Reviewed by Jonathan Spergel, MD, PhD, Amy Dean, MPH, RD, LDN, Megan O. Lewis, MSN, RN, CRNP
Reviewed on 10/20/2025
Cow’s milk protein allergy (CMPA) & milk allergy: How are they different?
Cow’s milk protein allergy (CMPA) refers to a spectrum of difficulties infants and young children may experience when their bodies cannot tolerate – or properly process – proteins in cow’s milk. The spectrum of reactions can range from gastrointestinal symptoms like loose and/or bloody stools to an IgE-mediated allergy to milk. Treatment is different based on the type of reaction to the milk protein.
A cow’s milk protein allergy (CMPA) occurs when a child’s immune system mistakenly recognizes the protein in cow’s milk as a foreign invader. These types of milk allergies are most common in infants and young children. Milder forms of the disorder in infants – with bloody stools and no other symptoms – is called cow’s milk protein enterocolitis.
When an infant experiences delayed vomiting (2-4 hours) after ingestion of milk protein, and their skin appears gray, patchy or discolored, the condition is called food protein-induced entercolitis syndrome (FPIES).
Children who have a IgE-mediated milk allergy will typically show symptoms immediately, within minutes to up to 2 hours after consuming cow’s milk or products containing cow’s milk proteins (such as cheese and yogurt). Milk is among the foods most likely to cause anaphylaxis, a life-threatening allergic response. Other symptoms may include difficulty breathing, vomiting, nausea, rashes and hives.
Cow’s milk is the most common milk allergen, but children can also have allergic reactions to milk from other animals, including goats and sheep.
About 2.5 percent of children younger than 3 years old are allergic to some form of cow’s milk. However, most children will outgrow their milk allergy.
Causes of cow’s milk protein allergy
Cow’s milk and other milk protein allergies are typically caused when the body misidentifies the proteins in milk as being harmful. The body defends itself by releasing histamine, a chemical that causes symptoms such as coughing, wheezing and hives.
Signs and symptoms of milk allergies
If your child is allergic to the protein in cow’s milk, it may cause symptoms in multiple areas of the body, including:
- Skin: Hives (red, blotchy skin that can itch) and may include mild to severe swelling
- Lungs: Difficulty breathing, shortness of breath, coughing or wheezing
- Eyes: Itching, tearing or redness
- Throat: Tightness, trouble breathing or inhaling
- Stomach: Repeated vomiting, nausea, abdominal pain and cramping, or diarrhea
- Nose: Congestion, copious clear discharge, sneezing or itching
- Neurologic: Change in behavior or mood, dizziness
- Drop in Blood Pressure: This is the most dangerous symptom of a severe allergic reaction
If your child experiences any of these symptoms after consuming milk or dairy, call your pediatrician and arrange to have your child tested by a pediatric allergist.
If a child has any two body systems involved from the above list, this means they may be experiencing anaphylaxis.
If your child has symptoms of anaphylaxis, call 911 immediately.
Cow’s milk protein allergy vs. lactose intolerance
The difference between a cow’s milk protein allergy and lactose intolerance is the involvement of the immune system. When a child has a milk allergy, the body’s immune system creates IgE antibodies to the protein in cow’s milk which leads to the release of histamine and other chemicals that cause symptoms typical of allergic reactions.
Lactose intolerance, on the other hand, involves more of the GI system. Those with lactose intolerance lack an enzyme that breaks down lactose (the sugar in milk and dairy products). This causes GI symptoms that may include nausea, cramps, gas, bloating and diarrhea.
Testing and diagnosis of milk allergies
If you suspect your child is allergic to milk, clinicians at Children’s Hospital of Philadelphia (CHOP) will take a detailed medical history of your child, including information on any prior food reactions.
Based on your child’s history and reaction history, our clinicians may order one or more of the following tests.
Skin test
In allergy skin testing, a very small amount of the food allergen (in this case, the protein in cow’s milk) is introduced to the skin — typically on your child’s forearm — through a small pinprick. The appearance of a hive-like bump may indicate a milk allergy.
Blood test
In allergen-specific IgE blood tests, a small amount of your child’s blood is drawn and tested for antibodies the child may have produced in response to exposure to an allergen.
Food challenge
A oral food challenge involves giving your child small, but increasing, amounts of their allergen – in this case, milk protein – in a controlled, highly supervised clinical setting to monitor for any reactions. More than 70% of children with cow’s milk protein allergies can tolerate the baked form of the allergen (such as in cake). This can be determined in an oral food challenge. By incorporating baked cow’s milk and milk protein into the diet, it can enhance oral tolerance to native cow’s milk.
Treatments for cow's milk protein allergy
Once your child is confirmed to have an allergy to the protein in cow’s milk, the first step in treatment is avoiding cow’s milk and dairy products.
