Understanding infant feeding disorders and their misconceptions

Understanding infant feeding disorders and their misconceptions

Understanding infant feeding disorders and their misconceptions, by Registered Dietician Rachel Wood

Making an accurate diagnosis

A recent study published in 2020 found that while up to 14% of families believe that their child may have a cow’s milk allergy, the reality is that the true number of children with a condition may be closer to 1%. The same study points to official guidelines for detecting cow’s milk allergy as a possible cause for the overdiagnosis.(1)

Open Prescribing data recorded the total cost to the NHS (April 2021 - Jul 2022) for specialised formulations was over £11m.

The research analysed nine official medical guidelines for cow’s milk allergy published between 2012 and 2019. These guidelines were sourced from a range of international medical organisations across Europe. The study found that many of these guidelines cited symptoms such as excessive crying, regurgitating milk and loose stools as an indication of cow’s milk allergy, all symptoms that are very common in normal, healthy babies.

Specialist formula prescriptions for infants with cows milk allergy increased by 500% between 2006 and 2016 (2)

Infant feeding disorders are a common occurrence. With up to 50% of infants aged 0-6 months presenting symptoms of at least one Functional Gastrointestinal Disorder , it isn’t surprising that it can be difficult to make an accurate diagnosis.(3)

What are functional gastrointestinal disorders?

An FGID includes chronic or recurrent symptoms, in otherwise healthy individuals, that cannot be explained by any obvious structural or biochemical abnormalities. A functional condition is one that impairs the normal functioning of bodily processes without there being any apparent abnormality e.g. motility, peristalsis, microbiome, valve competence.(4,5)

The most common FGIDs in 0-6 month old infants are Colic (5-20%), constipation (3-27%) and GOR/regurgitation 30-67% (3,4)

In cases where these common symptoms are presented, practical feeding advice and reassurance to parents provided early on could omit the need for inappropriate prescribing of specialist formulas and medications.

What is lactose intolerance?

Lactose is the sole carbohydrate (sugar) found in breastmilk and is also in most infant formula. An intolerance is defined as difficulty digesting certain foods accompanied by unpleasant physical symptoms. It is important to note that an “intolerance” does not involve the immune system and is therefore a non-immune mediated response.

Lactose intolerance and FGIDs often present with similar symptoms to a Non-IgE Mediated allergy and it can be challenging to differentiate between them. A food allergy is a reproducible adverse reaction to the protein in the food, a food intolerance is a reaction to a carbohydrate component such as lactose.

Lactose is a disaccharide sugar made up of two monosaccharides, glucose and galactose. Lactose is broken down by the enzyme Lactase, which lives in the brush border of the duodenum (the first part of the small bowel). Lactase levels are at their highest at birth which accounts for why breast milk is so well tolerated by infants. Levels of lactase tend to reduce as we get older. The level of lactase that is produced depends on the levels of lactose we consume, thus often making symptoms dose dependent.(3,6)

Symptoms, testing and treatment

When lactase it is absent or is at reduced levels, lactose reaches the large intestine and ferments, leading to gassiness, diarrhoea and associated discomfort. The most reported symptoms in infants and children tends to be ‘explosive’ acidic stools & excoriated bottom. Where lactose is the cause, these symptoms will all typically settle down once it is reduced or entirely removed from the diet.

True cases of Lactose intolerance are relatively uncommon and are very difficult to test for as it is a malabsorption issue within the gut. However, as with non-IgE cow’s milk protein allergy, a detailed history is key. A feeding and symptom history is important to differentiate between allergy, intolerance, or another diagnoses. The reduction, elimination and re-challenge of lactose is the only true way to confirm a diagnosis. (3, 13)

CMPA Symptom management guide

A stool pH test and checking for faecal reducing substances can be helpful. Increased levels of carbohydrates (sugars) in the stool can indicate a specific sugar malabsorption. These are often difficult to accomplish however as a fresh stool sample needs to be in the laboratory within the hour. A normal stool pH is about 6 whereas <5.3 is deemed acidic and indicative of a sugar malabsorption. (14, 15, 16)

Secondary Lactase deficiency is the most common cause of lactose intolerance in the United Kingdom in babies and children. This deficiency is an acquired lactose intolerance and tends to present itself following damage to the digestive system and specifically the brush border where the lactase lives. Typically, this is identified following a gastrointestinal bug, a long courses of antibiotics, or through conditions such as coeliac disease or Crohn’s disease and only requires short term low lactose intake to allow lactase to start reproducing. (2, 3, 6)

Intolerance or allergy, or common feeding disorder?

