𝐆𝐚𝐬𝐭𝐫𝐨𝐞𝐬𝐨𝐩𝐡𝐚𝐠𝐞𝐚𝐥 𝐑𝐞𝐟𝐥𝐮𝐱 (GOR) is likely one of the most common causes of concern for 👫parents of infants/newborns.
⁉️Signs can some time be hard to understand, as not in all cases you will see the feed coming out. This is what is commonly called “𝘴𝘪𝘭𝘦𝘯𝘵 𝘳𝘦𝘧𝘭𝘶𝘹”.
🔶️There are common behaviours that can be used to make that diagnosis, though all need to be put into context as not always it means the child has reflux.
❓So what are they?
▶️Unsettled when lying flat
▶️Need to wind in an upright position for long periods
▶️Need to fall asleep upright
▶️Frequent hiccups (stimulation of phrenic nerve by acid in the oesophagus)
▶️Frequent feeding (feeding leads to release of endorphins, decreasing pain caused by acid reflux – if not treated, can lead to food refusal)
❓Do all need investigation and/or treatment?
🔹️Not at all.
🔹️In reality, most cases just need conservative measures.
⚠️When GER becomes severe (leading to GERD - GastroEsophageal Reflux Disease), there are several aspects we need to worry about, and appropriate action is required.
➡️The following are the complications to pay attention to:
✅Failure to thrive
✅Acute life-threatening events
✅Oesophagitis (endoscopy needed to make a diagnosis)
✅Haematemesis (vomiting blood)
𝐈𝐧𝐯𝐞𝐬𝐭𝐢𝐠𝐚𝐭𝐢𝐨𝐧𝐬 𝐟𝐨𝐫 GER
▶️Oesophageal pH study and/or impedance study
▶️Upper GI (gastrointestinal) endoscopy
‼Do bear in mind that a significant proportion of GER in infants might be associated with a🥛 milk allergy:
🔸️204 infants (<1yr) with GER
🔸️40% respond to cow’s milk exclusion (hydrolysate)
🔸️Responders typically had other GI symptoms and atopic features (eczema) (𝘐𝘢𝘤𝘰𝘯𝘰 𝘦𝘵 𝘢𝘭 𝘑 𝘈𝘭𝘭𝘦𝘳𝘨𝘺 𝘊𝘭𝘪𝘯 𝘐𝘮𝘮𝘶𝘯𝘰𝘭 𝟷𝟿𝟿𝟼; 𝟿𝟽: 𝟾𝟸𝟸-𝟽)
If you are worried and see any of the symptoms described above, go to your GP, and he/she will address those issues and eventually refer to a 𝐏𝐚𝐞𝐝𝐢𝐚𝐭𝐫𝐢𝐜𝐢𝐚𝐧, a 𝐏𝐚𝐞𝐝𝐢𝐚𝐭𝐫𝐢𝐜 𝐀𝐥𝐥𝐞𝐫𝐠𝐢𝐬𝐭 or 𝐃𝐢𝐞𝐭𝐢𝐭𝐢𝐚𝐧.
⚠️Do not try a Lactose Free formula if there are worries of a milk allergy! Lactose is the sugar in milk, not a protein.
⚠️Do not try medication for colic, as evidence suggests they are of no use. Often, it is either coincidental improvement or even the placebo effect on parents, as they feel something is being done.
⚠️Simple Food Protein Induced Enterocolitis Syndrome (𝐅𝐏𝐈𝐄𝐒) or Food Protein Induced Proctocolitis (𝐅𝐏𝐈𝐏) is often mistaken for a viral infection causing vomiting and diarrhoea, with occasional blood in stool.
‼️Often, and not wrongly, it may be diagnosed as a 𝘯𝘰𝘯-𝘐𝘨𝘌 𝘢𝘭𝘭𝘦𝘳𝘨𝘺, with the most common being CMPA.
✅This is because it normally tends to have mild symptoms.
⁉️Important to note that severe 𝐅𝐏𝐈𝐄𝐒 is relatively rare and less common than Anaphylaxis!
✴𝐅𝐏𝐈𝐄𝐒 most common triggers:
▶️But can be associated with a long list of food proteins
🧒👧Most children will be able to tolerate the food causing the reaction by the age of 2 or 3 years old. In some cases, it may persist throughout life.
❗Children with recurrent episodes may suffer from poor growth and weight loss - failure to thrive.
✅Usually children will recover very fast from an episode of 𝐅𝐏𝐈𝐄𝐒, as long as appropriate diagnosis and treatment is made.
🔴For severe cases, the best treatment is fluid resuscitation.
