Allergy and intolerance in infants with reflux

Adverse reactions to food can be categorised into IgE mediated reactions and non-IgE mediated reactions. Understanding the difference between the two is important as the approach to treatment is quite different. An IgE-mediated food reaction involves the immune system. The onset is sudden and includes vomiting, abdominal pain, urticaria and angio-edema. An IgE-mediated reaction to food can be diagnosed through a range of validated tests including skin prick testing.

A non-IgE mediated reaction does not involve the immune system. The symptoms develop slowly and may take hours or even days. Gastrointestinal symptoms such as reflux and chronic diarrhoea may be related to non-IgE mediated reactions. Faltering growth and eczema can also occur. The only way to identify a food trigger for these types of reactions is through structured elimination of food groups followed by a challenge or reintroduction phase.

Cow’s milk protein is one of the most common food triggers for adverse reactions in infancy. More recent research suggests that there is a higher prevalence of cow’s milk protein intolerance in infants with GORD compared to infants without. In one study, up to 30% of infants with diagnosed GORD who did not respond to medical intervention (omeprazole) were diagnosed with cow’s milk protein intolerance based on an elimination diet. The risk was higher in those with a family history of atopic disease. Most children (80%) will outgrow their cow’s milk protein allergy by 4 years of age. There is a high cross reactivity with goat’s milk (90%) and soy protein (20-50%) meaning these proteins may also need to be avoided.

Wherever possible, it is important to seek the advice of your treating team before embarking on an elimination diet. Over restriction of food groups and inadequate replacement with alternatives can lead to nutritional deficiencies and fatigue in (already tired!) breastfeeding mothers and their infants. A dietitian experienced in paediatrics and food intolerance can help you plan your diet in conjunction with your treating team. This will ensure you don’t miss out on important nutrients. They can also provide you with recipes/meal plans. For the breastfed infant, a short term (approximately 4 weeks) trial of cow’s milk/soy protein restriction in the maternal diet could be considered. This should always be followed with a systematic re-challenge of these proteins. Complete maternal restriction is rarely required but is encouraged during the first 4 weeks to assess response.

Where cow’s milk and soy protein need to be restricted in the maternal diet, the next best milk alternative is calcium and fortified rice milk (e.g. Vitasoy). When choosing alternative milks such as rice, oat and nut milks make sure the calcium fortification is close to 120mg/100ml. You can find this information on the nutritional label. Aim for 2-3 serves each day. Ensure adequate protein sources are included such as meat, chicken, fish, egg or legumes and nuts for vegetarian/vegan mothers. These milks tend to be low in fat; use good quality oils liberally in the diet. Cheese can be replaced with a blend based on cashews/pine nuts and nutritional/savoury yeast. Yoghurt can be replaced with a coconut based yoghurt. There are also coconut based ice creams and gelatos available – check your health food shop. Be mindful that these substitutes do not include calcium at the same level as a cow’s milk protein based product so they don’t count towards your dairy alternative serves for the day!

Rice, oat and nut milks are not suitable for children under 12 months and ideally not before 2 years. This is because they are low in protein and fat and the calcium fortification varies significantly. For formula fed infants, the only options are soy, extensively hydrolysed formula or an amino acid based formula. Extensively hydrolysed and amino acid based formulas are available on script for eligible infants but require review by Specialists such as Gastroenterologists or Immunologists/Allergists which can be difficult to access in some areas. Discuss this with your medical team who will be able to advise which is most appropriate for your child. Hypoallergenic (HA), goat and lactose free formulas are not appropriate for the treatment of cow’s milk protein allergy/intolerance.

Navigating the path of food intolerance is extremely tedious in most cases so it is important to get the right advice and support. It is also important to time changes in the diet appropriately and change just one thing at a time (food and medication!) so you / your treating team can decide which is the most effective intervention.

 

Author: Nicole Dennis APD/AN, Paediatric Dietitian

Last Reviewed: March 2014

 

Seed Nutrition and Dietetics

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References:

Australasian Society of Clinical Immunology and Allergy (ASCIA). Website accessed March 2014: www.allergy.org.au

Farahmand F, Najafi M, Ataee P, Modarresi V, Shahraki T, Rezaei N. Cow’s milk allergy among children with gastroesophageal reflux disease. Gut Liver. 2011; 5: 298-301.

Forbes, J. Mewling and puking: Infantile gastroesophageal reflux in the 21st century. J Pediatr Child Health 2013; 49: 259-263

Kemp A, et al. Guidelines for the use of infant formulas to treat cow’s milk protein allergy: an Australian consensus panel opinion. Medical Journal of Australia. 2008; 188:109-112.

Royal Prince Alfred Hospital Allergy Unit. Website accessed March 2014:

http://www.sswahs.nsw.gov.au/rpa/allergy

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