEL'S MILK
Further to my Response of 21 October:
The authors stated that goat, sheep and mare milk are not recommended because of high cross-reactivity.
So far as mare's milk is concerned I have not discovered any published material on this particular issue. I suggest therefore that mare's milk should not be "blacked" . It may be worth trying.
On the other points I raised on 21 October, there is still no input from areas where camel's milk is used. It is odd. I venture to presume that paediatricians in those countries do NOT see any problems. If my presumption is not presumptuous, the UK paediatricians and dieticians could consider a trial?
Competing interests: As previously indicated in response posted on 21 October
I have been retired for some years now, so my knowledge of paediatics is perhaps a little out of date. However, I think it is worth mentioning that in infants one of the commoner manifestations of cow’s mild allergy is seborrheic dermatitis. This presents as cradle cap, seborrhoea on the face and often severe napkin rash, which may not be obviously seborrheic, but simply appear as raw-looking skin and is evidently quite painful for the child. If swabs are taken for bacterial infection they almost always reveal a heavy growth of Staphylococcus aureus. Treatment of this with local or systemic antibiotics may improve the condition but does not cure it. Removal of cow’s milk from the diet has a dramatic effect and in fact obviates the need for antibiotics.
Other important effects of cow’s milk allergy, especially in small premature infants, are persistent iron-deficiency anaemia and persistent failure to gain weight. In my experience bloody diarrhoea is quite rare. IgE mediated allergy is much rarer than non-IgE mediated allergy, which is very common in the first year of life.
Competing interests: No competing interests
I am grateful for the lucid guidance of Ludman, Shah and Fox - even though I have retired.
May I seek clarification on two points, please?
1. Cross-species allergenicity between mammalian milks.
As far as I am aware, mare's milk is not a common allergen for cow's milk allergies. I wonder if there are any recorded data for the frequency. (Of course I for one would not dare milk a mare. The risk of a well-shod hoof-in-the face is a deterrent stronger than a uranium-tipped ballistic.)
Recalling events of about sixty years ago, a) ass's milk was reputed to be closest to human milk. Again, having been kicked by an ass in the praecordium some sixtyfive years ago, it would be asinine of me to start an asinine dairy.
Camel's milk. Available in the UAE. Camel and cow are mutually infertile and are as different as chalk from cheese. I suggest, somewhat timorously, that camel milk might prove a worthy substitute. Given the "globalisation" of the West End and even the East End, it should be easy to order.
2. I am struck by the considerable increase in the allergies in This England, in the past half a century. Is this a global phenomenon?
I for one would appreciate the thoughts of readers beyond the seas; particularly from Pakistan, North West India (areas with great deal of Bos milk), Saudi Arabia, UAE, Libya (camelus milk and other milks).
Competing interests: Have seen cow's milk allergy in family.
This review on Cow's milk allergy is excellent and timely as it comes with pathways which should be easy to follow in primary care.
Nevertheless the plethora of milks available, some marketed as being easier to digest and others which are prescription only; makes it even more confusing for "well informed" parents.
From personal experience, some babies are more unsettled than others and as suggested by the authors, following an elimination diet a home challenge using cow's milk should be an integral step of the diagnostic process.
A universal and clear care plan for parents would help them gain confidence in this decision making process which can be perplexing in non IGE mediated Allergy.
It is of course very important to remember that a variety of rare but potentially dangerous conditions ( metabolic / cardiac) can present similarly in young babies who seem fussy and slow to grow.
An early referral to the local Paediatric team should still be contemplated, should there be continuing concerns about the diagnosis.
Competing interests: No competing interests