⚠️What does not work to treat them:
Though you will often see all of them being used due to the worry it is either Anaphylaxis or Sepsis.
✴In the case of 𝐅𝐏𝐈𝐏, most symptoms tend to resolve by 6 months of age (50%) or 9 months of age (95%).
✳The advice is to reintroduce the causing food into the mother's diet after an exclusion period of 6 months or give it to the child when reaching 12 months of age.
⚠️For both cases, if the child is formula fed be aware that:
1️⃣Medical and dietetic advice needs to be sought before a restriction diet is done
2️⃣It might take 2 weeks for improvement to be seen
3️⃣The child will need and Extensively Hydrolysed Formula (EHF - first choice) or eventually an Amino Acid Formula (AAF - second choice)
❗In the case of a breastfeeding mother, a restriction diet needs to be guided by a dietitian.
✅This is to be sure appropriate nutrition (focusing on protein and calcium) is achieved.
‼️For 𝐅𝐏𝐈𝐄𝐒, there seems to be a 30% chance of people involved to develop either 𝘢𝘵𝘰𝘱𝘪𝘤 𝘥𝘦𝘳𝘮𝘢𝘵𝘪𝘵𝘪𝘴 (eczema), 𝘢𝘴𝘵𝘩𝘮𝘢 or 𝘩𝘢𝘺𝘧𝘦𝘷𝘦𝘳 (allergic rhinitis).
Which came first: the chicken or the egg?
❓The (almost) eternal debate on what came first has persisted through decades.
🌆Countless evenings have been spent around a table, with a 🍷wine glass (or plenty more), with people throwing arguments against or in favour of one of the answers.
🤔Despite all thoughts, in reality, the answer is relatively simple.
⚠️The first animals to lay eggs were the dinosaurs.
🥚𝐒𝐨 𝐭𝐡𝐞 𝐞𝐠𝐠 𝐜𝐚𝐦𝐞 𝐟𝐢𝐫𝐬𝐭!🐣
🇺🇲A discovery made in 1990 in North America showed a nest of eggs from a carnivore dinosaur called “Maniraptoran”.
🦕This dinosaur is believed to be the animal from which birds came to develop into new species.
✅Some suggest the new question: What came first, the dinosaur or the egg?
But we will leave that one for another time…
𝐂𝐡𝐢𝐜𝐤𝐞𝐧 𝐌𝐞𝐚𝐭 𝐀𝐥𝐥𝐞𝐫𝐠𝐲 and 𝐁𝐢𝐫𝐝 𝐄𝐠𝐠 𝐒𝐲𝐧𝐝𝐫𝐨𝐦𝐞
❓How many times have I been asked if children should avoid chicken if they are allergic to eggs?
❗Not as often as parents telling me their child is allergic to chicken meat or start sneezing when there is either cooked eggs or cooked chicken around.
⁉️Can this really happen?
✔Actually, it can, but we need to understand that 𝘢𝘭𝘭 𝘢𝘳𝘦 𝘳𝘦𝘭𝘢𝘵𝘪𝘷𝘦𝘭𝘺 𝘳𝘢𝘳𝘦.
Chicken Allergy can be primary or secondary; this one often called Bird Egg Syndrome.
✳But let us take this into the several aspects that might cause any of the above symptoms.
➡️The main difference between the two types is that the primary kind is associated with a protein called 𝘎𝘢𝘭 𝘥 𝟽 and the second called 𝘎𝘢𝘭 𝘥 𝟻.
What does it mean?
✴𝐆𝐚𝐥 𝐝 𝟕 is 𝘩𝘦𝘢𝘵 𝘴𝘵𝘢𝘣𝘭𝘦 (long term allergy), and 𝐆𝐚𝐥 𝐝 𝟓 is 𝘩𝘦𝘢𝘵 𝘥𝘦𝘨𝘳𝘢𝘥𝘢𝘣𝘭𝘦 (very likely to outgrow the egg or chicken meat allergy).
🔻The symptoms vary, according to age group:
▶️In adults, the signs are usually respiratory associated (asthma or wheeze) or affect the eyes or nose (rhinoconjunctivitis).
▶️In children, it will mainly affect the gastrointestinal tract or leading to breathing problems.
👫Children with egg allergy and respiratory symptoms related to bird egg syndrome, tend to either acquire tolerance later or not outgrow it.
𝘜𝘴𝘶𝘢𝘭𝘭𝘺, 𝘴𝘺𝘮𝘱𝘵𝘰𝘮𝘴 𝘴𝘵𝘢𝘳𝘵 𝘭𝘢𝘵𝘦𝘳 𝘪𝘯 𝘵𝘩𝘦𝘪𝘳 𝘭𝘪𝘷𝘦𝘴.
