IRON DEFICIENCY

PART 2

Written by Dr Nické Theron, Pediatrician.

Iron deficiency anaemia occurs when the iron stores are so empty that there is not enough iron to make proper new red blood cells. The new red blood cells are thus fewer, smaller and paler and cannot carry oxygen effectively. Your body will always prioritize the available iron to first be used in the red blood cells, but iron has many other functions in the body (see previous post). So by the time that there is iron deficiency anaemia, the brain especially has already suffered from the lack of iron.

This is a sneaky disease because there are almost no symptoms initially. It is thus important that your doctor asks about the risk factors for developing iron deficiency during well-child-visits.

Babies and toddlers between the age of 6months to 3years have an especially high risk to develop iron deficiency anemia. The American Association of Pediatrics recommend that all children should be screened between 9-12 months of age because of the serious effects it has on long term neurodevelopment. Several studies show that the delays in development improves with treatment, but does not normalise completely.

The most common cause of iron deficiency is insufficient intake (see previous post for tips on prevention). Other causes could be blood loss from the gut, specific syndromes where iron is not absorbed from the gut or chronic inflammatory diseases.

Symptoms of Iron deficiency anaemia:

Mild:

  • No specific symptoms
  • Iron deficiency could lead to behavioural changes in your child that is sometimes difficult to pin-point eg. children become more wary, hesitant, solemn, unhappy, keep closer to their mothers.
  • Restless leg syndrome, breath holding spells, sleep disturbances, short attention span, learning difficulties have also been seen to improve when iron deficiency was treated.
  • Pica : an intense craving for weird non-food items such as clay, dirt, chalk, soap, paper, raw rice or ice (pagophagia). No one knows how this works, but it responds very well to iron supplementation.
  • Poor growth

Severe:

  • Pallor (seen especially around the eyes, in the mouth, the nails and on the palms/soles)
  • Severe tiredness and loss of interest in otherwise fun activities
  • Irritability
  • Poor appetite, sores in the corners of the mouth, painful tongue
  • Fast heartbeat, heart failure, fast breathing.
  • Other complications associated with iron deficiency anaemia: Febrile seizures (although no relational cause could be found, several studies have found that children with febrile seizures are more prone to be iron deficient). Iron deficiency also causes paralysis of some parts of the immune system.

If your doctor suspects iron deficiency anaemia blood tests will be the next step to confirm. A hemoglobin or full-blood count and ferritin count will be enough. Treatment with Iron supplements will be started and the effect on the red blood cells will be evaluated after one month of treatment. If there are no response further investigations should be done for other causes of the anemia.

Treatment of iron deficiency anaemia

Ferrous sulphate 3-6mg dly (can be given once a day or in divided dosages.
The best absorption of iron happens when you give it with orange juice (or other juice high in Vitamin C as this improves absorption) in between meals. Foods that can block absorption of iron are dairy, eggs, tea or coffee, whole-grain breads and cereals / bran.

Iron supplements are notorious for having many side effects. However if you start at a low dose and slowly increase it, and give the iron with meals most children tolerate it quite well. Remember to give the drops at the back of your child’s mouth or give it mixed in juice with a straw. Some iron supplements may stain the teeth, but this can be removed by brushing with baking soda (talk to your dentist first). There are many different iron formulations of which some are better absorbed/better tolerated, but this also comes with a significant price increase. In the end the most important thing is that your child drinks the supplement. (Studies show no difference in the end-result for different formulations).

VERY IMPORTANT: Treatment for iron deficiency anaemia should be given for at least 3months, even if the blood count normalises before that. Remember that the body will use any available iron for the red blood cells first, and then the stores still need to be filled to prevent future problems.

Dietary advice

It is important that your child’s diet is also adapted to include more iron rich foods. It is adviced that they should eat at least 2-3 iron rich meals per day. Remember that the iron in animal products is absorbed better and thus you need to eat bigger quantities of plant-based iron to absorb the same amount.

