Introducing Milk

Dear Lisa,

I have a 1 year old daughter and I was wondering about the best way to introduce her to milk. She is currently on Nutramigen formula because as a newborn she was constantly spitting up and vomiting the other formulas and she was a bit colicky. Is it OK to start with whole milk?

“Introducing Milk”

Dear “Introducing Milk”,

It is a good idea to introduce milk slowly to babies who had previous symptoms of a sensitivity or allergy to milk based formula. Symptoms such as vomiting and colic in infancy could be a sign of either a milk allergy or Gastroesophageal Reflux. Most babies outgrow both of these problems by the time they are 9 to 12 months old. Children with a history of severe milk allergy in infancy should not start milk at one year old until they are evaluated by an Allergist. Symptoms of a severe allergy to milk include difficulty breathing, hives and facial swelling.

Although most babies “outgrow" food sensitivities by one year old, there are some babies that tend to manifest symptoms longer. There has been some recent literature reporting milk allergy lasting longer than what was originally thought. In particular children with Asthma, Eczema or those with a history of a severe reaction to milk tend to keep their allergy longer. (1)

I found in my practice that by one year old, many babies have ingested small amounts of milk mixed in foods that they have eaten. For examples, parents commonly reported that their babies ate yogurt, a piece of cake made with milk or a pancake made from milk. Babies that ingested small amounts of milk in other forms and didn’t develop a reaction, tended not to have a problem with milk when it is introduced at a year old. On the other hand, those babies that developed symptoms when they ate items that contained milk, tended to have problems when they introduced whole milk at one year old.

If your daughter ingested small amounts of milk in other forms in the last couple of months and developed symptoms, it is a good idea to have her evaluated by your health care provider before adding whole milk to her diet. When introducing whole milk to your child, it should be introduced slowly so that she can become accustomed to the new taste and temperature. If you hand a bottle of cold milk to a child who is used to Nutramigen, there's a good chance that she'll throw it at you!

Start by taking an 8 ounce bottle and fill it with 6 ounces of Nutramigen (at the temperature that you normally give it to her) and 2 ounces of cold whole milk. Coninue to give these same proportions for three days and watch for a reaction. The most common signs of a food allergy include, hives, eczema, other rashes, vomiting, abdominal pain, diarrhea, congestion, cough, difficulty breathing, and wheezing. (2) I found children who are allergic to milk may also develop a rash on the skin where the milk dripped or red blood streaks in the stool.

If there is no reaction then progress to 4 ounces of Nurtramigen mixed with 4 ounces of cold whole milk. Give this for three days and watch for a reaction. Next, give her 2 ounces of Nutramigen and 6 ounces of cold whole milk for three days. Once again watch for a reaction and if everything is unchanged give her full strength cold whole milk. Over this period of time your daughter will get used to the taste and temperature of cold milk and you shouldn’t have problems with her refusing the bottle.

If at any point your daughter develops symptoms consistent with an allergy or sensitivity, go back to full strength Nutramigen and contact your health care provider. I found that many children who continued to have symptoms at 12 months tended to outgrow their allergy later; closer to 15 months. If this is the case, try reintroducing milk at 15 months, following the same procedure.

If severe symptoms such as hives, facial swelling or problems breathing occur when you introduce milk you should contact your healthcare provider right away. Children with severe milk allergy should be seen by an Allergist.

References:
(1)Fiocchi A, Terracciano , Sarratud T. On tolerance to cow’s milk in various clinical presentations. Abstract 11. Presented at: 63rd Annual Meeting of the American College of Allergy, Asthma and Immunology; Nov. 4-9, 2005; Anaheim , Calif.
(2) Wood RA. Food allergy: comprehensive diagnosis. Workshop 37. Presented at :63rd Annual Meeting of the American College of Allergy, Asthma an Immunology; Nov. 4-9, 2005; Anaheim, Calif.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

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