COW’S MILK PROTEIN ALLERGY

PART 2

Dr Nické Theron, Pediatrician.

Whether you are pregnant and wondering how to prevent allergies in your little one, or have a baby that has already been diagnosed with Cow’s Milk Protein Allergy and struggling with treatment, read on to find the latest research and tips here:

PREVENTION OF COW’S MILK PROTEIN ALLERGY (CMPA):

There are several risk factors for allergies and unfortunately not so many proven measures to reduce these risks. If you have a family history of allergies or atopic disease (especially eczema or asthma), your children will have an increased risk of developing CMPA – up to 3 times higher in one study. This is the most important factor to consider. Other risks include: Caesarean Section delivery, Prematurity, Older maternal age and Environmental factors.

Measures that have been proven to reduce the risk of CMPA (ONLY necessary when you have a family history of allergies or atopy):

  • Exclusive breastfeeding is the preferred method of feeding up to the age of 6months. Although it has not been proven to prevent CMPA specifically there is good data to prove it has a significantly protective effect against eczema.
  • If you cannot exclusively breastfeed, it is important to use a “partially hydrolysed” infant formula (eg Nan HA, Similac) to decrease the exposure to the full cow’s milk protein. In these formulas the very “offensive” part of the protein has been removed, but it is still perceived by the body as a cow’s milk protein and thus “exercises” the immune system.
  • “Extensively hydrolysed” formula has also been proven to reduce the risk of CMPA, but they are very expensive and have a bad taste, thus rather used in the treatment of CMPA.
  • “Amino Acid formulas” are NOT used in the prevention of CMPA.
  • The mother DOES NOT have to exclude any allergens during pregnancy.
  • When you start solid foods, it is recommended to start no earlier than 17 weeks (4 months) and no later than 27weeks (6 months). It is important to give a varied diet from the start (a restricted diet has a higher risk of allergies) and to introduce allergens such as cow’s milk, fish, peanuts, eggs, soy, wheat early and regularly. Although this is not proven to prevent CMPA specifically, it does decrease your risk for peanut and egg allergy.
  • Unfortunately the studies on the use of pre- and probiotics in babies does not show any reduction in the risk of CMPA. Although we know that your microbiome plays a big role in the fight against allergies and atopic diseases, scientists are struggling to find out exactly which organisms and how much of what gives us an advantage. I am sure there will still be very interesting research in this field!
  • Having pets at home reduces your risk for CMPA according to some studies. 😉

TREATMENT OF CMPA:

Unfortunately none of the above are fool proof to reduce CMPA and if your baby had the symptoms and a positive exclusion test (symptoms improved when cow’s milk protein was removed) you are facing the realities of treating an allergy. Although it can be scary (especially if your child has dramatic, immediate symptoms) and difficult to screen ALL food for cow’s milk protein, it is worth it to see the improvement in your child. I will walk through the basics of the treatment with you, but in the end a dietitian is invaluable to help you with the specifics of exclusion and re-introduction of cow’s milk protein. Please remember that this is just a generalised guideline to explain some of the concepts to you. There is such a big variety in the types of CMPA and the rest of your child’s unique case that you should always discuss any management plans with your pediatrician and dietitian.

Diagnostic Elimination:

  • Breastfeeding infants: Mothers are encouraged to keep on breastfeeding, but to cut out all cow’s milk products (fresh milk, yoghurt, cheese, but also reading all labels for hidden sources) from her own diet for 2 – 4weeks.
  • Formula-fed infants: All cow’s milk protein should be eliminated from baby’s diet and formula changed to an “extensively hydrolysed formula” (eg Similac Alimentum, Pepticate) for 2 – 4weeks. If there is still no improvement in symptoms you can try an “amino acid formula”. However, these are all very expensive and babies take some time to get used to the taste.

If your baby’s symptoms improved after removing cow’s milk, you continue the exclusion diet:

  • Breastfeeding infants: Mother continues to eliminate cow’s milk protein and should drink Calcium supplements (your breastmilk will use the calcium from your bones to provide enough for your baby if you do not eat enough calcium).
  • Formula-fed infants: Most recommendations are to continue “extensively hydrolysed formula” for baby.
  • What about Soy formula (eg Isomil)? This is a much cheaper option, but there are some concerns about cross reaction (in up to 15% of babies) of the allergy, and certain hormonal contents of soy (isoflavone is a phyto-estrogen). Be careful when choosing this option in babies below 6 months.
  • Other mammalian milks such as goat, sheep, camel also has a risk of cross-reacting and might not be nutritionally adapted for use in babies. Please work closely with your pediatrician and dietitian.
  • Rice formulas are gaining popularity but are not yet available everywhere. There is no risk for cross-reactions, but there is a concern that these formulas contain arsenic and have not been studied in CMPA, so once again, be careful.
  • If your baby starts solids, all cow’s milk protein should be excluded from their diet, but all other food groups should be introduced between 17-27weeks, especially the other high-risk allergens.
  • A Dietitian can help to assess your child’s diet to ensure whether the supply of nutrients, especially proteins, calcium, vitamin D, and vitamin A, is sufficient.

