Cow’s milk, egg, wheat and soya (MEWS) free diet

Introduction

Your child has been diagnosed or is suspected to have a cow’s milk, egg, wheat and soya (MEWS) intolerance or allergy. This information sheet is intended as a guide to identifying suitable foods for this diet.

Although there are obvious sources of milk, soya, egg and wheat, derivatives of milk, soya, egg and wheat are also found in many manufactured foods.

Symptoms of food allergy

Immediate symptoms may include a combination of the following:

• itchy skin rashes (redness or hives)
• swelling of the face, eyes or lips
• runny nose, itchy eyes
• eczema
• coughing
• vomiting
• swallowing or breathing difficulties (rare)

Delayed symptoms may include a combination of the following:

• diarrhoea - often with a sore bottom (nappy rash)
• constipation – often associated with excessive straining
• gastro-oesophageal reflux disease (reflux)
• profuse vomiting
• abdominal pain, bloating or distension
• mucus and/or blood in the stools
• nausea
• painful wind, excess gas

Management of a MEWS free diet

Checking food labels

Cow’s milk, egg, wheat and soya allergy should, in most cases, be treated with a strict elimination of these foods. Your Dietitian will help you to ensure your child avoids all the relevant ingredients while making sure that nutritional intake is not affected

Milk

Babies requiring a milk-free diet, who are not breastfed, will be advised on the most appropriate type of formula replacement depending on your child’s clinical history.

You should discuss with your Dietitian whether your child needs to avoid all lactose (milk sugar) or not. Some hypoallergenic milk formulas contain lactose but are still suitable for most babies/children with cow’s milk allergy.

Egg

Children with egg allergy are not usually allergic to chicken. They are however very likely to be allergic to eggs from birds other than hens as they contain similar proteins (e.g. geese, quail, duck), so these should also be avoided.

Wheat

Your child may also need to avoid the other gluten containing cereals; rye and barley, as these grains contain similar proteins to wheat. Discuss with your Dietitian whether your child needs to avoid these as well as wheat. Trace amounts of wheat may be found in standard oats, but gluten free oats will be free from any trace amounts of wheat. Your dietitian will advise whether your child can have standard oats, gluten free oats or completely avoid oats.

Soya

Most children with a soya allergy do not need to avoid other legumes e.g. peas, beans and lentils. Your Dietitian will discuss this with you.

UK food allergen labelling law requires that common food allergens used as ingredients or processing aids must be declared on the packaging or at the point of sale. The list of 14 common food allergens includes milk, egg, wheat and soya. This may be in bold, underlined, or in italics. As of October 2021, Natasha’s Law was implemented in the UK. This means that foods made and packaged on site (such as in a café or bakery – called pre-packed foods for direct sale) must also have a full ingredients list on the food with the allergens highlighted in the same way as for pre-packed manufactured foods.

There must also be a list of product ingredients available for all foods that may not be labelled as they are sold loose such as those sold in a delicatessen or bakery. This may be written down or explained to you verbally.

Labels that say ‘may contain...’ are not covered by labelling laws. They are used to indicate that the food is produced in the same area as foods containing allergens, and there may be a risk of cross contamination. This should be following a strict risk assessment.

There are many ways in which milk, egg, wheat and soya can be labelled, so carefully check the ingredients list on food items. By law you must be able to clearly tell that a product contains milk, egg, wheat or soya e.g. if casein is listed, it should tell you in brackets that this is ‘from milk’.

Avoid foods with the following ingredients:

Milk

• Buttermilk
• Cow’s milk (fresh, UHT)
• Condensed Milk
• Cream/artificial cream
• Evaporated milk
• Butter, butter oil
• Ghee
• Margarine
• Cheese
• Fromage Frais
• Ice Cream
• Yogurt
• Casein (curds), caseinates
• Calcium or sodium caseinate
• Hydrolysed casein
• Hydrolysed whey protein
• Lactoglobulin
• Lactoalbumin
• Lactose*
• Milk powder, skimmed milk powder
• Milk protein
• Milk sugar
• Milk solids, non fat milk solids
• Modified milk
• Whey, whey solids, hydrolysed whey
• Whey protein, whey syrup sweetener

*Lactose - Please discuss with your Dietitian to what extent your child will need to avoid lactose.