Your child’s doctor can give you detailed information on how to read food labels to help you identify and avoid milk protein. (See How to read a label for a milk-free diet below.)
No matter how careful you or your child are there may be times when your child accidentally ingests milk protein and has an adverse reaction. When that happens, you can treat the symptoms with antihistamines or epinephrine.
If more than one body system is involved in the allergic reaction — for example, the throat and skin — it is recommended to use epinephrine. Epinephrine comes in a variety of forms, including auto-injectors such as Epi-Pen, Auvi-Q and other generic forms as well as nasal sprays, such as Neffy.
If your child’s reaction is mild and only involves a few hives, an over the counter or prescription-strength antihistamine can ease their symptoms. Your child’s doctor can help you decide which option is best for your child in each circumstance.
Children with cow’s milk protein allergies should carry epinephrine with them, or it should be readily available at places where they routinely spend time, such as school, daycare and home.
When to call 911
If your child has a severe reaction or signs of anaphylaxis, administer epinephrine and call 911 right away. In some circumstances, children may need more than one dose of epinephrine, so it is important to have medical assistance in these situations if needed.
Your Child's Food Allergy Center Appointment
Learn what to expect during your child's visit with the Food Allergy Center.
Oral immunotherapy
Oral immunotherapy (OIT) may help desensitize your child to cow’s milk protein and other milk products. Your child will ingest small quantities of cow’s milk protein in a controlled setting with medical staff standing by to monitor for reactions; then continue ingesting that amount of milk protein every day at home. The amount of cow’s milk protein will be gradually increased under close medical supervision at the hospital. Your child’s healthcare provider can help you decide if oral immunotherapy may be appropriate for your child. If so, you'll receive a referral to CHOP’s Oral Immunotherapy Program.
Follow-up care for milk allergies
Most of the ongoing treatment for food allergies like cow’s milk protein allergies can be done at home. Once your child has been diagnosed with a cow’s milk protein allergy or milk allergy, you and your family will be given more information on how to avoid exposure to products containing cow’s milk and treat any reactions you child may experience.
You should share information about your child’s food allergy with your extended family, close friends and your child’s school so everyone can help reduce the chance of your child being accidentally exposed to their food allergen outside your home.
Some children with food allergies, including cow’s milk protein allergies, will eventually outgrow them. It's important that your child undergo a supervised test — such as an oral food challenge — to determine if they must continue avoiding the trigger food or can safely incorporate it into their diet.
Dairy-free Diet
Many children with cow’s milk protein allergies will not grow out of their allergy. To avoid allergic reactions, these children should maintain an allergen-free diet. The key to this type of diet is to avoid giving your child the foods or products containing the food to which they are allergic. The items that your child is allergic to are called “allergens”.
Cow’s milk protein is found in many foods. Obvious forms include cream, cheese, butter, ice cream and yogurt. But milk and milk products may also be minor ingredients in commonly eaten foods – even those you would not think had milk or milk protein. Some examples include processed meats, like hot dogs, sausages and luncheon meats. These frequently contain milk or are processed on milk-containing lines. To avoid foods that contain any milk products, it is important to read all food labels.
Be sure to avoid foods that contain any of the following ingredients:
- Artificial butter flavor
- Butter, butter fat
- Buttermilk
- Casein
- Caseinates (ammonium, calcium, magnesium, potassium, sodium)
- Cheese, cottage cheese, curds
- Cream
- Custard, pudding
- Ghee
- Half and half
- Hydrolysates (casein, milk protein, protein, whey, whey protein)
- Lactalbumin or lactalbumin phosphate
- Lactoglobulin
- Lactose
- Milk (derivative, protein, solids, malted, condensed, evaporated, dry, whole, low-fat, nonfat or skim)
- Nougat
- Pudding
- Rennet casein
- Sour cream
- Sour cream solids
- Whey (delactosed, demineralized or protein concentrate)
- Yogurt
Other possible sources of milk or milk products:
- Brown sugar flavoring
- Caramel candies
- Caramel flavoring
- Chocolate
- High protein flour
- Luncheon meats, hot dogs, sausages
- Margarine
- Natural flavoring
- Simplesse
Learn more about a dairy-free diet in children.
How to read a label for a milk-free diet
- The FDA requires common allergens like cow’s milk to be labeled clearly (using the word “milk”) on food packages. Milk must be listed as an ingredient, or the package will state “contains milk” underneath the ingredients. Some products use both methods in an abundance of caution.
- The words "non-dairy" or “nondairy” on a product label indicates it does not contain butter, cream or milk. However, this does not necessarily indicate it does not have other milk-containing ingredients.
- The Kosher food labeled "pareve" or "parve" almost always indicates the food is free of cow’s milk and milk products. A "D" on a product label next to the circled "K" or "U" indicates the presence of milk protein. These products should be avoided.
