The cow’s milk protein–free diet for non-IgE cow’s milk allergy

What are cow’s milk proteins?

Cow’s milk proteins (CMPs) are proteins found in dairy. CMPs include casein and whey.

What is non-IgE-mediated cow’s milk allergy?

Non-IgE-mediated cow’s milk allergy (CMA) is the most common type of milk allergy in infants and children. In non-IgE-mediated CMA, parts of the immune system are activated by the proteins found in cow’s milk. This causes inflammation of the gastrointestinal (GI) tract, which can lead to symptoms such as vomiting, diarrhea, poor weight gain, and blood and mucus in the stool. Sometimes, the skin and respiratory (breathing) systems are involved. For more information, please see Cow's milk allergy (CMA) (also known as cow's milk protein allergy (CMPA)).

Infants and children diagnosed with non-IgE-mediated CMA, or parents providing breast milk to infants with non-IgE-mediated CMA, are unable to eat or drink any source of CMPs and must follow a CMP-free diet.

What the CMP-free diet is NOT:

• A dairy-free diet. The CMP-free diet excludes all sources of CMPs found in foods or drinks, not just dairy-based foods or drinks.
• A lactose-free diet. Lactose is a sugar found in dairy, so lactose-free products still contain CMPs, which are not allowed on a CMP-free diet.

Getting started on the CMP-free diet

CMPs are found in dairy, as well as in many packaged and processed products. The obvious sources of CMPs are dairy-based foods or drinks, such as cheeses, yogurts, butter and milks. However, there are also many foods and drinks where CMPs are hidden as an ingredient. It is very important to always read the product labels of all food and drinks, as well as product monographs for medications and natural health products, to check for any sources of CMPs.

Milks from other mammals and products containing these milks, including goat, sheep, buffalo, mare or camel milk, should also be avoided on the CMP-free diet because there is a risk of cross-reactivity. This means a risk of allergic reaction because the immune system may mistake similar proteins in other milks for CMPs.

In some cases, your health-care provider may advise your child/you to avoid soy proteins. See the “Soy protein–free diet” section below for information about eliminating soy protein to manage non-IgE-mediated CMA.

Other names for milk/dairy or sources of cow's milk proteins (CMPs)

• Beta-lactoglobulin
• Casein, rennet casein
• Caseinate (ammonium caseinate, calcium caseinate, magnesium caseinate, potassium caseinate, and sodium caseinate)
• De-lactosed or de-mineralized whey
• Hydrolyzed casein
• Lactalbumin and lactalbumin phosphate
• Lactoferrin, lactoglobulin
• Whey and whey protein concentrate

Sources of cow's milk/dairy

• Butter, buttermilk
• Cheese, curds
• Cream
• Gelato
• Ghee and butter fat
• Ice cream
• Kefir (fermented drink)
• Kumiss (fermented drink)
• Sorbets
• Sour cream
• Yogurt

Examples of foods, drinks and products that may contain milk/dairy CMPs

• Infant formula, infant cereals
• Artificial butter, butter flavour or butter oil
• Baked goods (including some types of bread) and baking mixes
• Battered and fried foods
• Broths and bouillons
• Caramel colouring or flavouring
• Casseroles, frozen prepared foods
• Cereals, crackers
• Chocolates
• Desserts (e.g., custards, puddings)
• Dips and salad dressings
• Egg and fat substitutes
• Fat replacers (e.g., Opta™ and Simplesse®)
• Glazes, gravies and sauces
• High-protein flours
• Malt-drink mixes
• Margarine
• Pâtés, sausages
• Pizza
• Plant-based products (e.g., vegetarian cheeses)
• Potato products (e.g., instant) or dishes
• Seasonings
• Soups, soup mixes, cream soups

*The above are not inclusive lists. Always read the product label for any source of milk/dairy or CMPs. Check the Health Canada and Canadian Food and Inspection Agency (CFIA) websites for any updates about milk/dairy or CMPs.

Ingredients that do not contain milk/dairy or CMPs

Some ingredients may read like they contain milk/dairy or CMPs but are safe on the CMP-free diet. These ingredients are:

• calcium/sodium lactate
• calcium/sodium stearoyl lactylate
• cocoa butter
• cream of tartar
• oleoresin

Reading food labels

It is important to read labels on food, drink, medication and natural health products every time you buy or eat them because ingredients can change on products without notice.

• Avoid any food and/or drink that has a source of milk/dairy or CMPs in the ingredient list or as part of a “Contains” statement on the product label.
• In non-IgE CMA, there is no need to avoid products that contain a precautionary allergen statement (e.g., “may contain” or “may contain traces of”) for any source of milk/dairy or CMPs.
• If you are not sure about the safety of a product, call the manufacturer to clarify ingredients.
• If the product does not have an ingredient list, do NOT buy the product.
• Be careful when buying imported products or products in bulk as they may contain sources of milk/dairy and CMPs even if these allergens are not labelled.

Soy protein–free diet

Your child’s/your health-care provider may recommend a soy protein–free diet. If a soy protein–free diet has been recommended, your child/you must avoid foods, drinks and products that contain soy. For non-IgE-mediated CMA, there is no need to avoid soy lecithin or most soy-based oils because these ingredients and products contain no or trace amounts of soy protein.