Reintroducing Cow’s Milk Protein:

It is recommended that the cow’s milk is eliminated until at least 1 year of age, or for at least 6 months from diagnosis. If however the diagnosis was not confirmed with positive blood tests, or if the symptoms were very mild to start with, your doctor might reintroduce cow’s milk after 1 month.

There are different ways of reintroducing the allergen (also called a “challenge”). If your child was very ill / has immediate reactions, the reintroduction should be done in a hospital. If your baby just had eczema / reflux, you can reintroduce the cow’s milk at home with the guidance of a dietitian.
(See the “Milk Ladder” below.)
If the symptoms return, go back to the previous diet and retry after 6 months.

My take-home message is to take heart! Equip yourself with knowledge, a friendly dietitian and explore some new recipes! Your life does not have to be ruled by fear and FOMO for your child’s sake. Most children will outgrow their CMPA and you can make such a difference in their symptoms until then. The world of allergies is evolving so fast, you can play your part in the education of other moms and who knows, you might just support someone else with a new diagnosis!

“Praise be to the God and Father of our Lord Jesus Christ, the Father of compassion and the God of all comfort, 4 who comforts us in all our troubles, so that we can comfort those in any trouble with the comfort we ourselves receive from God.”

2 Cor 1:3-4

RESOURCES:

1. Ralf G. Heine, Fawaz AlRefaee, Prashant Bachina, Julie C. De Leon, Lanlan Geng, Sitang Gong, José Armando Madrazo, Jarungchit Ngamphaiboon, Christina Ong, and Jossie M. Rogacion;  “Lactose intolerance and gastrointestinal cow’s milk allergy in infants and children – common misconceptions revisited”; World Allergy Organ J. 2017; 10(1): 41.
2. Yvan Vandenplas, Martin Brueton, Christophe Dupont, David Hill, Erika Isolauri, Sibylle Koletzko, Arnold P Oranje, and Annamaria Staiano; “Guidelines for the diagnosis and management of cow’s milk protein allergy in infants”; Arch Dis Child. 2007 Oct; 92(10): 902–908.
3. Koletzko S, Niggemann B, Arato A, Dias JA, Heuschkel R, Husby S, Mearin ML, Papadopoulou A, Ruemmele FM, Staiano A, Schappi MG, and Vandenplas Y; “Diagnostic Approach and Management of Cow’s-Milk Protein Allergy in Infants and Children: ESPGHAN GI Committee Practical Guidelines”
4. http://www.uptodate.com
5. Vandenplas Y, Al-Hussaini B, Al-Mannaei K, Al-Sunaid A, Ayesh WH, El-Degeir M, El-Kabbany N, Haddad J, Hashmi A, Kreishan F and Tawfik E; “Prevention of Allergic Sensitization and Treatment of Cow’s Milk Protein Allergy in Early Life: The Middle-East Step-Down Consensus”; Nutrients. 2019 Jul; 11(7): 1444
6. Sardecka I, Łoś-Rycharska E, Ludwig H, Gawryjołek J, Krogulska A; “Early risk factors for cow’s milk allergy in children in the first year of life”; Allergy Asthma Proc. 2018 Nov 1;39(6):e44-e54.

COW’S MILK PROTEIN ALLERGY

Written by Dr Nické Theron, Pediatrician.

Cow’s milk protein allergy. So many misconceptions, misunderstandings, fears and confusion locked up behind those few words for both moms and health-care professionals. I was privileged to attend the congress of the European Academy of Pediatrics two weeks ago and the master course focused on nutrition in childhood. I finally have a better understanding of CMPA (Cow’s Milk Protein Allergy) and I hope I can explain it better to you too.

As with many food allergies, CMPA is an allergy (where the immune system mistakenly identifies a protein as harmful and reacts to cause symptoms) to one or multiple of the different protein-structures in cow’s milk. Unfortunately the occurrence of all types of allergies are increasing in Western societies at an alarming rate, with CMPA being the most common (2-7% of babies). Food allergies specifically can cause a lot of anxiety in parents and children as you have to be on alert at all times, and any symptom can be seen as an allergic response. It is high maintenance to totally exclude a specific food group from your child’s diet and this can also cause deficiencies in their diet. It is thus important that your child is diagnosed correctly, and that you have the necessary dietary assistance to help you and your child reach the top of this mountain.

The good news about CMPA specifically is that many babies outgrow it by 1 year of age, and most children should tolerate cow’s milk proteins by the age of 3 years and can return to a normal diet. Having a sibling with CMPA does not increase a new baby’s chance to develop CMPA, but if there is a family history of atopy/allergies the 2nd child will have the same type of risks as the first.

It is important to know that not all symptoms caused by ingesting food are caused by an allergy.

