June 13, 2016

Milk Intolerance and Allergy - a retake

Milk has been a cornerstone of childhood nutrition for as long as one can remember. Our children are expected to drink milk at home, in school and at restaurants. The positive health benefits of milk have been touted by the dairy council and the federal government for years. Not all physicians agree that it is that good or even necessary for all.

Now usher in 2016. The world is changing faster than medical research can keep pace. Childhood allergy and food intolerance is on the rise and parents are rightfully getting frustrated with both sides of the debate regarding food avoidance. Children cannot have peanut butter sandwiches at school or camp anymore. Rightfully so as many parents are living with the dread fear of anaphylaxis (a severe food allergy) in their child.

Babies are developing eczema and milk protein induced intestinal inflammation at increasing rates. The root cause of the problem is still under intense investigation, but believed to be multifactorial including intestinal permeability, immune dysregulation and host genetics.

I have personal experience with cow milk intolerance. My daughter had classic milk protein intolerance at 2 months of age. She was purely breastfed. Somehow she still developed eczema, colic and green bloody stools. My wife's sole intake of dairy was cheese on her salads a few times a week. Yet, the cow milk protein, casein, was passing through the breastmilk to my daughter and causing an intense self destructive immune reaction.

My wife promptly removed all dairy from her diet. Within one week my daughter was symptom free. Since those unsavory days, my daughter has healed her permeable gut and can now tolerate low volumes of dairy as cheese without issue. She still self selects to avoid milk and yogurt because she "doesn't like them", but loves cheese. Some things just taste too good.

These days it seems that this story is increasing in frequency and severity at our office. It is a rare week that goes by that I am not counseling a family to put their child on a four week dairy elimination challenge for dairy sensitivity.

The purpose of this article is to raise awareness to the symptom complex of cow milk protein intolerance, allergy and also lactose intolerance.

First, lactose intolerance is the inability of the body to metabolize the sugar in milk called lactose. This intolerance is based on the lack of production or function of the enzyme lactase. Roughly 65% of humans on the planet have reduced lactase function after infancy. It is more common in people of African and Hispanic descent than Caucasion Europeans. The deficiency also increases with age in all humans.

The symptoms of lactose intolerance are bloating, flatulence, cramping, diarrhea and vomiting. If you think that you have these symptoms after drinking milk, then you should refrain from milk for a few days and rechallenge your system with a glass of milk. If the symptoms return, then avoidance of milk is a good idea. These individuals can alternatively consume lactose free milk without suffering any symptoms. They can also take an enzyme supplement that contains lactase to achieve the same effect.

Second and more importantly, cow milk protein allergy is an IgE antibody mediated immediate reaction to a cow milk protein. Cow milk protein intolerance is a slower, hours to days, IgG or IgG4 subclass immune reaction to the protein. The two main proteins are whey and casein, and an individual may be allergic or sensitive to either or both, however, most react to casein. The casein is the curd that forms when milk is left to sour, and the whey is the watery fraction which is left after the curd is removed. The symptoms overlap between both types of reactions. The speed of the reaction is the differentiator.

If the allergic reaction is immediate and involves any part of the mouth, stomach or airway or other anaphylactic symptoms, strict avoidance and injectable epinephrine in case of accidental exposure are a must for safety.

Symptoms of cow milk protein intolerance:
Colic, diarrhea, gastric reflux and vomiting, eczema, chronic nasal stuffiness, recurrent sinusitis/ear infection, wheezing, coughing, failure to thrive and bloody stool.

Early recognition of these symptoms can save a child many courses of unnecessary antibiotics, reflux medicines and general pain. It is paramount to think of the root cause of the illness and not seek the bandaid approach of drug suppression of symptoms.
Avoidance of all dairy is the best treatment. The likelihood of resolution of the allergy or casein protein sensitivity improves with every year of life. Unlike peanut allergy, most milk allergic children outgrow the allergy by 6 years old. Many IgG sensitive children maintain the intolerance for decades.

Now we have been taught that milk is necessary for good nutrition. That it is important to ensure adequate sources of vitamin D and calcium. I am one of a growing voice of providers of care that emphatically disagree. I believe that the best way to achieve this nutrient goal is to spend a half hour in the sun without sunblocking creams and eat a diet rich in green leafy vegetables that are loaded with calcium, such as kale, greens, spinach and broccoli everyday.

The debate regarding the need for dairy should be settled by each individual based on their genetic history coupled with their nutritional needs. The time of milk for all is over as my prescription pad has been worn out writing notes to schools for countless children with milk allergy and intolerance.

I will give a few opinions based on questions I receive in the office everyday.

In our clinic, the number one cause of chronic constipation is dairy consumption. Removal of dairy is a must for any child suffering from constipation. If that does not completely correct the problem, then have your child evaluated for other causes.

One year in a weekend walk in clinic, I walked into an exam room to evaluate a 3 year old child who was white as a ghost. My immediate reaction was "oh no - leukemia". After a blood evaluation showed pure anemia, I went back for more history. I was blown away to find out that this child was consuming over 50 ounces milk daily. Cause identified! Excessive dairy consumption causes anemia and as in this case it can be profound.

I think that the use of rBGH, recombinant bovine growth hormone, that is used to increase milk production, is unlikely to be healthy and definitely unnatural. We would never use human analogues of such hormones to routinely increase maternal breast milk. Its use is banned in the European Union, Canada, New Zealand and Australia. Look for hormone free animal products until the safety is proven without a doubt.

In many studies the over consumption of animal protein including milk has been linked to increases in prostate cancer, GI cancers and other diseases. See work by T. Colin Campbell, Walter Willet, Neal Barnard and others. I believe that animal fats and proteins are a vital part of the diet but in reasonable amounts. Dairy after infancy is a personal choice and the volume should be limited. 80% of a child's diet should come from vegetables, fruits, nuts, beans, seeds and whole grains that they are known to tolerate. The remainder should be made up of fish, grass fed and well cared for animal meats and fats.

I am starting to believe that all humans after the age of one year old should try a dairy free month and assess how they feel. If they have no change in overall health, then a moderate dairy dietary budget sounds appropriate.

Don't believe the hype that you need dairy. You don't. It is a choice and one that each individual should make.
Fighting the system that thinks that juice and milk should be free for school kids while water is only available with a fee.

Dr. M