Milk free foods may also be referred to as being ‘dairy free’

Soy and soy derivatives

• Soya milk, soya yoghurts and desserts Hydrolysed vegetable protein
• Soya lecithin E322
• Soya protein products; for example, miso, tofu, edamame, tamari, nimame, natto, okara, soja, tempeh
• Soy sauce, Worcestershire sauce, oyster sauce, teriyaki sauce, vegetable broth, vegetable starch

Please note: A product labelled ‘free from soya or soya derivatives’ may contain soya oil and/or soya shortening. Soya oil, as used in manufactured products, is refined and contains no protein; it is considered soya free. Cold pressed soya oil, available from health food shops, may contain soya protein and should be avoided

Egg

• Egg/ fresh eggs (including all birds' eggs)
• Egg protein (albumin, ovalbumin, globulin, ovoglobulin, livetin, ovomucin, vitellin, ovovitellin)
• Dried egg
• Egg albumin
• Egg lecithin E322 Egg yolk
• Egg white Frozen egg Pasteurised egg

Wheat

• Breadcrumbs or batter
• Hydrolysed wheat protein
• Wheat bran
• Wheat flour
• Wheat germ
• Wheat germ oil
• Wheat gluten
• Wheat starch (please note that many gluten-free products still contain gluten-free wheat starch and are therefore not wheat-free)
• Raising agents (check for presence of wheat starch, or cross contamination)

Please note: All branded products are cow’s milk, soya, wheat and egg free at the time of printing but are subject to change without notification. Always check the ingredients. Detailed information on manufactured products can be obtained from the customer services department of most supermarkets.

Rarely, breast fed babies can react to milk, egg, wheat and/or soya proteins transferred in breast milk from the mother’s diet. If your baby reacts to your breast milk, you may be advised to avoid milk (dairy), egg, wheat and soya products whilst breastfeeding. This is usually done as a trial for between 2 to 6 weeks to see if your baby’s symptoms improve. If they do not, and you were following the diet strictly, you can return to your normal diet.

If your baby is having infant milk formula with or without any breast milk it will need to be changed to a prescribed hypoallergenic infant formula. Your Dietitian will give advice on the best one for your baby. These are available on prescription from your GP and there are two main types:

• extensively hydrolysed formulas (where the milk protein is broken down into small pieces) making them very likely to be tolerated
• amino acid formulas (this formula is not based on cow’s milkmilk, and the protein is completely broken down).

Please note: any partially hydrolysed formulas such as ‘HA’ formulas designed for prevention, anti-colic and constipation ‘Comfort’ formulas and anti-reflux formulas are not suitable for the treatment of cow’s milk allergy.

In instances where a specialist formula is not indicated, or where a child is more than two years of age, other milk substitutes can be used, such as almond milk, soya milk and oat milk. Rice milk is a suitable substitute for children over the age of 4½ years. It is recommended that you choose one with suitable vitamin/mineral supplementation, especially added calcium and iodine if possible.

Tips for eating out

Current Law states that if a business provides food to their customers directly, for example in a restaurant or cafe, they must provide allergen information in writing. This could be either:

• full allergen information on a menu, chalkboard or in an information pack
• a written notice placed in a clearly visible position explaining how their customers can obtain this information - for example by speaking to a member of staff. For further information see Allergen guidance (opens in a new tab)

Depending on your child’s reactions, particularly if they are severe, you may find some of these tips useful:

• Carry your child’s emergency medication with you and make sure it is in date.
• Check out the restaurant’s website – many contain nutritional and allergy information.
• Ring the restaurant in advance to ensure they can cater for your child’s allergy. Try to call at off-peak times when the staff will have more time to deal with your query.
• Get to know the chef in your favourite local restaurant.
• Speak to your waiter/waitress or the chef on arrival to check they are all aware of your child’s food allergy.
• You may find it helpful to use a ‘chef card’
  

Hand the card to your waiter/waitress and this will help to ensure that correct information is passed to the chef and if necessary that the food you have requested should not have any contact with or products that contain milk, egg, wheat or soya.

