Is your baby making lots of 'urrrgghhh, urrrgghhhh, urrrggghhhh' noises and squirming a lot? Then read on...this may be the very reason why.
- Your baby may have lots of pooey nappies and they may be sticky or mucousy.
- They have tummy ache or colic and it may be worse at night time.
- They may be gaining weight or not.
- Why your baby might have an unsettled tummy and have problems sleeping.
It may be cows milk protein intolerance or allergy.With my sleep work as a baby whisperer, I meet a lot of babies with food allergies, intolerances and reflux (GORD). Many of these babies have a family history of an atopic disease - asthma, eczema and hay fever.
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.
Between 5-15% of infants will display symptoms indicating cows milk protein intolerance (CMPI) whilst 2-7.5% of infants will have a prevalence of Cows Milk Protein Allergy (CMPA).
Here's a long read via the link to the Archives of Disease in Childhood journal paper on - Guidelines for the diagnosis and management of cow’s milk protein allergy in infants: https://cdn.shopify.com/s/files/1/0612/7760/2021/t/11/assets/description_image_902.full.pdf?v=1644489658
Elimination of cow's milk protein from the infant's or mother's diet and challenges are the gold standard for diagnosis.CMPA can be easily missed and misdiagnosed. These are very unsettled young babies and they present in a variety of ways. Often it can be misdiagnosed as reflux, colic as well as a myriad of other conditions.
Reactions to other foods, especially egg and soy, but also wheat, fish, peanut and other foods may occur in combination with CMPA. This means that complementary feeding and, preferentially, all supplementary feeding should be avoided during the diagnostic elimination diet.
Exclusive breastfeeding during the first 4–6 months of life reduces the risk for CMPA and most severe allergic diseases during early infancy. CMPA is lower in exclusively breastfed infants compared to formula‐fed or mixed‐fed infants. Only about 0.5% of exclusively breastfed infants show reproducible clinical reactions to CMP and most of these are mild to moderate. This might be related to the fact that the level of CMP present in breast milk is 100 000 times lower than that in cow's milk. In addition, immunomodulators present in breast milk and differences in the gut flora in breast‐fed and formula‐fed infants may contribute to the prevalence of CMPA in breast‐fed compared to formula‐fed infants.
While in some young infants there is a strong association between atopic dermatitis and CMPA, many cases of atopic dermatitis are not related. The strength of the association depends on the age and severity of atopic dermatitis: the younger the infant and/or the more severe atopic dermatitis, the stronger the association.
It is so important that health professionals, GP's and Paediatrician's take a thorough history of
- Feeding - breast and or formula (which formula) - how often and how much
- Stools - how often, colour and consistency
- A family history of food intolerances or atopic disease - asthma, eczema and hay fever. The risk of atopy increases if a parent or sibling has an atopic disease (20–40% CMP and 25–35% CMPA, respectively), and is higher still if both parents are atopic (40–60%)
- Weight measurements are important. The earlier the CMPA presents the greater the effect on growth retardation.
- Skin irritations/eczema
What are some of the signs and symptoms of cows milk protein intolerance?
- Poor weight gain
- Mucousy/sticky stools
- Irritability and crying following feeds
- Can be constipation
And symptoms of Cows Milk Protein Allergy?
- Blood in stools, often looking like redcurrant jelly
- Angio-oedema, swelling around the eyes and vocal cords, coughing post feeds
- Reflux (GORD)
So how do you exclude or prove its CMPA?
- An elimination diet is the only way. It's very restrictive. Mums often complain a lot about it and it's important to be managed correctly so as not to cause any nutritional imbalances.
- Elimination diet of at least 2 weeks and up to 4 weeks in cases of allergic colitis and atopic dermatitis.
- Elimination of all milk products and egg are recommended. Less proven is elimination of wheat, peanuts and fish. The mum will need calcium supplements of 1000mg per day divided into several doses.
- If symptoms improve substantially or disappear during the elimination diet, one food per week can be reintroduced to the mother's diet.
- If symptoms do not re‐appear on the reintroduction of a particular food to the mother's diet, the elimination of that specific food can be discontinued.
- If symptoms re‐appear, the food responsible should be eliminated from the mother's diet as long as she is breastfeeding. If solid foods are introduced into the infant's diet, care should be taken to ensure solids are free from the food proteins that the infant is allergic to.
- If CMP is the responsible allergen, the mother should continue to receive calcium supplementation during the elimination diet. If the mother is on a CMP‐elimination diet for a long period, appropriate nutritional counselling is required.
- When the mother wants to wean her infant, the child should receive an extensively hydrolysed formula (eHF) with demonstrated clinical efficacy.
If your baby is formula-fed which infant formulae are suitable for babies with CMP intolerance?
- NAN HA Gold or Karicare HA Gold - this is more for prevention.
- Karicare Allerpro - this is more for treatment and especially combined with atopic dermatitis.
And CMPA allergies?
- An extensively hydrolysed infant formula, soy or amino acid-based formula usually only available on prescription and from a paediatric gastroenterologist (in Australia) such as Neocate, Alfare, Pepti-Junior, Allerpro and EleCare.
- After 6 months it is reasonable to try a soy infant formula.
So will my child grow out of their allergy? That's the 100 dollar question.
- For the majority of children, their cow's milk protein allergy will resolve.
- 50% of children with cows milk allergy will resolve within 2 years and 80% by 3-4 years after diagnosis.
- The doctors will determine whether your child has grown out of their allergy by a combination of skin testing and food challenge with milk.
Challenges may need to be done in a hospital by experienced medical staff. Do not do challenges at home unless instructed to do so by your doctor.
Some further reading
- The Royal Children's Hospital of Melbourne guide to Cows Milk Allergy - http://www.rch.org.au/uploadedFiles/Main/Content/allergy/Cows%20milk%20allergy.pdf
- Archives of Disease in Childhood journal paper on - Guidelines for the diagnosis and management of cow’s milk protein allergy in infants: https://cdn.shopify.com/s/files/1/0612/7760/2021/t/11/assets/description_image_902.full.pdf?v=1644489658
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