FeaturesApr/May 2012 Issue

Lactose Intolerance & Milk Allergy

Identifying and treating dairy allergy and lactose intolerance symptoms

[Updated June 27, 2016]

If you have a dairy allergy, chances are you’ve heard this question many times: So, you’re lactose intolerant, right?

Those with dairy issues commonly encounter confusion over milk intolerance and milk allergy. Over the years, I’ve received questions from relatives who can’t understand why tiny amounts of milk could be deadly for me, from new acquaintances who are curious about my dietary needs and from restaurant wait staff who are confused by my special-diet requests. Sound familiar?

To get to the bottom of this widespread confusion, we compiled your top questions (and mine) and put them to some of the nation’s leading allergists who specialize in milk allergy. We hope that this information helps you understand dairy issues better and gives you the tools to educate those around you.

The difference Between Lactose Intolerance and a Dairy Allergy

“A milk allergy involves an attack on milk protein by the immune system, the part of the body that fights infections,” explains pediatric allergist Scott Sicherer, MD, author of†The Complete Idiot’s Guide to Dairy-Free Eating. In most cases, a type of antibody known as IgE (immunoglobulin E) responds to milk protein as if it’s a dangerous invader, triggering a cascade of immune response that causes potentially dangerous symptoms.

In contrast, says Sicherer, “a milk intolerance, also called lactose intolerance, is trouble with digesting the sugar in milk.” Lactose is the milk sugar and lactase is the enzyme that digests it. Unlike an allergy, dairy intolerance involves problems in the digestive system that stem from this missing enzyme.

The Commonality of Lactose Intolerance and Milk Allergies

Data on milk allergy prevalence is relatively limited. Evidence suggests that in Westernized countries, about 1 to 2 percent of children have experienced a milk allergy, which most ultimately outgrow. Milk allergy is found more commonly in boys than girls. “For lactose intolerance, persons of Asian descent have the highest rate—over 90 percent,” says Sicherer. “Additionally, about 70 percent of Native Americans and African Americans have lactase deficiency. Thus, being lactose intolerant is basically the norm for adults worldwide. However, rates are lowest (5 to 20 percent) among Caucasian adults.”

Developing a Dairy Allergy or Lactose Intolerance

In the case of lactose intolerance, babies and young children usually have sufficient amounts of the lactase enzyme to digest milk sugars. However, the amount of lactase produced by the body decreases over time. Thus, dairy intolerance more commonly develops in later childhood and adulthood and once established, it’s less likely to resolve.

“Milk allergy most often has an early onset,” explains Robert Wood, MD, chief of pediatric allergy and immunology at Johns Hopkins Hospital in Baltimore. “It most often develops by one year of age. The majority of milk allergy will be outgrown by age 5 or 6; only about 10 to 20 percent will keep it for their entire lifetime.”

Lactose Intolerance Symptoms

Lactose intolerance generally involves only gastrointestinal symptoms, including:

abdominal bloating,
abdominal cramping,
gas,
vomiting,
diarrhea

These symptoms can occur up to several hours after ingesting dairy. Those with lactose intolerance may be able to eat small amounts of milk without a problem.

Dairy or Milk Allergy Symptoms

In contrast, an allergic reaction to milk generally involves multiple body systems, affecting the skin, lungs, digestive system and circulatory system. Symptoms can include:

itchy rashes,
hives,
swelling (often of lips and face),
wheezing,
throat tightness,
trouble breathing,
trouble swallowing,
abdominal pain,
vomiting,
diarrhea,
paleness/weakness,
confusion,
fainting,
low-blood pressure

Allergic symptoms usually begin minutes to an hour after ingestion. A very small amount of milk can potentially trigger a reaction. Thus, those with a milk allergy typically need to avoid milk completely.

How to Tell the Difference Between Lactose Intolerance and a Dairy Allergy

© Thinkstock 2012/iStockphoto

One of the main causes for confusion stems from the fact that both milk allergy and dairy intolerance can cause gastrointestinal symptoms.

“There are two main ways to differentiate in people who are having abdominal pain,” explains Wood. “First, it’s rare for someone with an allergy to have just abdominal pain. Usually, there are other symptoms, such as hives or other rashes, breathing difficulty or anaphylaxis. Second, it’s likely that an allergy would cause problems with much smaller doses of dairy than an intolerance.”

