Breastfeeding
in Infants with
CMPA

Importance of continuing to breastfeed in infants with CMPA.

Breastmilk contains a diverse range of bioactive components including, immunoglobulins, hormones, and oligosaccharides or human milk oligosaccharides (HMO) (Wiciński et al 2020).

Newborns therefore obtain maternal immune support through factors in breastmilk, including HMO, secretory immunoglobulin A (IgA), lactoferrin, antimicrobial peptides (AMPs) and others (Field CJ, et al. J Nutr. 2005. Cederlund A, et al. PLoS One. 2013).

Breastmilk therefore provides the ideal balance of nutrients for the infant, including those with CMPA.

The composition of
Breastmilk

Human Breastmilk
Macronutrients,
Micronutrients,
and HMO
Water
Solid Components
Proteins
(about 8 g/l)
HMO (5-15 g/L)
Lactose
(about 70 g/L)
Lipids
(about 40 g/L)
HMO
...
Sialyllacto-N-tetraose
3’ -and 6’- Sialyllactose
3’ - Fucosyllactose
LNT & LNnt
Lacto-B-fucopentaose
2’FL

HMO are the third most abundant solid component of breastmilk (Figure 2.) and play an especially important role in nurturing the growing immune systems (Zivkovic A, et al. PNAS. 2011).

There are over 200 of these structurally complex carbohydrates known today, two of them – 2’ Fucosyllactose (2’FL) and Lacto-N-(neo_tetraose (LNnT) - account for more than 30% of HMO in breastmilk (Vandenplas Y et al. Nutrients.  2018).

Managing infants
with CMPA when
breastfed

In rare cases when CMPA is suspected in an exclusively breastfed infant, a diagnostic maternal exclusion of cow’s milk/dairy-free for 2-4 weeks is recommended whilst continuing to breastfeed (Vandenplas et al., ESPGHAN CMPA guidelines 2022 – under review). Following this exclusion period, in order to confirm the diagnosis, cow’s milk/dairy should be reintroduced back into the maternal diet while monitoring of infant’s symptoms.

During the maternal exclusion the mother is advised to eliminate all sources of cow’s milk/dairy from her diet as well as that of her baby (if complementary feeding has started). Guidelines recommend that professional dietary counselling during the exclusion period to ensure the quality of the mother’s diet, as well as follow-up to ensure that the exclusion of foods does not continue if not effective (Januszko P, et al 2020).

In case of a prolonged maternal elimination diet then supplementation with calcium and vitamin D is recommended – up to 1000 mg of calcium and 10 micrograms of vitamin D/day (Ludman S, et al. BMJ. 2013). In addition, supplementation with iodine and vitamin B12 can be considered (Vandenplas et al., et al., ESPGHAN CMPA guidelines 2022 – under review).

Note: Breastfeeding mothers should only avoid eating or drinking a food that their baby is reacting to in their milk (National Allergy Strategy Australia. 2018). Removing foods from the mother’s diet, unnecessarily, puts the mother’s nutritional health at risk, particularly when removing food groups such as dairy, wheat or multiple foods. Dietary exclusion during breastfeeding should also be supervised by a dietician (ASCIA, 2022).

Several clinical studies reported the protective effect of breastfeeding.


For infants, including a reduced incidence of:

Effect

Gastroenteritis and diarrhea

Effect

Respiratory tract infections

Effect

Atopic manifestations