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From Elagamy, E.I., 2015. Milk Protein Allergy. Reference Module in Food Sciences.
Elsevier, pp. 1–5. doi: http://dx.doi.org/10.1016/B978-0-08-100596-5.00971-9
ISBN: 9780081005965
© 2015 Elsevier Inc. All rights reserved.
Academic Press
 Author's personal copy

Milk Protein Allergy

EI Elagamy, Faculty of Community (Unaizah), Qassim University, Unaizah, Saudi Arabia
Ó 2016 Elsevier Inc. All rights reserved.

Background 1
Definition of Allergy 1
Allergic Reactions Nature 1
Milk Protein Allergy and Intolerance 1
MPA Clinical Manifestations 2
Diagnosis of MPA 2
Milk Protein Allergens 3
Infant Formula 3
Extensively Hydrolysed Formula (EHF) 3
Amino Acid-Based Formula 3
Soy Formula 3
Alteration of MPA 3
Heat Treatment 3
Enzymatic Treatment 4
Human Milk Proteins and Their Alternatives 4
Milk Protein Cross-Reactivity 4
Further Reading 5
Change History 5

Background

It is well known that human milk is the best food for human infants, but when breast-feeding is not available, milk from other
species or infant formulae is usually used as a substitute for human milk. This substitution can lead to some nutritional and immu-
nological problems. One of these is milk protein allergy. In this context, the term milk allergy is focused on allergy caused by cow
milk proteins due to the fact that cows’ milk is one of the most common food allergies in children. Although most children out-grow
milk protein allergy (MPA) by the age of 4 years, some retain the allergy for life. MPA may occur in adults, usually involving imme-
diate allergic reactions or eczema. Several studies in different countries showed that the incidence of MPA varies widely from 0.3% to
7.5% of the population. In some cases allergy to goat and sheep milk or cheeses made from them has also been recognized.

Definition of Allergy

The word allergy means an altered or abnormal reaction. Such a reaction may occur when there is contact between a foreign protein
‘an allergen’ and body tissues, that are sensitive to it. The allergy may reach the tissues by direct contact with the skin or mucous
membranes or through the blood stream after absorption.

Allergic Reactions Nature

The allergic reactions have been classified into two types:

l The immediate reaction type in which the allergic manifestations occur within hours of the patient coming in contact with the
allergen and often within seconds or minutes; in this form of allergy, skin tests are nearly always positive.
l The delayed reaction type in which manifestations may not appear for many hours or even for 2 or 3 days; in this type, skin tests
are usually negative.

Milk Protein Allergy and Intolerance

MPA is clinically an abnormal immunological reaction to milk proteins, which may be due to the interaction between one or more
milk proteins and one or more immune mechanisms, and resulting in immediate IgE-mediated reactions. On the other hand, reac-
tions not involving the immune system are defined as milk protein intolerance (MPI). MPI produces a non-IgE antibody and is not

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2 Milk Protein Allergy

detected by allergy blood tests. It produces a range of symptoms very similar to MPA symptoms, but can also include blood or
mucus in the stools.

MPA Clinical Manifestations

Symptoms of MPA can appear immediately or start several hours or even days after the intake of moderate to large amounts of cows’
milk or infant formula. A wide spectrum of clinical manifestations has been recorded with MPA (Table 1). Clinical symptoms
involve immediate or delayed reactions operating separately or together. Immediate reactions are mainly IgE-dependent, leading
to cutaneous, intestinal or respiratory symptoms and in some cases to anaphylactic reaction. Delayed reactions happen after T-
cell-dependent mechanisms and can be operative both at the skin and the intestinal level. The most frequent symptoms among
the common manifestations of MPA are gastrointestinal, which are encountered in 50–75% of patients with MPA. Respiratory
and the skin symptoms are also commonly involved in MPA. These symptoms are recorded in 10–30% and 50% of patients
with MPA, respectively. Rhinitis is the most common respiratory manifestation of MPA in some infants. Anaphylactic shock is
a particularly serious symptom of MPA. In some cases, death can result. Anaphylaxis has been noted in 12% of patients with
MPA, but it is less commonly observed than most other symptoms.