Some foods that are high in iron include:

  • Meat – red and white. Liver is especially high in iron.
  • Other animal sources: Eggs (especially the yolk), fish
  • Dried fruits: raisins, apricots
  • Green leafy vegetables
  • Dried beans and lentils
  • Oats, other grains
  • Soybeans

I hope you now feel more confident in the whys and hows of iron deficiency. There are still so many ongoing studies and new developments with regards to the influence and treatment of different neurodevelopmental diseases such as autism and ADHD that I am sure this is a topic that we will still hear a lot about!

Resources

  1. Ozdemir N; “Iron deficiency anemia from diagnosis to treatment in children”; Turk Pediatri Ars; 2015 Mar; 50(1): 11-19
  2. http://www.uptodate.com
  3. https://www.mayoclinic.org/drugs-supplements/iron-supplement-oral-route-parenteral-route/description/drg-20070148

IRON DEFICIENCY

PART 1

Written by Dr Nické Theron, Pediatrician.

This is a topic that I have been avoiding for a while because there is so much conflicting advice and evidence available. I started giving our son iron supplementation from 6months but because it tasted horrible and stained all his clothes and he struggled with constipation, I stopped at around 10months. After attending the European Academy of Pediatrics congress in September I was reminded about how important iron is for brain development, and I felt very guilty that I did not give Eran enough iron-supplements. But was it really necessary? When should babies and toddlers use iron-supplements and what sort of iron should they use? Read on to learn with me:

Iron is a vital mineral in our bodies. It is used in red-blood cells to carry oxygen and to help manage the storage and usage of oxygen in the muscles. Iron also plays a very important role in brain development in babies and toddlers, regulating the structure as well as the hormonal messengers of the brain. The immune system also needs iron to function well. Luckily the body regulates iron very closely, and as red blood cells break down it is recycled and used again. We do however loose a small amount of iron daily from our skins and gut, and during menstruation. If we do not take in enough iron to counter-act these losses, it leads to iron deficiency.

Adults need to absorb about 5% of their daily iron needs from food. Children need to absorb up to 30% due to their rapid growth and development. This already places them at a high risk for iron deficiency.

“Iron deficiency” occurs when there is not enough iron in the “stores” of the liver. (Mostly measured by doing a “Ferritin level” on a blood test). If there is no treatment it will progress to “Iron deficiency anaemia” where the iron-levels in the red blood cells are also dropping, leading to fewer and smaller red blood cells. (Measured by testing the “Hemoglobin level” or a “Full Blood Count”). It is mostly only when a child becomes pale and tired that the problem is picked up. However there is already a big effect on brain-development, behaviour and growth long before the “Iron deficiency anaemia” causes symptoms. Sadly iron deficiency is the most common nutrient deficiency in the world, and the effect it has on children’s behaviour and development is scary.

“As iron sharpens iron, so one person sharpens another”

Proverbs 27:17

Children who have a high risk of iron deficiency are:

  • Mother has an iron deficiency during pregnancy (the baby will still take the iron it needs, but there is not enough iron to totally fill all the stores)
  • Mother has hypertension or diabetes mellitus during pregnancy (the iron in the mother’s body is not as easily available for baby / the baby has a higher need for iron)
  • Premature babies (iron stores are filled during the last few months of pregnancy, so premature babies miss out on this. They also have a smaller blood volume and undergo many blood-tests while in NICU).
  • Low-birth-weight babies (multiple reasons for high risk)
  • Early cord clamping (allowing more blood to flow to the baby from the placenta increases the amount of iron they start out with)
  • Insufficient dietary intake during early infancy
  • Early introduction (<1 year) of unmodified cow’s milk or consuming large amounts of cow’s milk (>500ml) after 1year of age. (Early introduction may cause an increase of blood loss from the bowels as the bowels are not ready for the large proteins / via allergic reactions. Cow’s milk contains very little iron, thus the risk is high if your baby does not eat enough other iron-containing foods)
  • Exclusive breastfeeding for longer than 6months (breastmilk has a very low iron content. See below. It is important to start iron-rich supplemental food from 6months).
  • Picky-eaters, children with multiple food allergies, children following specific diets.
  • Obese children
  • Children with malnutrition, chronic diseases or bowel-diseases.