Dr Nické Theron

Lactose intolerance is one example, where poor breakdown (by an enzyme called lactase) and absorption of the sugar component (lactose) in cow’s milk, causes too much lactose to end up in the large intestines resulting in symptoms such as bloating, diarrhoea and abdominal pain. This is very rare in infants who usually have enough lactase-enzymes to digest the lactose in up to 1 litre of breast milk per day. Any left-over lactose in an infant’s gut acts as a prebiotic and improves the development of the immune system. As a baby starts to wean, the lactase percentage drops slowly in about 70% of the population, and this could lead to symptoms of lactose intolerance after the age of 5 years. Even in these children it is usually not necessary to cut out all lactose from their diets as they can cope with a small amount. Premature babies might have lactose intolerance due to their immature gut, and very rarely babies are born with a congenital abnormality where they produce no lactase and they will then present with severe diarrhoea.

Another more common cause of lactose intolerance is a sick gut (secondary lactose intolerance). If your baby had a bout of infective diarrhoea or has severe inflammation of the gut due to eg CMPA, the inside lining of the intestines becomes very thin and then lactase cannot be produced. Removing lactose from the diet can then help to give the intestines a chance to restore the lining and lactose can be reintroduced after 2-4 weeks.

Ok, back to CMPA:
This allergy can develop in exclusively breastfed babies as the cow’s milk protein is passed relatively unchanged through the breastmilk. It can also present later when cow’s milk is introduced into a baby’s diet.

SYMPTOMS

Unfortunately there is not one specific symptom for CMPA, and babies and children can present with a wide variety of symptoms. It can cause anything from vomiting, regurgitation (can be misdiagnosed as reflux), blood in the stools, diarrhoea, constipation, eczema, wheezing or anaphylaxis (a state of shock where the allergic reaction overwhelms the body and is a medical emergency). See the table below for more detail.

Some babies become critically ill shortly after ingesting the protein, while others are happy, healthy and growing with some nagging symptoms. I am sure you can now understand why it is so difficult to diagnose CMPA!

To complicate the matter and the diagnosis even more, there are different types of CMPA because of the different ways the immune system responds to the protein. Some children will have “IgE-mediated CMPA”. (IgE is a specific antibody of the immune system that recognizes proteins as bad and rapidly responds to it.) Children with asthma and eczema also have high levels of IgE in their blood. The advantage is that we can test for this type. They will usually have a positive skin-prick test and positive blood results specifically for CMPA. The disadvantage of this type is that the children usually take longer to outgrow the allergy, and they are more prone to develop other atopic diseases later in life. Their reaction to CMP is also usually more severe and they can develop anaphylaxis.

The immune system can also respond without IgE, leading to a more delayed reaction (some children can still get very ill!) that is usually outgrown earlier. However there are no tests we can do to prove this type of allergy and this can be very frustrating to parents and doctors!

The latest guidelines have thus suggested that the best way to diagnose any type of CMPA is with a good history and physical examination, followed by an elimination of the cow’s milk protein from the diet. If the symptoms improve the child should be “challenged” by giving the cow’s milk protein again, and if the symptoms return the diagnosis is confirmed.

Other tests that might be done are blood tests for total IgE and specific food allergies or a skin-prick test where the reaction of the skin to different allergens are tested.

I will leave you so that you can digest this chunky piece of information, please feel free to ask if you do not understand anything! In my next post I will address the management of Cow’s Milk Protein Allergy from a medical perspective and help you to understand where a Dietitian fits into the picture.

RESOURCES

  1. Ralf G. Heine, Fawaz AlRefaee, Prashant Bachina, Julie C. De Leon, Lanlan Geng, Sitang Gong, José Armando Madrazo, Jarungchit Ngamphaiboon, Christina Ong, and Jossie M. Rogacion; “Lactose intolerance and gastrointestinal cow’s milk allergy in infants and children – common misconceptions revisited”; World Allergy Organ J. 2017; 10(1): 41.
  2. Yvan Vandenplas, Martin Brueton, Christophe Dupont, David Hill, Erika Isolauri, Sibylle Koletzko, Arnold P Oranje, and Annamaria Staiano; “Guidelines for the diagnosis and management of cow’s milk protein allergy in infants”; Arch Dis Child. 2007 Oct; 92(10): 902–908.
  3. Koletzko S, Niggemann B, Arato A, Dias JA, Heuschkel R, Husby S, Mearin ML, Papadopoulou A, Ruemmele FM, Staiano A, Schappi MG, and Vandenplas Y; “Diagnostic Approach and Management of Cow’s-Milk Protein Allergy in Infants and Children: ESPGHAN GI Committee Practical Guidelines”
  4. http://www.uptodate.com

TANTRUMS & TAAI TOFFIES

“Nee, Mamma moet. Mamma moet by my lê! Nie Pappa nie. Mamma!!!”

Só kerm-huil-skreeu my groot-oog amper-3-jarige kabouter net voor slaaptyd oor wie hý besluit het vanaand by hom moet lê tot hy na Droomland weggevoer word…

Dis al weer een van dáái dae. Daai hóógs uitdagende dae: van verseg-om-my-middag-slapie-by-die-skool-te-vat-en-nou-is-ek-totaal-verby-moeg-en-aaaaaalles-is-‘n-stryd!