Diagnosis of MPA

The clinical diagnosis of MPA differs widely due to the multiplicity of symptoms. Diagnosis can be achieved by skin or blood tests. A
positive blood or skin test is obtained only with the immediate reactions, that develop after a few minutes because these detect IgE
that is involved in the immediate type reaction. In the young child, about 60% of milk allergy reactions are not of the immediate
type but are the delayed type ‘intolerant,’ and consequently are unlikely to give positive results with blood and skin tests. Different
reliable diagnostic tests are shown (Figure 1).
A skin Prick Test (SPT) is a qualitative test that based on immunoglobulin E (IgE) being produced by patients when subjected to
cow milk proteins, that reside on the surface of mast cells present in the skin. Therefore, small drops of the suspected milk are placed
on the forearm of patients to expose the mast cells present in the skin to the specific allergens (milk proteins). After 15 min a wheal
and flare reaction may appear, revealing that the patient is allergic to milk. Generally, SPT is used for the diagnosis of milk allergy
cannot be considered reliable unless a strong reaction is noted. If it is desired to know to which particular protein the allergic indi-
vidual is sensitive, then purified proteins must be used. There is no minimum age for SPT, which can be performed on babies and
older children with useful results.
Radioimmunosorbent test (RAST) and enzyme-linked immunosorbent assay (ELISA) are being used frequently to give more reli-
able results. Both of them measure the levels of IgE in the blood serum of the patient.

Table 1 Manifestations of milk protein allergy

Organ involved Manifestations

Respiratory tract Rhinitis, wheezing, chronic cough, pulmonary infiltrate,

serous otitis
Gastrointestinal tract Vomiting, recurrent diarrhea, excessive colic, abdominal
pain, malabsorption, constipation, oesophageal reflux,
steatorrhea
Skin Atopic dermatitis, atopic eczema, angioedema, urticaria
General Anaphylactic shock

Figure 1 Methods of MPA diagnosis.

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Milk Protein Allergy 3

Elimination-challenge test is used frequently to confirm allergy. If elimination of cow milk and products-containing cow milk
from the diet results in symptomatic improvement and re-introduction of cows’ milk causes recurrence of symptoms, the allergy is
confirmed.
Recently, a combination of assays has been used for MPA diagnosis, such as proliferative assay of peripheral blood mononuclear
cells to cow milk, the quantitation of TNF-a (one of the mediators involved in adverse reactions to cows’ milk proteins), and serum
specific IgE. These assays are useful to identify MPA in patients with immediate and non-immediate adverse reactions, and they
reduce the need for allergen challenges in young children.

Milk Protein Allergens

Cow milk contains more than 20 protein allergens that can cause allergic reactions. The main proteins are casein and whey proteins.
Casein fractions (as1-casein, as2-casein, and b-casein) and b-lg are the main allergens in cow milk. Allergic reactions to bovine serum
albumin (BSA), immunoglobulin G (IgG) heavy chain and a-lactalbumin (a-la) have also been noted. Genetic polymorphisms of
milk proteins play an important role in MPA development. Goat milk with the as2-casein genotype caused less intestinal and
systemic sensitization than goat milk with the as1-casein genotype in guinea pigs. This is very interesting and may have great poten-
tials in selecting goat breeds for different casein genotypes, especially for as2-casein, which is found in less amount in cows’ milk
comparing to as1-casein. Allergic responses to lactoferrin and some cows’ milk enzymes have been detected in some patients with
MPA but none to mammalian lysozyme. The balance between casein and whey proteins in cow milk may determine its allergenicity.
Allergenicity to goat and sheep milk caseins and cheese has been reported for some patients.

Infant Formula

Infant milk formula is an alternative cow milk substitute in which the protein is a hydrolysed cow milk protein or goat milk protein.
Casein and whey or soy protein is hydrolysed by proteolytic enzymes to develop a number of casein, whey or soy protein hydro-
lysates. The products have been classified according to the degree of protein hydrolysis as extensively or partially hydrolysed protein
products. Casein hydrolysates have been used for almost 50 years, whereas whey hydrolysates are a more recent alternative. Both
casein and whey protein hydrolysates appear to have a similar clinical tolerance. Generally, infant formulae can be classified into
three categories:

Extensively Hydrolysed Formula (EHF)

This is a cow milk-based formula, that has been treated with proteolytic enzymes. This formula often has a poor flavor and the taste
may be bitter; however, it is recommended as a first alternative in children with MPA before using other formulae. EHF is different
from the partially hydrolysed formula, since the latter is not indicated as a supplement for cow milk allergic children. In Italy,
formulae made from goat milk are used and recommended by some physicians for feeding babies with MPA.

