This is a problem I encounter with young children quite often, as cow’s milk is the top food allergen in this age group. Parents bring their children to see me because the pediatrician has recommended a visit with a dietitian, and/or they want do ensure their child is consuming enough good food sources of calcium.
A recent study in the journal Pediatrics (1) reported that 6% of children (in a small study group with an average age of 7 years) with cow’s milk allergies (CMA) had low bone mass density as compared to none in the control group of children who consumed dairy foods. Both groups appeared to have adequate calcium in their diets – those with CMA had an average calcium intake of 930 mg per day, the controls took in 1435 mg. The recommended intake is 1,000 mg/day. Keep in mind that dietary records collected via food frequency questionnaires are not highly reliable so these calcium amounts are, in my opinion, just estimates.
Neither group had a dietary intake of vitamin D that met the current recommendations of 600 IU per day. Blood levels of vitamin D were similarly low in both groups; however 3 children in the CMA group had outright vitamin D deficiency with blood levels under 12 ng/mL
The contribution from sunshine can vary from meeting all of a child’s vitamin D needs, to having no impact at all if a child is: indoors most of the time, covered with clothing, has deeply pigmented skin, or has sunblock applied the majority of time. This is important to keep in mind because over half of all the children in this study had low vitamin D despite most meeting or coming close to the RDAs from their diet. The evidence is accumulating that children (like adults) need more than the RDA, and the sun is the optimal source as it supplies generous quantities. The body can store vitamin D so appropriate sun exposure during the summer months is important.
Over one third of the children in the CMA group were being given calcium supplements, and almost half were given vitamin D; both of these were supplemented most days of the week. There was no discussion on the type of calcium provided or the dose of vitamin D.
While the study doctors said the lower bone density in the CMA group was not large enough to warrant concern about bone fractures, over the long term it can be a concern. Children establish peak bone mass between the ages of 10 and 20; after age 30, bone mass stabilizes before generally declining with age. Children who don’t reach their peak bone mass have a higher risk of developing osteoporosis later in life.
My thoughts on this are several. An interesting finding is that only 37% of the children with cow's milk allergy were taking calcium supplements, and yet, those taking calcium supplements did not have greater bone mass than those who did not. The type of calcium supplement was not recorded, nor how the supplements were administered. Some types of calcium, such as calcium carbonate, are difficult to absorb and can actually also reduce the absorption of other nutrients such as iron due to the effect of lowering stomach acidity (Tums for example). Also, dividing calcium supplementation into at least two separate times per day is very important.
The specific types and sources of calcium is something I discuss in depth with parents so we can avoid products that could be contaminated with lead and find a form that can be routinely included while the child is avoiding dairy. While the data is limited, it is unclear whether homemade bone broth is a rich source of calcium, containing around 150 mg per liter or quart. Other foods like calcium fortified orange juice may be recommended as needed. For the parents who want to forgo supplements and fortified foods, egg shells finely ground may be an option.
Cow’s milk allergies will also mean the elimination of yogurt and cheese. Vitamin K2, supplied best by aged full-fat cheese, and to a lesser extent by full-fat yogurt, is critical for optimal bone development and works in concert with vitamin D, vitamin A, and calcium. There are few good sources of vitamin K2 in the American diet, liver is another one, and vitamin K1 found in green vegetables, while also helpful, cannot replace an adequate intake of K2.
So where does that leave us? Newer protocols suggest that children can often be “eased into” foods they are allergic to by introducing very small amounts and increasing slowly – always under a doctor’s supervision. To reduce the chance for food allergies in the first place, it is now recommended to not delay introduction of the top allergenic foods (dairy, eggs, fish, soy, peanuts, nuts, wheat), but rather to introduce gradually between 4-6 months of age (2). Ideally, a child will simultaneously have the benefit of breastfeeding which promotes the maturation of the initially “porous” GI track of an infant, thereby limiting the passage of allergenic proteins into the bloodstream.
The feeding of a cow’s milk exclusively containing A2 casein, instead of A1 casein in almost all milk available in the U.S., could be a good way of initiating introduction of dairy. It has been shown to be much better tolerated by those with reactions to dairy products. I am currently researching the availability of this type of milk in the Raleigh area and will share once I have identified a reliable source.
To provide vitamin K2, ghee, a form of clarified butter revered in India, can be gradually introduced as the first “dairy” source, with the pediatrician’s approval of course. Deep yellow ghee is an excellent source of vitamin K2 when made with butter that comes from cows grazing on green grass. Ghee is a rich source of butyric acid (think but-ter), a fat recognized for gut health. For a baby with CMA, mix ghee into mashed or pureed vegetables and it will also soften some of their bitter flavor (as will salt), making a baby much more likely to accept these nourishing foods. The extra fat will keep a baby’s tummy full a bit longer as well!
Chicken livers also contain vitamin K2, and are an excellent source of choline, vitamin A, iron, and vitamin B6, nutrients often difficult to obtain elsewhere. Babies fed chicken livers, cooked slowly to keep them soft, will tend to accept them with a pinch of salt for flavor. Egg yolks from pastured hens, with a deep golden color, contain vitamin K2, and choline and vitamin A as well. Mash with a little breastmilk, ghee, and/or other liquid and a pinch of salt. Please don’t be afraid of salt – it contains two essential minerals – sodium and chloride.
If you still need more support for a child who has a cow’s milk or other food allergy, consider meeting with a qualified registered dietitian. Avoidance of the offending food must be accompanied with ensuring the child is meeting their nutritional needs.