I would like to explain a little more about the iron-needs in babies. Term, healthy infants usually has enough iron in their bodies for the first 5-6months of life (they have a relatively high “hemoglobin” at birth and their stores are filled during the 3rd trimester). Their iron-needs are thus quite low during the first few months. Breastmilk contains very little iron (+- 0.3mg/L) but it is very easily absorbed (up to 50%). Formula milk is usually supplemented with up to 12mg/L iron, but it is not as available to be absorbed (4-6%).

After 6months of age the iron requirements increase rapidly, and thus breastmilk alone is not enough to sustain the iron-needs in babies. They need to take in extra iron in some form. Iron-rich foods and iron-fortified foods such as cereals has been shown to be more effective than medical supplements in the long term to sustain normal iron stores. (If your baby already has a deficiency it is easier to fill up the stores with medical supplements, see next article).

So how do you prevent iron-deficiency?

  • The American Association of Pediatrics recommends that all healthy term babies who are exclusively breastfed should receive supplemental iron (1mg/kg/day) routinely from the age of 4months until they eat sufficient quantities of iron-rich food. (At least 2 meals per day containing iron rich food or iron-fortified food). The European society feels that there is no need for general iron supplementation in healthy babies and children as long as there are no other risk factors.
  • Formula-fed babies should receive enough iron in the formula for the first 6months and thus do not need further supplementation.
  • All premature babies should receive iron supplementation from the age of 2weeks until 1year (2-4mg/kg/day).

You can give the supplements as part of a multivitamin (eg Vidaylin with iron) or separately (eg Ferro-drops or Ferrimed). Seeing that there are some risks involved in using iron supplements in otherwise healthy children (some studies show that babies with normal iron stores that were supplemented with iron did not grow as well in length as those that were not supplemented) I think it is very important to discuss this topic with your pediatrician at the 6week check-up to make an informed decision with them after looking at all the risk factors for YOUR baby.

Iron deficiency has serious implications in your child’s development and should be carefully managed and monitored. In the next article I will discuss the effects of iron deficiency anemia and the treatment thereof.

Resources:

  1. Lonnerdal B, Georgieff MK, Hernell O; “Developmental physiology of iron absorption, homeostasis and metabolism in the healthy term infant”; J Pediatr 2015 Oct; 167(4 0): S8-S14
  2. Baker RD, Greer FR, The Committee on Nutrition; “Diagnosis and Prevention of Iron Deficiency Anemia in Infants and Young Children (0-3years of age)”; American Academy of PediatricsClinical Report
  3. Friel J, Qasem W, Cai C; “Iron and the Breastfed infant”; Antioxidants (Basel). 2018 Apr; 7(4): 54
  4. ESPGHAN guidelines for Iron Requirements of Infants and Toddlers
  5. http://www.uptodate.com

OUMAS (& OUPAS)

Dit is ‘n ongelooflike voorreg as oupa en ouma naby genoeg bly om gereeld oor en weer te kan kuier. Kleinkinders hou die grootouers jonk😉 en oupas en oumas kan soveel wyshede vir ons kinders leer en onvoorwaardelike bederf-liefde in hul hartjies deponeer.

‘n Mamma met ‘n pasgebore baba het iemand nodig wat vir babalyfie kan vashou, dat sy net vinnig iets kan eet of stort of aantrek of badkamer toe gaan – dat sy net weer mens kan voel. Dis wonderlik as Ouma of selfs Oupa naby is om hand by te sit.