Moet my nie verkeerd verstaan nie. Ek is ontsettend lief vir my 2 seuntjies. Maar party dae voel dit asof my geduld en kreatiewe-redenasie-vermoeëns tot die uiterste beproef word! Veral met Oudste (Boetiebaba praat (gelukkig?) nog nie terug nie, maar gil net in sy skril stemmetjie as hy gehóór wil word).

Terug by vroeër vandag:
Die groen plastiek-eetlepel móés eintlik blou gewees het, Rupert het sy hand gelek😱, en hý wou die asmapompie se oranje doppie “SELF” (julle ken mos daai woord😉🙈) afgehaal het. Emosies het behoorlik gesneeubal in ‘n sneeu(senu-ineen)storting…

Vanaand is almal moeg. Hierdie mamma het nog soveel om te doen voor dit mý beurt is om in te kruip. En hier sit Oudste Kabouter steeds kiertsregop en verseg om te slaap. “Want Mamma moet by my lê!” (Alhoewel Pappa nog altyd die laaste paar maande goed genoeg was!)…

Ek bid vir wysheid. Ek bid vir onderskeiding: Dat ek sal weet wat om te doen, wat om te sê.
Wanneer is dit als net die moegheid wat praat en wanneer is dit pure ongehoorsaamheid (soos wanneer hy aspris kliphard geluide maak as ek met manlief probeer praat)?

Wanneer moet ek grense stel en dissiplineer en wanneer het hy net liefde en aanvaarding nodig – net vir my nodig om by hom te wéés?

Vanaand het ek die “by-hom-te-wees” opsie gekies, my arms om sy snikkende lyfie gevou en hom net vasgehou. ‘n Paar sout-trane-soentjies op die wang en twee snot-tissues later, krul sy mondhoekies weer in ‘n half-glimlag op en soek sy groot oë myne. En ek weet in my hart dit was die regte besluit. Ons siele het ontmoet en ons verhouding het verdiep.

KREATIWITEIT

Ek het die laaste week of wat gevoel ek ly bietjie aan “writer’s block”…

Daar was ‘n swetterjoel van emosies – opwinding, vreugdes en effense senuagtigheid – maar ek kon nét nie my gedagtes kreatief inryg en sinvol verwoord nie!

So, ‘n mens kan glo nie jou kreatiwiteit OP gebruik nie… En hoe méér kreatief jy is en jou passie uitleef, hoe meer GROEI dit…Maar my woorde hét min geword.

Ek word toe stil in Boetie se kamer (deesdae is dit my plek van stiltetyd hou, met Kleinboet in my arms)! En sjoe, ons Pappa-God is getrou – ek ervaar: my kreatiwiteit is ‘n uitvloeisel van my verhouding met Hom (die beste skrywer, skilder, pottebakker en algehele Skepper)…

Belê in ONS verhouding, en kreatiwiteit sal die vrug daarvan wees.


INTIMITEIT

Volheid en glorie
My lewe, U storie
My begeertes, U drome
Geplant langs waterstrome

Stukkie vir stukkie
Word stil vir ‘n rukkie
Koester verhouding
Net dán kan dit uitkring

Gefluisterde soene
Trek uit my skoene
Bely met my mond
Dis Heilige grond

SONDAG-INSPIRASIE

“For God has not given us a spirit of fear, but of power and of love and of a sound mind.” 2 Timothy 1:7 NKJV

Vrees is simpel. En sommer net boos. Dit ketting jou vas en belemmer dít wat God reeds (deur Sy gees) in jou geplaas het: Sý krag, Sý liefde en (bonatuurlike) selfbeheersing. Vrees wil soos ‘n parasiet aan ons kom vasklou. Twyfel, onsekerheid oor wie ons is, ‘n konstante gedagte-oorlog en aanval op ons emosies – dít is die (vrot) saad wat vrees in ons lewens wil saai.

Vrees is een van die kragtigste wapens wat die vyand teen ons wil (en kan) gebruik. Dit is ‘n slinkse aanvaller van ons emosies, en as ons nie paraat is nie, kan dit ‘n vastrap-plekkie in ons gedagtewêreld kry!

Vrees sê vir ons ons gaan dit nie maak nie, ons is nie sterk genoeg nie, nie waardig genoeg nie, nie regtig geliefd nie en dat ons nie eintlik iets spesiaals het om te bied nie. Dís waar die vyand ons wil hê – hy wil hê ons moet die leuens glo. Vrees wil ons verlam – sodat ons nie in ons lewensdoel kan GROEI en FLOREER nie. Ons God-gegewe talente wil hy help begrawe. Ons liggie word liefs onder ‘n emmer gebêre – want wie is ons om só helder te skyn?

So, hoe veg ons teen hierdie vrees-gedagtes? Deur die 2de deel van die skrif ons eie te maak: God het, deur Sy Gees, vir ons Sý krag en Sý liefde én selfbeheersing gegee. Ons hoef nie op ons eie krag staat te maak nie!