Amino Acid-Based Formula

This is another cow milk-based formula. It is necessary in around 10% of MPA children, who are allergic to EHF.

Soy Formula
Soy formulae offer equivalent nutritional benefits to EHF but are more palatable. Soy formulae are not recommended for all cases of
MPA infants, since 17–47% of milk allergic infants can have adverse reactions to soy. However, around 53–83% of MPA children
can tolerate soy-based formula.

Alteration of MPA

Several attempts have been made to reduce the allergenicity of cow milk proteins, and various technological processes have been
applied as:

Heat Treatment
Application of prolonged heat has been used to modify the protein components of cows’ milk in an effort to reduce their allergenic
potential. It has been found, that heating milk at 120  C for 15 min does not affect the antigenicity of caseins from cow, buffalo or
goat milk. Bovine whey protein heated at 100 or 115  C for 30 min results in no sensitization of guinea pigs or anaphylaxis. Heating
of goat milk at 100  C for 30 min results in alteration of BSA and IgG, whereas the antigenicity of a-la and b-lg was not affected by

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4 Milk Protein Allergy

heat treatment. Allergenicity of bovine b-lg is affected by heat treatment, since rats immunized with native b-lg had higher levels of
total serum IgE than those immunized with heat-denatured b-lg.

Enzymatic Treatment
Another method for reducing the allergenicity of milk proteins is by enzymatic treatment with a variety of enzymes. However, it was
found that products resulting from enzymatic treatment do not have an acceptable taste due to the development of bitterness and
off-flavors, which are attributed to the liberation of peptides and amino acids from proteolysis. The proteolytic digestion might itself
generate new antigenic substances. It was reported that partial digestion of bovine milk with pepsin or pepsin and trypsin results in
peptides derived from b-lg, that bound to IgE from patient’s sera with MPA. The antigenicity of bovine b-lg and a-la were decreased
by treatment with soybean trypsin inhibitor for 1 h, while BSA and Igs were more stable.

Human Milk Proteins and Their Alternatives

Human milk proteins are different in their composition and structure from those of the milk of other species. It is known, that the
major whey proteins of bovine milk are b-lg, at 55% of total whey proteins, a-la at 20%, and BSA at 7%. These proteins differ in their
types and ratios between goat, sheep, cow, camel, human and buffalo milk. Human milk is free of b-lg, one of the major allergens in
cow milk, similar to camel milk, which also has no b-lg. b-lg is a major whey protein in cow, buffalo, sheep and goat milk. Elec-
trophoretic patterns of native caseins in the milk of these species have been differed in migration positions as well as number of
fractionated polypeptides on the gel. Differences in amino acid composition and the peptide mappings of these caseins have
also been reported. b-Casein (55%) is the major casein fraction in goat milk, which is more like that of human casein
(60–70%) and different from cow casein (36%). b-Casein was more sensitive in goat and human casein to the action of pepsin
than as-casein. The peptide mappings of goat and camel milk a-la and b-lg are different from those of cows’ milk. Proteomic eval-
uation of proteins from different mammalian species was suggested as a suitable method of testing whether proteins from the milk
of different mammalian species may be used as a substitute for untreated bovine milk (D’Auria et al., 2005).
Several studies have evaluated the clinical use of milk from different animals such as cow, goat, camel, sheep, mare, donkey, and
buffalo as alternatives to human milk. Some studies showed that goat, mare, donkey (and camel milk (El-Agamy, 2009; Ehlayel
et al., 2011; El-Agamy, 2015) can be considered as proper alternatives to human milk due to hypoallergenic properties of their
proteins. On the other hand, other studies showed that milk of goat, sheep, and buffalo may not be useful in all cases as alternatives
to human milk, because they can be as allergic as cows’ milk.