Guidelines for a cow’s milk protein allergy diet: What's allowed and what's not?
Beverages
| Allowed: | Not allowed: |
| Water | All milks (whole, low-fat, skim, buttermilk, evaporated, condensed, powdered or hot cocoa) |
| Carbonated beverages | Yogurt, eggnog, milkshakes, malts |
| Coffee | |
| Tea | |
| Soy substitute-milk formulas | |
| Fruit juice |
Breads
| Allowed: | Not allowed: |
| Milk-free breads | Wheat, white or rye breads that contain milk |
| French bread | Biscuits, donuts, muffins, pancakes, waffles, zwieback, crackers, saltines that contain milk. There are now several mixes available that do not contain milk. Be sure to carefully read labels. |
| Wheat, white, rye, corn, graham, gluten and soy breads made without milk or milk products | Most commercially prepared breads and rolls contain milk or milk products |
| Graham cracker and rice wafers | French toast made with milk |
Cereals
| Allowed: | Not allowed: |
| Any cereal to which no milk or milk products have been added | Prepared and precooked cereals with milk solids, casein or other milk products added |
Desserts
| Allowed: | Not allowed: |
| Meringue, gelatin, popsicles, fruit ice, sorbet, fruit whip and angel food cake | Cake, cookies, custard, pudding, gelato, cream desserts or sherbet containing milk products |
| Cakes, cookies and pie crusts made without milk or milk products such as Vegan desserts | Ice cream, cream pie |
| Pastries brushed with milk |
Eggs
| Allowed: | Not allowed: |
| Prepared without milk | Scrambled with milk, creamed eggs or egg substitutes |
Fats
| Allowed: | Not allowed: |
| Vegetable oil, meat fat, lard, bacon, shortening, milk-free gravy | Butter, cream, margarine |
| Peanut butter (made without milk solids) | Salad dressing or mayonnaise containing milk, milk solids or milk products |
| Margarine without milk solids | Some butter substitutes and nondairy creamers |
| Kosher margarine | |
| Vegan butter substitute |
Fruits
| Allowed: | Not allowed: |
| Fresh, frozen or canned fruits and juices | Any fruits served with milk, butter or cream such as whipped cream |
Meats, fish, poultry and cheese
| Allowed: | Not allowed: |
| Baked, broiled, boiled, roasted or fried: beef, veal, pork, chicken, turkey, lamb, fish, organ meats or tofu (prepared without milk or milk products) | All cheese, cottage cheese, cream cheese |
| Sausage, deli/luncheon meats or ham if made without milk products | Some sausage products, bologna and frankfurters |
| Note: A small number of people with cow's milk allergy may develop a reaction to beef. Thus, those with cow's milk allergy should be careful when consuming beef or foods containing beef. | Breaded meats, meatloaf, croquettes, casseroles, hamburgers (unless made without milk) |
| Commercial entrees made with milk or milk solids |
Potatoes and substitutes
| Allowed: | Not allowed: |
| Macaroni, noodles, spaghetti and rice | Au gratin, buttered, creamed, scalloped potato or substitutes |
| White or sweet potatoes prepared without milk, butter, cream or allowed margarine | Macaroni and cheese |
| Mashed potatoes containing milk or butter | |
| Frozen French fries sprayed with lactose |
Soups
| Allowed: | Not allowed: |
| Bouillon, broth, consommé or soups with broth base plain or with all allowed foods | Bisques, chowders, creamed soups |
| All soups made with milk or milk products |
Sweets
| Allowed: | Not allowed: |
| Corn syrup, honey, jam and jelly | Candy made with milk, such as chocolate, fudge, caramels or nougat |
| Hard candy and candy made without milk or milk products | |
| Granulated, brown or powdered sugar |
Vegetables
| Allowed: | Not allowed: |
| All fresh, frozen or canned vegetables without milk or milk products added | Au gratin, buttered, creamed or scalloped vegetables |
| All vegetable juices | Batter and dipped vegetables |
| Vegetable souffles |
Miscellaneous
| Allowed: | Not allowed: |
| Ketchup, olives, pickles, nuts, herbs, chili powder, salt, spices, condiments | All items containing milk, cheese, butter, whey casein, caseinates, hydrolysates, lactose, lactalbumin, lactoglobulin or milk solids, or artificial butter flavor |
| Any foods that are milk-free, cheese-free, or butter-free, or that do not contain powdered milk or whey | Nondairy substitutes containing caseinate |
Resources to help
Food Allergy Center Resources
Caring for a child with a food allergy can be challenging. To help you find answers and feel confident with the care you’re providing your child, we’ve created the following list of health resources.
Meet your team
Your child’s medical team is led by Jonathan M. Spergel, MD, PhD, Terri F. Brown-Whitehorn, MD, and Megan O. Lewis, MSN, CRNP. We develop customized treatment plans for children with all types of food allergies.