Het jy geweet: God se volmaakte liefde verdryf vrees? Ek vra Hom vandag om my te help om elke negatiewe- & vreesagtige gedagte gevangene te neem en te onderwerp aan Hom en Sy volmaakte VREDE & LIEFDE.

“Waar liefde is, is daar geen vrees nie, maar volmaakte liefde verdryf vrees, want vrees verwag straf, en wie nog vrees, het nie volmaakte liefde nie. Ons het lief omdat God ons eerste liefgehad het.”
1 JOHANNES 4:18-‬19 AFR83

“Die Heilige Gees, wat deur God aan ons gegee is, is nie lafhartig nie, maar sterk. Hy maak ons ook sterk, gee vir ons liefde vir ander en help ons om nie verkeerde dinge te doen nie.” 2 Timoteus 1:7 DB

Oh ja, en mammas, onthou om vandag te SKYN! ♡

CONSTIPATION

Dr Nické Theron, Pediatrician.

There is such a large variety of normal when it comes to baby and toddler-poo. So how do you know when to start worrying and when is it constipation? I want to explain how the process of constipation works, because then you will understand the treatments better: (Warning: this is quite a “crappy” topic, excuse all the puns! )

Stool-patterns vary by age and diet. The number of stools passed decrease as your baby gets older (with an average of 4-5 stools per day for the first week of life, then 3-4 for the first three months and 1-2 by 2 years of age). In exclusively breastfed infants it can be normal to pass stools 7 times in one day, or only once in 7 days! (If your baby has passed no stools for 10-14 days I would rather help them to prevent a hard stool.) There is also a difference in stool-patterns with different formulas: soy-based formulas produce harder and less frequent stools, while hypo-allergenic formulas can produce looser and more frequent stools.

“When the going gets tough, the tough get going.”

Joseph Kennedy

There are a few developmental milestones in your baby’s life when constipation is more likely to be a problem:
• Introduction of formula
• Introduction of solid food
• Introduction of cow’s milk
• Potty training
• Going to school

Constipation in an infant (below 1 year) is diagnosed when there is a change in the stool pattern for your baby, it looks like your baby has pain / excessive straining while passing the stools AND the stools are large, hard, dry or pellet-like. This last part is especially important, because many babies have dyschezia. This big word just describes what we see with most young babies: they strain, become red in the face and cry before passing a stool. The stool is then always soft, and the baby is otherwise healthy. This is not constipation, but happens because the baby is still too young to coordinate his muscle movements when trying to pass a stool. You can help your baby to relax the pelvic floor by gently bending his hips and bringing his knees up to his stomach. Dyschezia usually resolves as your baby grows and no further treatment is necessary.

Toddlers are prone to constipation when they potty-train, start school or when any other life-altering changes happen in their lives. They can also just be too busy enjoying life to waste time on the loo!

That first hard stools can then trigger a chain-reaction of bad experiences. Painful defecation due to large, hard stools or even anal fissures (a small tear in the skin around the anus) can cause withholding behavior and this turns into a very vicious cycle.

Withholding behavior can be anything associated with not responding to the urge to poo. If you ignore the urge for long enough, it goes away, but the problem does not. Are you ready for the gory details?

The “urge” is triggered by the stretching of the rectal wall (the part of your colon just before the anus) when it is filled with stool. If you do not relax your anal sphincter muscles, the stools are pushed back and the urge goes away. However the rectum is still stretched, and over time becomes less sensitive to stretching when the next stool enters. The rectum’s main function is to extract and conserve as much water as possible. This is why the stool gets harder and more dry the longer it stays in the rectum. Children with fecal loading (where large masses of stool heaps up in their rectum) or impaction (where it is very difficult / painful / impossible for the child to pass the stools without help) can sometimes even seem to have diarrhea when the “newer” stool trickle past the hard stool. This can also manifest as fecal soiling (also called encopresis) where stool leak into the underwear (overflow incontinence).

So when should you worry? And when is it something more than functional constipation (meaning it is a common childhood/lifestyle problem with no serious pathology causing the problem)? Constipation in babies and toddlers are mostly (>95%) functional, so take a step back and relax, this too (like all poo…) shall pass!

RED FLAGS :

(These are signs or symptoms that will worry me if you tell me your baby does not poo and he has one of the following. Please consult your doctor asap.)

  • No stools passed in the first 48hrs of life
  • Constipation before one month of age
  • Associated with other symptoms such as a distended abdomen, vomiting, fever, not passing any gas
  • Any blood in / on the stools
  • Any abnormalities of the spine, buttocks, genitals or legs
  • Not growing well
  • Recurrent lung infections

TREATMENT:

To treat any constipation successfully you need to remove the dry, hard stools that are currently causing pain, and then you have to address the cause and keep the next stools soft so that it is easier to pass. It is important to maintain a frequency of at least 1 stool per day.

The treatment of constipation in babies and toddlers differ slightly, although we use mostly the same medication.

BABIES UP TO 1 -2 YEARS:

To help your baby remove the initial hard, dry stools :

Glycerine suppository for babies (you can cut it in ½ or ¼ and insert it with some lubricating jelly). You can also squirt 1ml of liquid glycerine into the anus with a small syringe. This softens the stool and the insertion also stimulates the bowels to pass the stool.