We know there is a strong cross over of symptoms with lactose intolerance, CMPA and common feeding disorders that affect a substantial number of infants. The key to properly treating the situation lies in healthcare professionals having the correct knowledge to make an informed diagnosis.

Although the research discussed shows that the true incidence rate of CMPA is lower in comparison to other FGIDS, the prescribing costs of extensively hydrolysed and amino acid formulas to the NHS are increasing very significantly. In many cases of colic, reflux, constipation and possible lactose intolerance infants can experience relief of symptoms from a reduced lactose, partially hydrolysed formula. If an infant is presented with feeding difficulties, healthcare professionals should consider the different possible diagnoses before prescribing a more medicalised formula.

If healthcare professionals can be afforded the appropriate education and resources to properly navigate the process of diagnosis, we stand to reduce the number of infants consuming food for special medical purposes and reduce the cost to the healthcare system.

Watch the video here

References

  1. Munblit D, Perkin MR, Palmer DJ, Allen KJ, Boyle RJ. Assessment of Evidence About Common Infant Symptoms and Cow’s Milk Allergy. JAMA Pediatr. 2020;174(6):599–608. doi:10.1001/jamapediatrics.2020.0153
  2. https://www.bmj.com/content/363/bmj.k5056
  3. Functional Gastrointestinal Disorders in Infancy: Impact on the Health of the Infant and Family Yvan Vandenplas. Pediatr Gastroenterol Hepatol Nutr. 2019 May;22(3):207-216 https://doi.org/10.5223/pghn.2019. 22.3.207
  4. Natelson B. Yale University Press 1998; p.33; 5.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6506429/ accessed October 2022
  5. www.nhs.uk/conditions/colic/ accessed October 2022
  6. First Steps Nutrition Trust. Infant Milks in the UK, A practical guide for health professionals, Sept 2029. Accessed 4/10/2022 Infant Milks in the UK, A practical guide for health professionals
  7. https://www.nice.org.uk/guidance/ng1
  8. Vandenplas Y, Brueton M, Dupont C, et al, Guidelines for the diagnosis and management of cow’s milk protein allergy in infants, Archives of Disease in Childhood 2007;92:902-908.
  9. World Allergy Organization. Food allergy. 2017. Available at: https://www.worldallergy.org/ education-and-programs/education/allergic-disease-resour ce-center/professionals/food-allergy (accessed October 2022)
  10. National Institute for Health and Care Excellence (NICE). Cow’s milk allergy in children. [Internet]. 2021. [Accessed October 2022]. Available from:https:// cks.nice.org.uk/topics/cows-milk- allergy-in-children/
  11. National Institute of Health and Clinical Excellence. Food allergy in children and young people. Diagnosis and assessment of food allergy in children and young people in primary care and community setting. NICE Clinical Guideline 116, February 2011
  12. Diagnosis and management of non‐IgE mediated cows’ milk allergy in Infancy ‐ a UK primary care practical guide Carina Venter, Trevor Brown, Neil Shah, Joanne Walsh, Adam Fox www.ctajournal.com/3/1/23 2013
  13. Benninga MA, et al. Gastroenterol 2016;150(6):1443–55; 15. Hyman PE, et al. Gastroenterol 2006;130:1519–1526;
  14. Vandenplas Y, et al. J Pediatr Gastroenterol Nutr 2015;61(5):531–7.
  15. Shulman, R.J., Wong, W.W. and Smith, E.O. (2005) Influence of changes in lactase activity and small intestinal mucosal growth on lactose digestion and absorption in preterm infants. Am. J. Clin. Nutr. 81, 472-479
  1. Vandenplas Y, et al. J Pediatr Gastroenterol Nutr 2015;61(5):531–7.
  2. Shulman, R.J., Wong, W.W. and Smith, E.O. (2005) Influence of changes in lactase activity and small intestinal mucosal growth on lactose digestion and absorption in preterm infants. Am. J. Clin. Nutr. 81, 472-479
  3. Luyt D, et al. BSACI Guideline 2014, Clin & Exper Allergy.2014; 44(5): 642-672 2. Venter C, et al. Clin Transl
  4. www.breastfeedingnetwork.org.uk

 

Back to Recent posts