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).
It is an Allergy or an Intolerance?
🥛In a milk allergy, the body reacts to milk proteins, not milk sugar.
❗In lactose intolerance, there is little to no lactase (an enzyme produced by our body), so the milk sugar (lactose) cannot be digested.
⚠️Cow's milk protein allergy (CMPA) affects from 2 to 6% of children, with the highest prevalence during the first year of age.
➡️About 50% of children have been shown to resolve CMPA within the first year of age, 80-90% within their fifth year.
➡️Symptoms usually develop within a week of cow's milk introduction, although it may be delayed for many weeks, reported up to 24 and 36 weeks.
🔶️Lactose intolerance has 4 types:
1️⃣Primary (the most common form in which our bodies decrease the production of lactase from 5 years of age)
2️⃣Secondary (after a gut injury, illness or surgery our bodies produce less lactase)
3️⃣Developmental (mostly affecting preterms and resolving soon after birth)
4️⃣Congenital (rare and genetic in origin, where there is little to no lactase production - higher incidence in Finland)
💉The tests for both are different.
➡️skin prick tests or blood tests (specific IgE) for IgE mediated for milk allergy
➡️hydrogen breath test or stool sample for lactose intolerance
➡️no tests available for non-IgE mediated (normally food exclusion is the only option)
⚠️Obviously, the symptoms are also different.
➡️IgE mediated (immediate kind) affects the skin most commonly, then the gastrointestinal tract, and least frequently the respiratory system. Cardiovascular symptoms are rarely reported. Symptoms can range in severity from mild to life-threatening. Their onset is typically within minutes of exposure.
➡️Non-IgE-mediated (delayed kind) have typically an onset several hours and in some instances several days after ingestion. They tend to cause skin changes (eczema) and gastrointestinal disturbances (reflux with or without vomiting; constipation or diarrhoea).
➡️Lactose intolerance presents mainly with gastrointestinal problems (abdominal pain, flatulence and diarrhoea).
If you or your child have an immediate reaction to a food, avoid it and ask for a referral to either a Paediatric Allergist or an Adult Allergist.
In case the reactions are delayed (2 hours to several days), your best option is to be seen by either a Paediatric Dietitian or an Adult Dietitian.
"The importance of feeding is part of human life from the day we are born.
"For the first few months, babies are only able to taste sweet and sour, leading to their first choice favouring the sweet taste of mother’s milk. Eventually, at around 6 months, the taste buds develop further. The baby’s palate becomes more sensitive not only to tastes but also to textures."
Read the full blog post on My Allergy Kitchen.
Dr Costa is a Consultant Paediatrician and fellow of the Royal College of Paediatrics and Child Health.