Bend baby’s legs at the hips and push his legs toward his stomach to relax the pelvic floor.

To keep the stools soft:

Diet:

Constipation often occurs after starting a solid diet as there are insufficient fibre and fluid in the transitional diet (often only consisting of cereals). It is thus important to increase the fibre by adding fruit and vegetable purees. Prune, apple, pear and pea purees worked for us. Be aware of banana and sweet potato as these often have the opposite effect. Try to change from rice-cereals to whole-wheat / mixed grain / barley cereals. Try to rather stay away from fruit juices as these contain a lot of sugar and very little fibre.If your baby develops constipation when you change from breast-milk to formula milk, it is worth-while to consult your doctor to discuss the best type of formula to use for your baby. You can also add a teaspoon of olive oil or sorbitol-containing fruit juice to their formula.

If your baby develops constipation when adding cow’s milk to their diet, it is important to ensure that they are not allergic to the cow’s milk.

Medication:

  • Lactulose is a safe and effective medication in the treatment of constipation. It is an indigestible and osmotically active sugar, which means they do not absorb any of it and it only works by pulling water into the bowels to soften the stools. It is not “addictive”, it will not make the bowels lazy and you cannot really overdose your baby. It is safe to start with 2.5mls twice a day, and then increase to three times a day / increase the dose by 2.5ml increments until your baby passes 1-2 soft stools per day. Decrease the dose or frequency if the stools become too loose.
  • Polyethylene Glycol (PEG) can also safely be given as an osmotic laxative after 6 months of age.
  • Glycerine suppositories: Rather keep these for a backup as baby can get used to the anal stimulation to initiate a bowel movement, he needs to stay sensitive to the internal stimulation that the stretching of the bowels provide.
  • Do not give stimulant laxatives or enemas to infants.

TODDLERS:

Acute treatment:
If there are any signs of fecal loading / impaction, it is important to first empty the colon to break the vicious cycle of hard, large, dry stools causing pain – causing withholding – causing hard, large, dry stools. This can be done at home or your doctor might feel it is necessary for your child to be admitted if there is a risk of dehydration.

Disimpaction is done by the aggressive use of poly-ethylene glycol (a laxative called PEG eg Pegicol / Miralax), or enemas or a combination of the two. This breaks up and softens the hard stools and enables the child to pass them. Once the colon is empty you can start with phase 2 of the treatment. (It is not necessary to monitor this with X-rays. When your child passes only clear water you will know the bowel is empty).

Maintenance treatment:
It is important that your toddler’s colon is “retrained” to be sensitive to minimal stretching and that the anus can relax and withhold as needed. This takes time. So it is crucial that you and any other caregivers buy into the gameplan for the next 4-6 months.

The treatment consists of a combination of laxative use and behavioural therapy.

In short you need to ensure that your child passes 1-2 soft stools DAILY. You become the laxative-expert by increasing or decreasing the dose as needed. The prescribed laxatives (PEG or lactulose) is very safe and is not absorbed, so you cannot “overdose” your child. It is also safe for long term use and does not cause the bowels to become “lazy” as it does not stimulate contractions of the bowels.

The behavioural therapy adds a crucial part of the treatment. As a child needs to learn and practise walking / talking, they also need to learn and practise a healthy toilet-routine. Start by encouraging and supervising regular “toilet-sitting” times, 2-3 times a day after meals (this is when there is a natural reflex to pass stool, so use all the help you can get). Make these toilet-sitting times fun and stress-free. Sit for 5 min even if there is no poo, and just keep at it. Make sure your child has a good posture on the toilet (a squatting position opens up the pelvis and aligns the rectum in such a way that it is easier to pass a stool) and that they do not have any fears of the toilet. (For some comic relief of all this poo talk, do yourself a favour and watch the video about “The Squatty Potty“).

It is also important in the long term to address the child’s diet to increase fiber and water intake. These are important skills that you teach your children for maintaining healthy bowel habits for the rest of their life, so it is well worth the effort!

RESOURCES:

  1. Den Hertog J, van Leengoed E, Kolk F et al; ‘The defecation pattern of healthy term infants up to the age of 3 months.’; Arch Dis Child Fetal Neonatal Ed. 2012 Nov;97(6):F465-70.
  2. Benninga MA, Faure C, Hyman PE, St James Roberts I, Schechter NL, Nurko; ‘Childhood Functional Gastrointestinal Disorders: Neonate/Toddler.’; Gastroenterology. 2016 Feb;
  3. Nurko S, Zimmerman LA; Evaluation and Treatment of Constipation in Children and Adolescents; Am Fam Physician. 2014 Jul 15;90(2):82-90
  4. Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, Staiano A, Vandenplas Y, Benninga MA ; Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN; J Pediatr Gastroenterol Nutr. 2014;58(2):258.
  5. Dobson P, Rogers J; Assessing and treating faecal incontinence in children. Nurs Stand. 2009; 24(2):49-56
  6. Brazzelli M, Griffiths PV, Cody JD, Tappin D; Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children. Cochrane Database Syst Rev. 2011; (12):CD002240
  7. Beck DE; Constipation and Functional Bowel Disease; Clin Colon Rectal Surg; 2005 May, 18(2): 120-127
  8. Pashankar DS, Loening-Baucke V, Bishop WP; Safety of polyethylene glycol 3350 for the treatment of chronic constipation in children; Arch Pediatr Adolesc Med. 2003 Jul; 157(7):661-4.