Milk Protein Cross-Reactivity

Cross-reactivity between milk proteins either caseins or whey proteins (a-lactalbumin, b-lactoglobulin), from different mammalian
species and humans has been found due to the share part of their amino acid sequence or to the similar capacity to bind specific
antibodies (García and Lizaso, 2011). Cross reactivity between milk proteins either caseins or whey proteins (a-lactalbumin,
b-lactoglobulin), from cow, buffalo, sheep, and goat was in vitro studied (Spuergin et al., 1997). 92% of patients with allergy to
cow milk proteins showed a reaction to goat milk (Bellioni-Businco et al., 1999). In contrast, only 4% of children with allergy to
cow milk showed clinical reactivity to mare milk (Businco et al., 2000). Donkey milk (Vita et al., 2007) and camel milk (El-Agamy,
2009; El-Agamy, 2015) also seem to be less allergenic than cow milk.
It was found that IgEs from sera of children allergic to cows’ milk are able to recognize most parts of milk proteins from
sheep, goat and buffalo. Weak cross-reactivity was observed with milk proteins from mares and donkeys, but none with camel
milk. IgEs from a child allergic to sheep’s milk did not recognize any proteins of camel milk. Cross-reactivity between as-casein
from goat, sheep and cow milk and their allergic potential was studied. In the three types of milk, as-casein shared more than
85% identical amino acids. When sera of children allergic to cow milk proteins were tested, significantly higher IgE and IgG
binding to goat and sheep a-casein was recorded, supporting the conclusion that goat and sheep a-caseins have an allergic
potential and are not always suitable for the nutrition of cow milk allergic patients another study showed cross-reactivity
between goat and human caseins, when antigoat casein was used in an immunoblotting technique. No cross reaction between
human a-la and antibodies against bovine a-la was detected. Human a-la is highly homologous to bovine a-la with 66% iden-
tity. Cross-reactivity between b-lg and casein from cow and goat milk was detected by an immunoblotting technique. It was re-
ported, that guinea pigs fed cows’ milk proteins and goats’ milk proteins with high as1-casein content developed high titres of
anti-b-lg, IgG1, with an important cross-reactivity between goat and cow b-lg. A recent study showed that when specific antisera
to camel milk proteins were applied in immunoblotting analysis, no immunological cross-reactivity between camel and cow
milk proteins was found. Similar results were obtained when sera from some children allergic to cows’ milk were tested for
the specificity of their IgE to camel milk casein or whey proteins (Figure 2). It was concluded that the absence of immunological
similarity between camel and cow milk proteins can be considered an important criterion from the nutritional and clinical
points of view, since camel milk may be suggested as a new protein source for the nutrition for children allergic to cow milk
and can be used as such or in a modified form.

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Milk Protein Allergy 5

Figure 2 IgE-ELISA inhibition of cow and camel milk proteins (El-Agamy, 2009).

