Volume 1 | Issue 5
Nurture Pediatrics Newsletter
Looking for a special Valentine’s Treat?
We are offering ear piercing for the month of February for $50 (discount from our usual charge of $65).
Dr. Pate uses sterile earring kits with 24k gold-plated ball type piercing earrings (included) as shown in the photo of some happy patients above.
- No scary ear-piercing gun!
- We cater to Nervous Nellies!
- After care instructions and kit included.
Cow Milk Concerns
Last month a mother in our practice asked me about A1 and A2 cow milk. Cow milk causes gastrointestinal problems for many people. There has been much investigation into the cause of these symptoms. I decided to do some investigating into the A1, A2 milk issue along with writing a summary for your review of other common milk issues that I see almost every week in pediatric patients.
Some people have lactose intolerance, meaning they cannot fully digest the sugar (lactose) found in cow milk. Lactose intolerance is not generally present at birth, but develops over time as the body naturally decreases the amount of the lactase enzyme made. Human breast milk and cow milk both contain lactose.
It can also develop following a viral intestinal illness. Viral Gastroenteritis damages the tips of the villi (absorbent fingers) of the small intestine where the lactase enzyme and lactose absorption occur. The surface of the small intestine looks smooth under the microscope rather than bumpy like a carpet, hence the term “slick gut.” It takes between 1-2 weeks for the fingertips to repair themselves and children should avoid any cow milk (and fruit juices) apart from yogurt during the first week of the illness. Cultured yogurt is generally low in lactose as the sugar is already processed by bacterial cultures in the yogurt.
When there is lactose in the intestines that is not absorbed by the body, the bacterial flora of the GI tract ferment the sugar leading to gases (think of beer bubbles, bread rising), diarrhea and cramping. Probiotics containing lactobacillus can be very beneficial to populate the intestines with healthy bacteria and crowd out the more harmful bacteria that flourish on the high sugar environment. For a child over 1 month of age with gastroenteritis, prompt supplement of a lactobacillus supplement can aid in quick recovery!
Some people who are lactose intolerant take a lactase enzyme supplement (available OTC) each time they consume milk to avoid this problem. Since their intestines no longer make an adequate supply of the lactase enzyme, they just take it directly by mouth.
Is that stomach ache lactose intolerance or cow milk allergy?
Cow Milk Allergy (CMA)
There are 2 types of protein found in cow milk: casein and whey. Both types contain subsets of proteins that can cause allergic reactions. Cow Milk Allergy (CMA) is common in infants and children, but not very common in adults.
IgE is the antibody made in response to an allergen. Measuring the blood IgE level for cow milk protein or performing a skin test can aid in determining if your child is allergic to cow milk and if they are likely to outgrow it by adolescence. It is not a definitive test and requires interpretation by your doctor. Some CMA is non-IgE mediated and a child can have a normal result on IgE testing and still be allergic to cow milk.
Symptoms of CMA may include the following:
- Rashes (abrupt onset of hives, chronic eczema)
- Vomiting (abrupt onset or chronic reflux, sometimes with blood)
- Abdominal pain (abrupt onset or recurrent chronic pain)
- Diarrhea, sometimes with blood and mucus
- Nasal congestion (recurrent bouts or chronic daily congestion)
- Breathing problems (wheezing, recurrent cough)
- Behavior problems (possibly due to persistent abdominal pain, poor sleep from chronic congestion)
- Recurrent headaches
Treatment of CMA requires avoidance of the cow milk protein. Fresh and pasteurized milk are the most concentrated and likely forms to cause allergic reactions. Milk proteins become denatured (allergy inducing shape is changed) when they are heated for a significant amount of time. Pasteurization is not long enough to denature the proteins, but milk cooked into foods is less likely to cause an allergic reaction than uncooked milk products. For children with modest elevations in cow milk IgE on lab testing, reading labels on food for milk content is not usually necessary. As a general rule, the higher the IgE level, the more risk for severe symptoms or allergic reaction.
Cultured yogurt is also less likely to cause an allergic reaction because the bacterial cultures ferment the lactose (sugar) in the milk making the pH more acidic. Low pH (high acidity) denatures milk protein (think of curdled milk when lemon juice is added) changing the shape and making it less allergenic. Many children who are allergic to cow milk, can eat yogurt with few to no symptoms.
Soy milk is not a good alternative to cow milk for the allergic child because at least 40% of children allergic to cow milk will be (or become) allergic to soy milk. Almond milk is an alternative and supplementation with a multivitamin containing calcium and Vitamin D (400 IU) is a good idea.
Being prepared to treat a cow milk allergy is important. Even though cow milk allergy is generally dose dependent (the more you eat, the worse you feel), some children can have unpredictable responses to cow milk resulting in anaphylaxis, a life-threatening allergic reaction. If your child has a high IgE level to cow milk on lab testing, it is important that you discuss an allergy action plan that includes treatments such as injectable epinephrine, benadryl (diphenhydramine) and albuterol inhaler with your doctor. You should have a clear understanding of how to respond to an allergic reaction and you should keep an allergy kit available when you are out of the home. Don’t forget that these medications are not stable in heat – don’t leave them in a hot car!