SONDAG-INSPIRASIE

Bethel se liedjie, TAKE COURAGE, speel al die hele naweek op “repeat” in my gedagtes! Hoe mooi is dié woorde? Ek deel gou ‘n uittreksel van die liedjie: (gaan luister hom!😊)

“Slow down, take time
Breathe in He said
He’d reveal what’s to come
The thoughts in His mind
Always higher than mine
He’ll reveal all to come

Take courage my heart
Stay steadfast my soul
He’s in the waiting
He’s in the waiting
Hold onto your hope
As your triumph unfolds
He’s never failing
He’s never failing

Sing praise my soul
Find strength in joy
Let His Words lead you on
Do not forget His great faithfulness
He’ll finish all He’s begun

So take courage my heart
Stay steadfast my soul

He’s in the waiting
He’s in the waiting
Hold onto your hope
As your triumph unfolds
He’s never failing
He’s never failing

And You who hold the stars
Who call them each by name
Will surely keep, Your promise to me
That I will rise, in Your victory
And You who hold the stars
Who call them each by name
Will surely keep, Your promise to me
That I will rise, in Your victory!”

Die Hebreeuse woord vir WAG is Qavah en dit beteken “om te wag, om te hoop vir iets, om uit te kyk vir iets wat jy verwag om te sien gebeur”.

Soms is dit baie moeilik om enige iets anders as jou probleme raak te sien. Dit verg dalk oefening om jou gedagtes op Hom en Sy beloftes te fokus.

Kies ‘n spesifieke skrif wat op jou situasie van toepassing is. Skryf dit neer op ‘n kaartjie of maak dit jou foon se agtergrond-prentjie. Elke keer wat jy bekommerd wil raak en fokus op jou huidige situasie, haal die kaartjie uit/plak dit teen jou spieël/lees dit op jou foon.

Soos jy vandag met hoop & ‘n nuwe verwagting op Hom wag, laat toe dat hy jou help om jou gedagtes op Hom & Sy beloftes te fokus. En wanneer jy kragteloos voel, draai na die Kragtigste Een. Onthou Paulus se woorde in Romeine 8:

“For I consider that the sufferings of this present time are not worth comparing with the glory that is to be revealed to us.” Romans 8:18 ESV

Gaan lees sommer die hele Romeine 8 😉 Dit het my opnuut aangespoor.

Seën vir julle! ♡

MY REGTERHAND

Ek wil graag Vrouemaand met ‘n storie oor ‘n merkwaardige vrou, afsluit. Sy is my kinders se oppasser, ons huishoudster en inspireer my daagliks. Makhulu. Ouma.

Deur die venster sien ek hoe die klein, fyn vroutjie nader stap. Ons interkom-klokkie lui en ek weet dis sý. Sy’s perfek op tyd vir werk. Sy moes vanoggend ver stap – vanaf die taxi ranks ‘n bus vang, en dan weer ‘n ent se stap tot by ons huis aan die bopunt van die woonbuurt. Ek sluit solank die voordeur oop en Rupert spring opgewonde onder my voete rond. Hy’s bly dat sy hier is – sy’s nog van die min mense wat behoorlik vir hom aandag gee (ongelukkig met die 2 kleintjies in die huis het ons interaksie met Rupert afgewater na “af Rupie” en “nee, Rupie”!)

Soos sy nader kom, kan mens sien sy stap effe mank. Net effens. As jy mooi kyk, is die letsel steeds daar…maar haar postuur is regop. Sý is ‘n trotse vrou.

Ek vertrou niemand anders met my kinders nie. Sy het 4 van haar eie stoksielalleen grootgemaak en dan was sy ‘n tweede mamma vir Oudste toe ek moes teruggaan werk toe.

My Regterhand. Ek ken min vroue soos sy. Die diep, donker valleie wat sy al moes trotseer, wens ek nie eers my vyand toe nie. En steeds bly sy staande. Ten spyte van al die uitdagings, die trauma, die hartseer en die pyn.

In 2015 is haar een nier verwyder. Daar was ‘n verdagte sistiese letsel op die ‘MRI scan’ en so moes die nier toe uit. Dit was ‘n hengse operasie en die herstel was lank… Intussen het sy ook met ‘n simpel senuwee in haar onderbeen gesukkel. Dié het naalde en spelde en soms ‘n dooie gevoel veroorsaak.