Further Reading

Allergy, U.K., 2013. Cow’s Milk Protein Allergy. Retrieved from: www.allergyuk.org.
Alvarez, M.J., Lombardero, M., 2002. IgE-mediated anaphylaxis to sheep’s and goat’s milk. Allergy 57, 1091–1092.
Bellioni-Businco, B., Paganelli, R., Lucenti, P., Giampietro, P.G., Perborn, H., Businco, L., 1999. Allergenicity of goat’s milk in children with cow’s milk allergy. J. Allergy Clin.
Immunol. 103, 1191–1194.
Bevilacqua, C., Martin, P., Candalh, C., Fauquant, J., Piot, M., Roucayrol, A.M., Pilla, F., Heyman, M., 2001. Goat’s milk of defective alpha (s1)-casein genotype decreases intestinal
and systemic sensitization to beta-lactoglobulin in guinea pigs. J. Dairy Res. 68, 217–227.
Businco, L., Giampietro, P.G., Lucenti, P., Lucaroni, F., Pini, C., Di Felice, G., Lacovacci, P., Curadi, C., Orlandi, M., 2000. Allergenicity of mare’s milk in children with cow’s milk
allergy. J. Allergy Clin. Immunol. 105, 1031–1034.
D’Auria, E., Agostoni, C., Giovannini, M., Riva, E., Zetterstrom, R., Fortin, R., Greppi, G.F., Bonizzi, L., Roncada, P., 2005. Proteomic evaluation of milk from different mammalian
species as a substitute for breast milk. Acta Pædiatr. 94, 1708–1713.
Docena, G.H., Fernandez, R., Chirdo, F.G., Fossati, C.A., 1996. Identification of casein as the major allergenic and antigenic protein of cow’s milk. Allergy 51, 412–416.
Ehlayel, M.S., Hazeima, K.A., Al-Mesaifri, F., Bener, A., 2011. Camel milk: an alternative for cow’s milk allergy in children. Allergy Asthma Proc. 32 (3), 255–258.
El-Agamy, E.I., 2015. Camel Milk May Be a Convenient Substitute of Cow Milk Allergic Subjects: A Clinical Study.
El-Agamy, E.I., 2009. Bioactive components of camel milk. In: Park, Y. (Ed.), Bioactive Components in Milk and Dairy Products. Wiley-Balckwell, USA.
El-Agamy, E.I., 2007. The challenge of cow milk protein allergy. Small Ruminant Res. 68, 64–72.
El-Agamy, E.I., 2006. Camel milk. In: Park, Y., Haenlein, G. (Eds.), Hand Book of Milk of Non-Bovine Mammals. Black Well, USA, pp. 297–344.
El-Agamy, E.I., Nawar, M., Shamsia, S.M., Awad, S., Haenlein, G.F.W., 2009. Are camel milk proteins convenient to the nutrition of cow milk allergic children? Small Ruminant Res.
82, 1–6.
Ezaki, S., Itoh, K., Kunikata, T., Suzuki, K., Sobajima, H., Tamura, M., 2012. Prophylactic probiotics reduce cow’s milk protein intolerance in neonates after small intestine surgery
and antibiotic treatment presenting symptoms that mimics postoperative infection. Allergol. Int. 61, 107–113.
Fiocchi, A., Schunemann, H.J., Brozek, J., Restani, P., Beyer, K., Troncone, R., et al., 2010. Diagnosis and rationale for action against cow’s milk allergy (DRACMA): a summary
report. J. Allergy Clin. Immunol. 126, 1119–1128.
García, B.E., Lizaso, M.T., 2011. Cross-reactivity syndromes in food allergy. J. Invest. Allergol. Clin. Immunol. 21 (3), 162–170.
Haenlein, G.F.W., 2004. Goat milk in human nutrition. Small Ruminant Res. 51, 155–163.
Hill, D.J., Hosking, C.S., 1996. Cow milk allergy in infancy and early childhood. Clin. Exp. Allergy 26, 254–261.
Spuergin, P., Walter, M., Schiltz, E., Deichmann, K., Forster, J., Mueller, H., 1997. Allergenicity of alpha-caseins from cow, sheep, and goat. Allergy 52, 293–298.
Tesse, R., Paglialunga, C., Braccio, S., Armenio, L., 2009. Adequacy and tolerance to ass’s milk in an Italian cohort of children with cow’s milk allergy. Ital. J. Pediatr. 35, 19. http://
dx.doi.org/10.1186/1824-7288-35-19.
Taylor, S.L., 1986. Immunologic and allergic properties of cow’s milk proteins in humans. J. Food Prot. 49, 239–250.
Vandenplas, Y., de Greef, E., Devreker, T., 2014. Treatment of cow’s milk protein allergy. J. Pediatr. Gastroenterol. Hepatol. Nutr. 17 (1), 1–5.
Venter, C., Brown, T., Shah, N., Walsh, J., Fox, A.T., 2013. Diagnosis and management of non-IgE-mediated cow’s milk allergy in infancy - a UK primary care practical guide. Clin.
Transl. Allergy 3 (1), 23. http://dx.doi.org/10.1186/2045-7022-3-23.
Vita, D., Passalacqua, G., Di Pasquale, G., Caminiti, L., Crisafulli, G., Rulli, I., Pajno, G.B., 2007. Ass’s milk in children with atopic dermatitis and cow’s milk allergy: crossover
comparison with goat’s milk. Pediatr. Allergy Immunol. 18, 594–598.

Change History

Update of: E.I. El-Agamy, Nutrition and Health: Milk Allergy. Encyclopedia of Dairy Sciences, 2nd Edition, 2011, pages 1041–1045.
July 2015. E.I. El-Agamy updated text and references.

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