‘n Moëe mamma is ook bitter baie dankbaar as Ouma die kinders bietjie kan besig hou – veral die besige kleuters met hulle oulike sê-goedjies en houdingtjies. Díé mini-mensies kan wel soms baie veeleisend raak as daar ‘n klein babalyfie ook in die huis is… (sien gerus “Die Baba-siklus” storie)

In ons geval, bederf Ouma en Oupa ons dikwels met saam-eet middagetes of ons ry uit na ‘n lekker restaurant met ‘n mooi uitsig. Dis presies wat hierdie ‘cabin-fever’-mamma nodig het om nie heeltyd net soos ‘n ‘jersey’ koei te voel nie!

Ek dink dis belangrik om aan die Oupas en Oumas spesifiek te kommunikeer oor wat jy van hulle verwag en hoe hulle jou kan help en bystaan. Elkeen se situasie lyk verskillend…

Mammas, dit is ook belangrik om grense te stel. Jy en jou huweliksmaat besluit saam oor hoe julle jul kinders wil grootmaak, die waardes wat jul hul gaan leer en hoe julle gaan dissiplineer ens. Grootouers moet die grense wat julle stel, respekteer. Al stem hul nie noodwendig daarmee saam of is dit nie dieselfde manier waarop hulle jóú groot gemaak het nie. (Hierdie kan soms ‘n taai toffie wees!)

Oumas (en Oupas), dit sal wonderlik wees as julle betrokke en beskikbaar kan wees…sonder om te veel voor te skryf. Om raad te gee wanneer daar vir jou gevra word… In my geval, het ek begin voel my ma laat my nie toe om die mamma te wees nie. Ek het gevoel my manier van dinge doen is nie goed genoeg nie. Want dis nie háár manier nie. Die oorsaak van hierdie “inadequate” gevoelens is ‘n kombinasie van postpartum hormone, slaap-tekort en leuens van die vyand. Oumas, wees maar bietjie meer sensitief daarvoor en luister na jou dogter/skoondogter se hart. As sy kla of huil, wees net daar. Sy’s op ‘n baie kwesbare en uitdagende plek in haar lewe, en gewoonlik wil sy graag net ‘n klankbord hê…en nie regtig iemand wat kom met lyste van “oplossings” nie.

Oumas, dit beteken nie jy het nóóit ‘n geldige opinie of moet op eiers loop nie! (Ek’s seker jy weet waarvan jy praat! Jy het immers jou kinders mooi groot gekry 😉) Dis maar net ‘n fyn balans van die regte hoeveelheid ondersteuning, sonder om “judgemental” oor te kom (al bedoel jy goed). Laat haar toe om self te probeer, leer en foute te maak – solank dit nie dodelik is of ewigheidskade aanrig nie!

Oumas, val maar eerder in by die ma. Vra byvoorbeeld eers wat die kinders mag eet of nie mag eet nie. Dieselfde reëls wat by die huis geld, moet by Ouma se huis ook toegepas word. Dubbelstandaarde is frustrerend en verwarrend. Konsekwentheid is die sleutel.

(Nuwe) mammas, ek wil afsluit deur te sê dat ons ook ekstra bietjie genade met die oumas moet hê. Ons moet onthou hulle was eens op ‘n tyd ook die mamma – en dít is wat hulle ken en onthou…Nóú moet hul ‘n splinternuwe rol aanleer en dít bring dalk onsekerhede en misverstande…
“Have a little grace. It goes a long way.”

TUISGEBAKTE BROOD

Hierdie resep is eenvoudig, maklik & vinnig… Perfek vir dié besige mamma van 2!

Plus! Dis ‘n gesonder opsie, sonder al die bymiddels en preserveermiddels van gekoopte massaproduksie-brood.

3 koppies bruin brood meel (ek gebruik 1wit & 2bruin)
2 koppies louwarm water
1 teelepel gis (‘instant yeast’)
1 teelepel sout

Meng droë bestanddele saam in ‘n groot mengbak. Voeg die louwarm water by en meng. Plaas deeg-mengsel in ‘n gesmeerde broodpannetjie. Kan bo-op met saadjies versier. Laat dit vir so uur op ‘n warm plek rys (bedek met ‘n doek, moenie in direkte sonlig sit nie). Ek skakel sommer solank die oond tot net-net aan en laat dit in die lou oond rys! 😉 Bak broodjie teen 180grade vir 30-40minute. (toets na 30min!)