Milk Protein A1 vs A2 Controversy
For people who have GI symptoms (abdominal pain, reflux or stool irregularities) with cow milk yet have normal tests for lactose intolerance and cow milk IgE, it is possible that they are intolerant to a breakdown product of milk.
Newly published article by Linni Kral on Jan. 27, 2017 in The Atlantic gives an easy to read summary: https://www.theatlantic.com/science/archive/2017/01/a-tale-of-two-milks/514397/
Some researchers (Bob Elliott, Corrie McLachlan, Keith Woodford author of The Devil in the Milk) have been studying the beta-casein proteins in milk for more than 20 years. There are 2 varieties of milk based upon the beta-casein protein: A1 found in the USA and Europe and A2 found in Africa, Asia, Australia and New Zealand. It is purported that all milk was initially A2 variety until a genetic mutation occurred in European cows approximately 8000 years ago. The Holstein (black and white spotted cows) produce almost exclusively A1 milk, as we drink in most of the USA and Europe. Goat milk and human milk (in mother’s who do not consume cow milk) does not contain the A1 protein.
Bear with me on the biochemistry now… proteins are made of amino acid building blocks. The beta-casein protein contains 209 amino acids strung together and interacting to create natural folds into a protein molecule. At position 67 on the amino acid chain, A2 milk bears the amino acid Proline. Somewhere along the way in cow genetics, the gene for this protein shifted and A1 milk developed bearing Histidine at the 67-amino acid position.
Due to this single amino acid difference, A1 milk digests into BCM-7 (beta-casomorphin 7), an opioid-like substance that is a purported toxin. The A2 Milk Company founded by Corrie McLachlan has published animal studies and human epidemiologic studies correlating A1 milk and BCM-7 with risk for heart disease, Type 1 diabetes, autism and other mental disorders, eczema and impaired tolerance of other food proteins (antigens). These studies do not show causality, only correlation and could be biased given the implications to the benefit of their company.
A research group from India without any ties to the A2 Milk Company has published studies showing mice fed BCM-7 developed increased GI symptoms.
A quick PubMed search pulls up many other small studies on A1 protein and BCM-7, but no human prospective, controlled, double blinded studies.
Nestle Corporation published a review article disavowing the reports from the studies made by the A2 Milk Company in 2011. None-the-less the A2 Milk Company is strong in Australia and New Zealand comprising up to 20% of the milk market and plans to move into the US market beginning in California in 2018. There are some A2 milk companies already selling the A2 milk in the Midwest of the USA.
How the US milk industry and milk consumers will view this planned marketing of A2 Milk given lack of controlled trials in people remains to be seen. For those with IgE-mediated Cow Milk Allergy, this will not be a solution as they are also likely to react to the A2 variety of milk. For newborns, it is very clear that human
breast milk is the safest option. It is wise of breastfeeding mothers to keep their own consumption of cow milk in check as the cow milk protein does pass through human milk and is a common irritant to newborn intestines (see next topic). More research is needed in regard to the other purported health benefits of A2 milk.
Infantile Milk Protein Sensitivity
Blood streaked soft stools in a young infant between 2 weeks to 2 months of age is most likely due to a reaction to Cow Milk Protein found in formula or passed through mother’s milk. This condition known as Infantile Food Protein Induced Proctocolitis can make the infant rather fussy along with mucus laden stools containing visible milk. Some people commonly refer to this condition as Milk Protein Sensitivity.
Cow Milk Protein is by far the most common protein that causes this condition and elimination of the cow milk protein (in mother’s diet or the formula) results in improvement within 5 days for most infants, but can take up to 2 weeks for some infants to recover. For infants over 1 month old who are very fussy along with the abnormal stools, addition of a lactobacillus probiotic supplement can aid in recovery, but should not be given less than 1 month of age due to lack of data in the newborn period.
Breastfed infants who improve with removal of cow milk protein from mother’s diet, but still have some symptoms, could also be reacting to soy protein or egg in mother’s diet. Sequential elimination of those proteins will aid in recovery. Almond milk is a good alternative for the breastfeeding mother who has eliminated cow milk from her diet.
This condition is generally limited to infancy and 50% of infants can tolerate gradual reintroduction of cow milk into the breastfeeding mother’s diet by 6 months of age and 95% by 1 year of age. For those whose symptoms persist until 1 year of age or if the infant shows other concerning signs such as eczema (skin rash), IgE testing for allergy mediated illness can aid in diagnosis. IgE testing prior to 9 months of age is not as helpful as a trial of elimination of cow milk protein, soy protein, egg protein and corn protein sequentially (in that order).