Cows milk protein intolerance or allergy is one of the most common causes of constipation in toddlers and children. Yet, I hear about so many children who have been prescribed stool softeners and bowel preparations to treat the problem. In Australia we don't know or understand about prevention in our current healthcare paradigm. It is literally a foreign concept. The problem with treating this problem is the childs body gets used to the stool softeners and this creates a lazy bowel and then the bowel forgets how to work properly once the stool softeners are removed.
Prevention and The Stats
Instead we need to approach this from a preventative point of view.
We know cows milk protein intolerance and allergy can run in families. A family history of food intolerances or atopic disease – asthma, eczema and to lesser extent, hay fever. The risk of atopy increases if a parent or sibling has an atopic disease (20–40% CMP (intolerance) and 25–35% CMPA (allergy), respectively), and is higher still if both parents are atopic (40–60%)
We know that approximately 16-42% of babies with GORD show signs or symptoms of cows milk protein allergy (CMPA). 15–21% of children with suggested or proven gastro‐oesophageal reflux disease (GORD) or CMPA suffer from both conditions. CMPA is also linked to colic and approx 10% of babies with colic will have CMPA.
Constipation affects 5–30% of children and is responsible for 3% of visits to the doctor. General practitioners (GPs) are frequently the first medical encounter for concerned parents regarding their child’s bowel habit.
What is True Constipation?
Functional constipation is defined as two or more of the following:
- two or fewer poo's per week
- at least one episode of faecal incontinence per week
- history of holding onto the poo
- history of painful or hard bowel movements
- presence of a large faecal mass in the rectum
- history of large diameter stools that may obstruct the toilet
- symptoms occurring at least once per month for a minimum of one month, with insufficient criteria to diagnose irritable bowel syndrome.
Causes of Constipation
The following conditions are causes of constipation in children
|Allergy – cow’s milk protein intolerance and/or other food protein intolerances|
|Electrolyte abnormalities – hypercalcaemia, hyperkalaemia|
|Drugs – opiates, phenobarbital, anticholinergics|
|Neuropathic disorders – Hirschsprung’s disease, internal sphincter achalasia|
|Spinal cord abnormalities – myelomeningocele, tethered spinal cord, syringomyelia
Stooling may occur without sensation or urge
|Anatomic malformations – imperforate anus, anteriorly displaced anus|
However the most common cause of severe constipation is cows milk protein intolerance or allergy.
If you Suspect Cows Milk Protein is a Likely Culprit What Should You Do?
This is the position statement of the Royal Australia College of GP's.
"Allergy testing is not recommended to diagnose suspected cow’s milk allergy in children with constipation, as it is usually not IgE mediated. A one-month trial of avoidng cow’s milk and soy protein may be indicated in children with intractable constipation. During this period, calcium intake should be supplemented with almond or rice products, or calcium supplementation. Dairy intolerance can improve with time in older children but data in small children is limited. Dairy is tried in the diet every 6–12 months as tolerated. Referral should be made to a paediatrician or paediatric gastroenterologist/allergist if there is suspicion of multi-food allergies. Normal fibre intake, fluid intake and exercise are recommended for children with constipation. Fibre supplements are not recommended."
Dr Alan Green Says
Dr Alan Greene says ' the classic symptoms of milk intolerance are diarrhoea, spitting up, or abdominal pain. Many kids with milk intolerance also wheeze, especially when they get a cold. They can also have the dry, sensitive skin of eczema and their noses always seem to be running. Ear infections are also more common than in other kids. Constipation, however, has not been typically associated with milk intolerance — until now.'
The observation of constipation being caused by milk intolerance has appeared in the medical literature from time to time, dating back as far as 1954 (Pediatric Clinics of North America, 1954; 4:940-962). But only recently has there been a well-designed study published showing this is fact. The results of this study, when widely known, can set many children free to enjoy childhood without pain.
Researchers at the University of Palermo in Italy studied 65 children with chronic constipation. All of these children had been treated with laxatives when dietary measures had failed. Even with the medical treatment, these children were still constipated, having hard, painful constipated poo's only every 3 to 15 days. Forty-nine of the their little bottoms had fissures and redness or swelling from the hard plugs of poo.
Each child received either cow’s milk or soy milk for 2 weeks, with no one knowing which was which. Next, they had a week during which they could eat and drink anything they wanted to wash out the effects of the first 2 weeks. Then they switched sides for 2 weeks and got the milk that they didn’t get the first time. Careful recordings of the bowel habits were made.
When the secret code was broken at the end of the study, they found status quo constipation for each child while he or she was on cow’s milk. But while they were taking soymilk (which causes firmer stools in most kids), 68% of these kids were no longer constipated! The redness, swelling, and fissures on their bottoms healed (New England Journal of Medicine, 1998; 339:1100-1104). How wonderful to finally have relief after diet and medicines hadn’t worked for so long!
The results were most dramatic in kids who also had frequent runny noses, eczema, or wheezing. Nevertheless, sometimes constipation can be the only symptom of cow’s milk intolerance.
Broad Implications for Practice
This has broad implications. The children in this study were those with severe chronic constipation unresponsive to medications. I am convinced these are only the tip of the iceberg. There must be a much larger group of mildly allergic children whose constipation improves with laxatives. Time may prove that it is better for these children to avoid the offending protein by switching milks rather than being treated with laxatives.
Unfortunately, 50% kids who are allergic to cow’s milk protein are also soy protein intolerant. . If you don’t get good results within 2 weeks, I suggest also eliminating soy from the diet for 2 weeks as a trial.
I hope this blog has helped your child. I myself have cows milk protein allergy and had eczema as a child and spent my childhood suffering from severe constipation. In those days we didn't understand the link between cows milk protein and constipation. Since coming off cows milk protein foods I no longer have this problem and my eczema is virtually non-existent.
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