• Keep to “simple” foods on the menu. Sauces and gravies contain many ingredients which cannot always be remembered by staff.
• If you do not understand the description of a menu item, it is safer not to order it.
• Avoiding the busiest times may be helpful in ensuring staff are attentive and have time to check ingredients.
• Remember milk, egg, wheat or soya may not be mentioned in the description of a dish – check for hidden sources e.g. marinades.
• Self-service areas, buffets and salad bars are also at risk of cross contamination from one dish to another.
• Make sure those you are dining with know about your child’s allergies and know what to do if a reaction occurs.
• If in doubt, choose to eat elsewhere.
• If eating with friends or at a party, remember to tell the host about your child’s milk, egg, wheat and soya allergy in advance so they can prepare suitable dishes.
• At children’s parties it may be helpful to take your own milk, egg, wheat and soya free foods. If you are not staying with your child, remember to explain how serious his or her reaction could be and how to deal with it. Ensure that your child/their host knows they should not swap foods/eat from another child’s plate.
• Some restaurants have signed up to the Allergy UK ‘Allergy Aware’ scheme (opens in a new tab). This shows that staff have had allergy training and the restaurant follow recommended procedures to ensure safety for customers with food allergies.
• In addition, restaurants may have received the Coeliac UK gluten free accreditation to ensure that, when required, a customer’s full meal has no cross contamination with gluten-containing grains. Many of these restaurants also include milk and soya in the gluten free menu as additional information. This may give you confidence that the restaurant takes allergies and preparation of allergen-free foods seriously, but always discuss your particular needs at the time of ordering.

Vitamin and mineral supplementation

If a calcium and/or vitamin supplement is required your dietitian will advise you on an appropriate product and dose for your child.

Egg replacers

Egg replacers have little nutritional value, but they can be useful in cooking for making cakes and such. They can generally be obtained from health food stores, large supermarkets or from the manufacturer. Some homemade ideas for egg replacers are mashed banana, chickpea water (or chickpea flour mixed with water in equal quantities) or grated fruit such as apple or pear.

Orgran: No Egg (200g); 1 pack = 66 eggs

Holland and Barrett: Vegan Egg Replacer (200g)

Free and Easy: Free From Egg replacer 135g; 1 pack = 45 eggs

Oggs: Oggs Egg Alternative Aquafaba (200ml); 1 pack = 4 eggs

Tesco: Tesco Egg alternative (135g); 1 pack = 22 eggs

Reintroductions

As most children will outgrow their allergies, it is important that they are regularly reviewed. This will help prevent unnecessary avoidance of foods. You should discuss with your Dietitian or Doctor when and how to re-introduce cow’s milk, egg, wheat or soya safely. In some cases, they may recommend that your child has a food challenge in hospital.

Cooking and processing can alter some of the allergenic proteins in milk, egg and soya, making it less likely that the proteins will be recognised by the body, so an allergic reaction is less likely. Therefore, some children are able to tolerate milk, egg or soya that has been baked at a high temperature (e.g. milk or egg in cakes or biscuits or soya flour in bread) but will still react to small amounts of less well-cooked milk, egg or soya e.g. milk in custard, quiche; egg in pancake mixture or scrambled egg; soya in yogurt or tofu.

It is important not to introduce cow’s milk, egg, wheat or soya at home unless you have been advised to do so by your Dietitian or Doctor.

NOTE: If your child can tolerate baked milk, baked egg or cooked soya, your Dietitian will be able to advise on foods that will be safe for your child to eat.

Resources:

Milk, egg, wheat and soya free diet for children – British Dietetic Association (14/02/2024)