Another important indicator, says Jennifer Kim, MD, a pediatric allergist at Mount Sinai Medical School, is the timing of symptoms. “A dairy allergy is generally a more immediate reaction,” she says. “Symptoms occur right away or at least within an hour or two of ingestion. In lactose intolerance, they can develop over several hours after ingestion.”

Diagnosing Lactose Intolerance and Dairy Allergies

Usually, a physician can determine whether someone is experiencing an allergy or an intolerance based solely on their symptoms and other factors, such as their age and ethnic background. If it’s unclear or more information is needed, there are diagnostic tests available.

In the case of suspected lactose intolerance, a doctor can administer a lactose tolerance test or a hydrogen breath test. Either test can detect whether someone is properly digesting lactose. Alternatively, a doctor may simply recommend cutting dairy out of the diet to see if symptoms improve.

Diagnostic testing for a dairy allergy would include blood tests to measure the amount of IgE antibodies in the blood that respond to milk proteins. In addition, an allergist may order skin prick testing, in which a small drop of milk extract is placed on the skin to see if it causes a local reaction. The most conclusive test is a food challenge, in which a person eats small amounts of milk to determine whether it causes symptoms. Food challenges should always occur under the supervision of a board-certified allergist with emergency medications on hand in case of a severe reaction.

All Milk Allergies Are Not the Same

Milk allergies differ from person to person both by the severity of the reaction and the specific symptoms that result.

“In every person who has a milk allergy, IgE antibodies bind to different parts of the protein, depending on the individual,” says Kim. These subtle differences at the molecular level are the reason allergic individuals can experience very different reactions from one another and why some can tolerate milk in baked goods and others can’t.

Milk Bottle

© Radius Images/Alamy

In addition, people may be allergic to either or both major milk proteins: casein and whey. Casein makes up about 80 percent of milk protein; whey accounts for the remaining 20 percent.

Although casein is thought to be more allergenic than whey, the specific protein causing the allergy is not relevant to the care and treatment a milk-allergic person receives. Thus, allergists don’t test for it.

What About Goat’s Milk or Sheep’s Milk?

“Most people—over 90 percent—who are allergic to cow’s milk will also react to most of the other mammalian milks,” says Sicherer. “We think this is simply because the proteins are similar.” Those with severe dairy allergy should not try other animal milks except under close medical supervision.

Lactose Intolerance and Dairy Allergies: Necessary Treatment and Dietary Changes

For lactose intolerance, treatment is relatively straightforward and involves avoiding milk products, taking supplemental lactase enzyme (via a pill) or using lactose-free products (such as Lactaidģ milk). Some dairy products, such as cheese, yogurt and ice cream, may be easier to digest because they naturally contain less lactose.

Dairy allergy is much more serious and requires guidance and monitoring by a board-certified allergist. An allergist helps a patient develop a detailed care plan based on the specific severity and symptoms of their milk allergy. Avoidance of any exposure to milk products is the most important management strategy.

You may need to carry doses of antihistamines to control symptoms in the event of accidental exposure. Depending on the severity, your allergist may also prescribe an epinephrine auto-injector, which can be used to temporarily treat symptoms in the event of a severe reaction, giving you time to get to a hospital.

Unlike a dairy intolerance, there are no supplements or special types of milk products you can use to prevent an allergic reaction to dairy. However, there are various milk substitutes available, made with plant “milks” such as rice, coconut, soy, hemp and nuts. This includes substitute yogurts, ice creams and cheeses.

Due to the lack of dairy products in the diet, it’s important in both cases to get calcium from other sources, such as other calcium-rich foods (leafy greens, broccoli, some types of fish or shellfish, etc.), calcium-enriched juices and calcium supplements.

The Latest on Anaphylactic Dairy (Milk) Allergy Treatment

Important research is being conducted around the country with promising preliminary results based on small sample sizes. Essentially, these studies are investigating oral immunotherapy, a treatment for milk allergy where study participants are given small amounts of milk in gradually increasing doses over time to try to alter the immune system’s response to the allergen.

“We’re doing a study of milk oral immunotherapy and we’re testing whether adding omalizumab (an anti-IgE treatment used for asthma) helps patients, as well,” says Sicherer, describing ongoing research at the Mount Sinai Medical Center.

What’s known so far? “What is clear is that oral immunotherapy is not tolerated by everyone. There are side effects and it is still an open question whether it can make a milk allergy permanently end or whether it simply allows for an increased threshold before a reaction does occur,” says Sicherer.