⛔As with egg allergy, be aware of the cross-reactivity between chicken meat and turkey meat.
🚫But there can also be reactions to duck or goose meat, 𝘵𝘩𝘰𝘶𝘨𝘩 𝘵𝘩𝘦 𝘳𝘦𝘢𝘤𝘵𝘪𝘰𝘯𝘴 𝘵𝘦𝘯𝘥 𝘵𝘰 𝘣𝘦 𝘮𝘪𝘭𝘥𝘦𝘳.
So you will need to avoid all those meats until a proper diagnosis is made.
❓One of the most common questions I get from mothers is "𝐢𝐬 𝐦𝐲 𝐜𝐡𝐢𝐥𝐝 𝐚𝐥𝐥𝐞𝐫𝐠𝐢𝐜 𝐭𝐨 𝐬𝐨𝐦𝐞𝐭𝐡𝐢𝐧𝐠 𝐈 𝐚𝐦 𝐞𝐚𝐭𝐢𝐧𝐠?".
🤱Many have decided to go on a food exclusion, without any 𝘗𝘢𝘦𝘥𝘪𝘢𝘵𝘳𝘪𝘤 𝘈𝘭𝘭𝘦𝘳𝘨𝘺 𝘋𝘪𝘦𝘵𝘦𝘵𝘪𝘢𝘯'𝘴 or 𝘗𝘢𝘦𝘥𝘪𝘢𝘵𝘳𝘪𝘤 𝘈𝘭𝘭𝘦𝘳𝘨𝘪𝘴𝘵'𝘴 advice, meaning potential nutritional deficiencies and substantial confusion to what is the causative agent, if any.
⚠️Fortunately, when there is a relationship between maternal food ingestion and an allergic reaction in a baby, they tend to be non-IgE mediated.
➡️Excellent information on the management of those reactions can be seen in an 𝐄𝐀𝐀𝐂𝐈 𝐏𝐨𝐬𝐢𝐭𝐢𝐨𝐧 𝐏𝐚𝐩𝐞𝐫: "Diagnosis and management of Non‐IgE gastrointestinal allergies in breastfed infants — An EAACI Position Paper.
👨⚕️For all the others, referral to a 𝘗𝘢𝘦𝘥𝘪𝘢𝘵𝘳𝘪𝘤 𝘈𝘭𝘭𝘦𝘳𝘨𝘪𝘴𝘵 should be considered, so investigations (mainly skin prick tests - SPTs) can be done.
▶️After that, coordination with a 𝘗𝘢𝘦𝘥𝘪𝘢𝘵𝘳𝘪𝘤 𝘈𝘭𝘭𝘦𝘳𝘨𝘺 𝘋𝘪𝘦𝘵𝘪𝘵𝘪𝘢𝘯 will lead to re-introduction of foods into the maternal diet and, eventually, into the child's diet as well.
▶️The dietitian will also advise on the need for supplementation if the diet is not adequate.
✅Before that appointment happens, it is always a good idea for mothers to keep a food and symptoms diary.
‼That often, on its own, can be enough for us to make a diagnosis and management plan.
⚠️Please do bear in mind that though only four main allergens have been investigated so far, it is highly likely all or most others will also be expressed in breast milk.
🔀Unfortunately, there is significant variability of allergen presentation in breast milk, which is often related to the method used to detect the proteins associated with those allergens.
👨💻Further research into a unified and conclusive investigative tool is of great importance, so clarifying and establishing a causal relationship between allergen ingestion on a mother and allergic reaction on a baby can be achieved.
⚠️Bottom line if worried about a potential allergic reaction in your breastfed child:
1️⃣Start a food and symptoms diary.
2️⃣Speak to your GP.
3️⃣Potential referral to a Paediatric Allergy Dietitian and/or Paediatric Allergist.
4️⃣Do not start a food exclusion on your own, especially extensive food exclusions.
🎄So it is 🎅Christmas, and how many of you are 🍰 baking with 🥚eggs?
‼️This is probably one of the seasons where we should be cautious with this type of allergy!
In what comes to allergies in children, and due to the nature of baby´s weaning, egg sits almost at par with 🥛cow’s milk as the most prevalent form of allergy. This is closely followed by 🥜peanut allergy.
⚠️Up to now, it was believed roughly 50% of children would outgrow their egg allergy by 3 years of age, with that percentage increasing to roughly 66% at 5 years of age. But it seems those percentages are decreasing with time.
❓The reason for that is unknown still.