Other names for soy

• Bean curd (dofu, kori-dofu, soybean curds, tofu)
• Edamame
• Kinako
• Natto
• Nimame
• Okara
• Soya, soja, soybean and soyabeans
• Yuba

Sources of soy

• Soybean sprouts
• Breadcrumbs, cereals and crackers
• Breaded foods
• Hydrolyzed plant protein (HPP), hydrolyzed soy protein (HSP) and hydrolyzed vegetable protein (HVP)
• Infant formula, follow-up formula
• Meal replacements (e.g., formulas for toddlers, children, adolescents, adults)
• Meat products with fillers (e.g., plant-based burgers)
• Miso
• Nutrient supplements (e.g., protein shakes)
• Sauces (e.g., soy, shoyu, tamari, teriyaki, Worcestershire)
• Simulated fish and meat products (e.g., surimi, imitation bacon bits)
• Stews and gravies
• Tempeh
• Vegetarian dishes

Examples of foods, drinks and products that may contain soy proteins

• Baked goods and baking mixes
• Beverage mixes (e.g., hot chocolate)
• Canned tuna and minced hams (when seasoned or mixed with other ingredients for flavour)
• Chewing gum
• Cooking spray, margarine, vegetable shortening and vegetable oil
• Dressings and marinades
• Frozen desserts
• Milled corn
• Meat products with fillers (e.g., cold cuts)
• Seafood-based products and fish
• Seasoning and spices
• Snack foods (e.g., soy nuts)
• Soups, broths, soup mixes and stocks
• Soy pasta
• Spreads, dips, mayonnaise and peanut butter
• Thickening agents
• Mono-diglyceride

*The above are not inclusive lists. Always read the product label for any source of soy. Check the Health Canada and Canadian Food and Inspection Agency (CFIA) websites for any updates about soy.

Nutrition and the CMP-free diet

Dairy and dairy-based products provide your child/you with important nutrients, including calcium, vitamin D and protein.

Calcium

When following a CMP-free diet, it can be challenging to get enough calcium from non-dairy sources of food and drink. Good sources of calcium include calcium fortified/enriched beverages, legumes (including soy if this protein is still in your child’s/your diet), nuts and canned fish with bones.

Non-dairy sources of calcium

Supplement with calcium if your child/you are not meeting calcium needs from diet. Refer to Table 1 for daily calcium needs based on age. Use online calcium calculators or speak with your health-care provider about calcium supplements on a CMP-free diet.

There are many calcium supplements available. Choose the type (e.g., tablet, gummy, liquid) that your child/you can take by mouth. It can be any form of calcium (e.g., calcium carbonate, calcium citrate, calcium gluconate), as tolerated.

Vitamin D

The body needs vitamin D to absorb calcium, as well for bone and immune health. Avoiding CMPs may lower the amount of vitamin D in your child’s/your diet. Dietary sources of vitamin D include fortified dairy products, egg yolk, some fatty fish and livers. Vitamin D status is also affected by exposure to sunshine. In Canada, sun exposure can be limited, especially during the months of October to April. It is strongly recommended that your child/you take(s) a vitamin D supplement to maintain optimal vitamin D status.

Table 1. Recommended dietary allowances (RDAs) for calcium and vitamin D based on age.

mg = milligrams; IU = international units.

Protein

Dairy-based food and drink are sources of protein that must be avoided on a CMP-free diet. This may affect your child’s/your ability to meet daily protein needs. Other sources of protein that can be eaten on a CMP-free diet include egg, poultry (e.g., chicken, turkey), meat (e.g., beef, pork, wild game), fish, seafood, legumes (e.g., beans, chickpeas) and grains (e.g., quinoa). The recommended amount of protein for all ages is 1 gram of protein per kilogram of body weight per day (e.g., if weight is 20 kg, then recommended protein needs are 20 grams daily), which can be met with many non-dairy food sources.

Table 2. Food and drink to choose and avoid while following a CMP-free diet.

Ideas for CMP substitutions

• Fortified plant-based milk alternatives, such as almond, coconut, hemp, oat, pea or rice milks.
• Plant-based dairy alternatives, such as spreads and butter, cream, cheese and yogurt alternatives (read the label for hidden CMPs).
• Plant-based frozen treats (e.g., coconut- or rice-based treats; read the label for hidden CMPs).
• Snacks including fruits and vegetables with nuts, seeds, avocado and legume-based spreads such as hummus or white bean dips.

Tips for eating out

• Call ahead to inquire if the restaurant can accommodate CMP-free meals.
• Be mindful when eating out during peak hours when staff may not be as available to address your dietary concerns.
• Don’t be shy to speak directly with the manager about your dietary concerns.
• Choose stock-based soups instead of creamed soups.
• Order salads with oil and vinegar instead of salad dressing.
• Choose grilled or barbecued meat, poultry, fish or alternatives without breading, sauces or marinades.

References

Vandenplas Y., Broekaert I., Domellof M., et al. (2024). An ESPGHAN position paper on the diagnosis, management, and prevention of cow’s milk allergy. JPGN, 78(2):386-413. Retrieved from: https://www.espghan.org/knowledge-center/publications/Gastroenterology/2024-Diagnois-and-Management-of-Cows-Milk-Alergy.

Resources

Health Canada: Milk – A priority food allergen
https://www.canada.ca/en/health-canada/services/food-nutrition/reports-publications/food-safety/milk-priority-food-allergen.html

Canadian Food Inspection Agency: Before you shop: food allergies and allergen labelling
https://inspection.canada.ca/en/food-labels/labelling/consumers/food-allergies

Food Allergy Canada: Milk
https://foodallergycanada.ca/allergies/milk/