In 2016 verloor sy haar permanente werk by ander mense wat verhuis het – dít was ons gesin se redding. Haar aanvanklike verlies en hartseer was ons wonderwerk. Ek moes terug werk toe, en wou bittergraag my seuntjie in bekende hande los…

2018 was ‘n ‘rollercoaster’ van siekte, skok, hartseer, letterlike pyn en wonderbaarlike oorwinnings. Sy is postmenopausaal en het ewe skielik swaar begin vloei…vir 2 maande lank. Sy is kort daarna met Endometriële kanker (binnewand van die baarmoeder) gediagnoseer en moes Tygerberg toe vir ‘n totale histerektomie…dank Vader, dit het nog nie versprei nie, en sy is toe 100% genees!

Tydens haar verjaarsdag in November het sy gesien en beleef wat geen ma ooit moet beleef nie: haar seun, haar jongste kind, is deur ‘n bende aangeval by die nabye kafee toe hy gaan lugtyd koop het. Hy is wreedaardig met ‘n panga verniel en vir die dood agtergelaat. Deur God se genade het hy merkwaardig herstel.

Dit bring ons by hierdie jaar. Die beroerte in Maart-maand het nie haar lewe geneem nie, maar dit het wel ‘n litteken gelos.
Die 2de aanval op haar seun (dié keer met ‘n koeël in die been) het seker die grootste wond agtergelaat…

My Regterhand. Sy bly steeds staande. Sy bly steeds trots en terselfdertyd nederig… en vol liefde. Al voel sy self swak, is sy sterk. In Hom. En vir ons.






WAY MAKER, MIRACLE WORKER

Vandag was ‘n wonderwerk-dag.

Jy ken daai dae wat jy voel jy wil eerder weghardloop en in die bed gaan klim met ‘n warm koppie tee en beskuit (óf koffie óf ‘hot chocolate’) en die duvet hoog optrek – want alles wat vandag moet gebeur, is net té veel!

Ek het onlangs weer voltyds begin werk (my 4 maande kraamverlof voel al soos iets in die verre verlede!) en my kollega (en goeie vriendin) is tans met ‘adoption leave’. So…daar word maar redelik soos ‘n af-kop-hoender rondgehardloop (ek drafstap regtig tussen die sale om tyd te spaar!) en elke nou en dan voel ek kompleet soos ‘n verkleurmannetjie op ‘n smartie-boksie. Okay, sommige dae is beter as ander. Maar jy kry die idee, nê?

Oppad werk toe sing ek ‘n liedjie van Leeland…ons het hom die naweek by selgroep geluister…”Way maker, Miracle worker, Promise keeper, Light in the darkness…that is who You are
…” en ek gesels sommer met die Here…okay, dalk meer net soos “Here help my asseblief, ek het geen idee hoe ek alles vandag gedoen gaan kry nie! Ek stres, ek’s moeg, ek kan nie… Want sien, vandag moet ek saalrondtes doen (so 40 pasiënte), die studie-pasiënte kom, dis Morbiditeit & Mortaliteit vergadering, ek wil nog die beloofde babakleertjies by George Child Welfare gaan aflaai én êrens moet daar nog uitgemelk word ook!

Ek het nul “geestelik” gevoel (watookal dit beteken, nê) en na my eenvoudige vra-vir-hulp van Hom vroeër die oggend het daar niks “supernatural” gebeur nie. Of so het dit (aanvanklik) gelyk.

Ek het admin begin doen, e-posse gelees, oproepe gemaak, voorskrifte geskryf, pasiënte ontslaan. 10uur kom en gaan en ek wik en weeg of ek eers moet uitmelk of tog maar gou saal toe moet gaan. Ek kies die saal…en daar staan die vrou van George Child Welfare by ons hospitaal se apteek! Sy was (toevallig?) die oggend daar vir ‘n vergadering. As ek besluit het om eers uit te melk, sou ek haar gemis het! Ek kon toe sommer die babakleertjies vir haar gee. Een ding maklik afgehandel sonder rondryery! Halleluja.

Die volgende ding was die studie-pasiënte. Die enigste man wat sou kom, het gekanselleer – hy kom eers môre. Halleluja.

En toe is dit die M&M vergadering. My baas bied aan om die vergadering te lei. Hy het reeds ‘n paar onderwerpe wat hy wil bespreek. So, ek hoef nie voor te berei of Powerpoints te maak nie. Halleluja.

Die kersie op die koek (want ons dien ‘n Pappa-God met ‘n Vader-hart wat sy kinders soms ‘n bietjie wíl bederf), is dat ‘n onlangse kennis (wonderlike mens, mamma en besigheidvrou – meer oor haar later) vir my met iets spesiaals wil “bless”! (Dankie! Jy weet wie jy is😘)

Ek staan verstom. Een na die ander ding het in plek geval en uitgewerk. Hierdie “horrible”, amper-onmoontlike dag met ‘n lang lys van “to do’s” was toe op die ou end glad nie so sleg nie…

Gaan luister ‘Way Maker’:
https://youtu.be/iJCV_2H9xD0
Ek’s seker dit sal jou “bless”. Dit het vir my baie beteken.

Lekker slaap, mede-mammas,