It is important to note that this type of therapy is under investigation. Although initial results are promising, it is not an FDA-approved treatment and it should not be tried at home under any circumstances.

Joshua Feblowitz, who has severe milk and nut allergies, is a freelance medical writer and a student at Harvard University Medical School.

Comments (9)

Thanks for this article. I developed milk allergy (anaphylaxis) a few years ago as an adult at about the same time I developed shellfish allergy. I'm at a loss as to why this happened, although my mother developed shellfish allergy at the same point in her life, too, so there maybe be a genetic component? She is not allergic to milk, though. Anyway, it would be lovely sometime to see an article in LW regarding theories about the development of allergic anaphylaxis in adulthood and possible immunotherapy options, if anyone is doing this research. I do OK, but every 6 months or so I have a serious reaction to trace dairy and it would be nice to know what steps to take to ratchet down the symptoms.

Posted by: Unknown | March 27, 2013 12:12 PM    Report this comment

Brandy

I read there was a study done in the U.S. about 40 years ago on "Lactose Intolerance", they estimate 75% have some level of intolerance. You can Google 70% of humans are Lactose Intolerant and see lots of people claiming this. I 1st heard about it when Researchers created a new GMO Cow and they stated that is why.

My point is that Lactose Intolerance is the most common allergen among humans, Race does not matter. Now if only Doctors knew how to test for it like I do, those numbers would probably be a lot higher.

Posted by: Scott R | January 1, 2013 6:49 PM    Report this comment

I have found that I am sensitive to pasturized milk. I get the stuffy nose, sneezing, closed throat stuff, but I can drink raw milk and not have that problem. I am also sensitive to gluten. I noticed that dairy and gluten sensitivities seem to go together.. Does anyone know why?

brandy

Posted by: brandy | January 1, 2013 3:06 PM    Report this comment

As Daniel touched on, another facet of milk problems that seems to be overlooked is an autoimmune response. Casein triggers an autoimmune attack on my thyroid. I have Hashimoto's autoimmune hypothyroidism. Both gluten and dairy trigger a spike in my thyroid antibodies. I've had enough lab work done to be 100% certain that this is the case.

Posted by: Diana R | January 1, 2013 11:32 AM    Report this comment

Has any tests been done on why people who have cows milk intolerance can drink cows milk that has been pasteurized but not homogenized without any of the usual effects?

Posted by: Sandra L | January 1, 2013 11:19 AM    Report this comment

The other point regarding lactose intolerance that many celiac experts note is that once the small bowel is healed a goodly percentage of those with CD (celiac disease) and even GS (gluten sensitivity) may find that issues with lactose intolerance resolve or at least improve - due to the ability of the cells in the villi to once again produce lactase (IBS, Crohn's etc. can have a similar issue). So there is a clear connection of CD and GS to lactose intolerance. Many celiac patients will turn to soy milk early on (before healing is achieved) thinking they also have an issue with soy when in fact it may be a known GI inflammatory - an emulsifier additive carrageenan (made from red seaweed species) causing the symptoms. Recently, because of the number of complaints by consumers about carrageenan, Whole Foods has started to offer their brand of carrageenan free almond milk, and soy and coconut milk carrageenan free are in the works.

Posted by: Sharon M | July 26, 2012 7:41 PM    Report this comment

@ LeAnn G.....would you be willing to elaborate on the specifics of how dairy affects your nervous system and muscular system? I think I may fall into this category too, and would love to hear more about it. I am newly gluten free (4 mos.), but am still not feeling 100%. Am wondering if eliminating dairy would help, although the only dairy I consume is local raw dairy so I initially thought it would be ok. Maybe not...... Thank you!

Posted by: Unknown | July 21, 2012 3:52 PM    Report this comment

our family has several gluten intolerant individuals (one with EoE to wheat), and it has been our experience that we do not follow the 'typical' dairy intolerant description. dairy affects our nervous systems, and for me also my muscular system. lee g

Posted by: LeAnn G | July 19, 2012 7:55 PM    Report this comment

Several different proteins can be involved and it isn't always just an IgE reaction. Sensitivity can be IgA and/or IgG mediated. The proteins I speak of are the common casein and whey but also butyrophilin that is produced by the cells that also produce milk fat. IgG and IgA reactions tend to be slower reactions than the IgE mediated types and are therefore harder to sort out. Some labs are providing antibody and other tests that can be helpful in learning sensitivities to some of these proteins.

Posted by: flynv | July 17, 2012 10:11 PM    Report this comment

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