✅So the earlier a diagnosis and intervention is made, the higher will be the chances for children to outgrow their allergy.
➡️The initial step is to perform skin prick tests, eventually followed by an open food challenge to baked egg.
😊If the child passes this step, they will have roughly 95% chance of outgrowing their egg allergy.
😔As you might imagine, failing that challenge will give them less than 5% of outgrowing the allergy.
▶️If you suspect your child has an egg allergy, don’t give up or become demoralized.
▶️There is a pretty good chance he/she will outgrow it.
⛔Exclude egg and peanut from their diet, exception if already eating peanut.
⚕Ask for a Paediatric Allergy referral and see if their department will also involve a Paediatric Allergy Dietitian.
✳Very important to understand that when we speak about removing chicken eggs from the diet, we also talk about removing eggs from other birds due to cross-reactivity.
🚫The birds’ eggs you should also exclude are 🦃turkey, 🦆duck, 🦢goose, seagull and quail.
🥚Some children who are allergic to egg can eat small amounts of egg that is well baked (in cakes and biscuits, for example).
❗Often they will not tolerate raw egg, whole egg or lightly processed such as mayonnaise or meringue.
⚠️𝐂𝐡𝐢𝐥𝐝𝐫𝐞𝐧 𝐰𝐡𝐨 𝐜𝐚𝐧 𝐞𝐚𝐭 𝐛𝐚𝐤𝐞𝐝 𝐞𝐠𝐠𝐬 𝐚𝐫𝐞 𝐦𝐨𝐫𝐞 𝐥𝐢𝐤𝐞𝐥𝐲 𝐭𝐨 𝐨𝐮𝐭𝐠𝐫𝐨𝐰 𝐭𝐡𝐞𝐢𝐫 𝐚𝐥𝐥𝐞𝐫𝐠𝐲.
😔Unfortunately, those children who cannot tolerate baked egg are less likely to grow out of their egg allergy.
✅It is important to know that egg may be found in a wide range of foods, including:
➡️𝘉𝘢𝘵𝘵𝘦𝘳𝘦𝘥 𝘰𝘳 𝘣𝘳𝘦𝘢𝘥-𝘤𝘳𝘶𝘮𝘣𝘦𝘥 𝘧𝘰𝘰𝘥𝘴
➡️𝘚𝘰𝘮𝘦 𝘪𝘤𝘦 𝘤𝘳𝘦𝘢𝘮𝘴
✅Also, food labels with the below items may suggest the presence of egg so look out for:
➡ ️𝘈𝘭𝘣𝘶𝘮𝘪𝘯 , which suggests the presence of egg;
➡️𝘓𝘺𝘴𝘰𝘻𝘺𝘮𝘦, which is an enzyme derived from egg;
➡️𝘌𝘨𝘨 𝘓𝘦𝘵𝘤𝘪𝘵𝘩𝘪𝘯, (𝘌𝟹𝟸𝟸), which may, in rare cases, be made from egg; It works as emulsifiers and often is in trace amounts. Though trace amounts are not common to cause an egg allergy.
➡️𝘌𝘨𝘨 𝘸𝘩𝘪𝘵𝘦, in some bread it is used as a washing agent. In wine, alcohol-based drinks, coffee drinks and soup stocks (and sometimes along with eggshells) it might be used as a clarifying agent.
✴Resolution of egg allergy tends to occur in stages, starting with tolerance to baked egg.
▶️Further steps will involve cooking the egg so that the protein causing the allergy will be less degraded.
▶️It will end on the last step, which is raw egg.
(𝘧𝘰𝘳 𝘰𝘵𝘩𝘦𝘳 𝘰𝘱𝘵𝘪𝘰𝘯𝘴 𝘰𝘯 𝘦𝘢𝘤𝘩 𝘴𝘵𝘦𝘱 𝘰𝘧 𝘵𝘩𝘦 𝘭𝘢𝘥𝘥𝘦𝘳, 𝘢𝘴𝘬 𝘺𝘰𝘶𝘳 𝘋𝘪𝘦𝘵𝘪𝘵𝘪𝘢𝘯 𝘧𝘰𝘳 𝘢𝘥𝘷𝘪𝘤𝘦)
✔The suggestion is to have an initial dose of ¼ of the age-appropriate dose the child would have in one day.
✔From then double the dose every other day and aim to give it 2 to 3 times per week.
‼️Remember to always be guided by your Paediatric Allergy Team, which should include a Paediatric Allergy Dietitian.
Dr Costa is a Consultant Paediatrician and fellow of the Royal College of Paediatrics and Child Health.