Geniet! ♡
Dankie aan Nicole Wiese van @ardobreastfeedingsa vir die heerlike resep!

Oh ja, praat van ARDO! Onthou, jy kan 10% afslag kry op enige borsvoedingsprodukte (borspompe, ‘breast pads’ ens.) wanneer jy my Promosiekode gee: MM10. Woweeee! E-pos na nicole@ardo.co.za vir meer inligting.

ARDO is ‘n Switserse maatskappy wat topgehalte mediese produkte, asook mamma- en babaprodukte vervaardig. Gaan loer gerus op hul webblad: https://ardo.co.za/

HUMMUS

* Kekerertjiesmeer *

“Kids LOVE dipping stuff” –
Dis ‘n maklike & potensieel gesonde manier om verskillende groente(stokkies) in jou kleinspan se lyfies te kry!

Die gesondheidsvoordele van Chickpeas sluit in:
Dis hoog in vesel, ‘n bron van proteïene, propvol vitamienes en minerale en het ‘n laer glisemiese indeks (‘low GI’) – wat beteken dat dit help om bloedsuikervlakke te beheer!

Loer hieronder vir 2 maklike Hummus resepte. Die eerste een is vir almal wat hou van ‘n vars ‘plain’ smaak. Die 2de resep het ‘n voller smaak en is vir dié wat bietjie meer met speserye wil eksperimenteer en hou van ‘n “skop”! Albei is baie ‘yummy’ en gesond!

WENK: Gooi ‘n klein bietjie koue water by die mengsel om dit makliker te meng/’blend’ en romerig te maak.

Dankie aan Nadene Esterhuizen en Nancy Cloete vir die 2 resepte!

SONDAG-INSPIRASIE

GASSKRYWER

‘n Vrou se handsak
Deur Magda Burger

Iets waaroor haar man definitief nie praat nie. En in ons huis lyk my man of die donderweer hom gaan tref as hy iets in myne moet soek.
So elke kort-kort moet ek maar inklim en regpak. My Pandora’s box hou nogal interessante dinge in, veral as die seuns dit ook gebruik.

Ek kry nou die dag ‘n klip in my handsak. Net ‘n gewone klip. Niks spesiaals nie. Inteendeel ek het deksels swaar aan die ding gedra! Vies haal ek dit uit.

Toe besef ek hoe baie klippe dra ons in ons harte:
Al die onnodige gemors. Is nie lus om daai ou te vergewe nie, en dan bly ek maar vies elke keer wanneer ek aan daai een dink. Die gekrap as iemand die hele tyd vir my vra om iets te doen. Vriendelik te wees en ‘n nors antwoord terug te kry, en dan maar dae lank daaroor ontsteld te wees. Soveel irritasies wat elke dag se mooi uitsuig.

Haal die klippe uit. Maak jou hart ligter. Dan kan jy in elk geval meer liefde inpak wat jy weer in oorvloed kan uitdeel.

TUISGEMAAKTE GRONDBOONTJIEBOTTER

Sommige Gesondheidsvoordele van Grondboontjiebotter:

  • Hoog in Proteïene
  • Hoog in Vesel
  • Hoog in Vitamiene B
  • Hoog in Minerale, soos Kalium & Magnesium
  • Hoog in Antioksidante
  • Help om Cholesterol te verlaag
  • Dit bevat meestal onversadigde vette (die gesonde soort vette)
  • Kan help met gewig-beheer
  • Reguleer bloedsuikervlakke
  • Sommige studies toon selfs ‘n vermindering in die risiko om Diabetes, Hartsiektes en Kanker te ontwikkel!

Pasop vir winkel-gekoopte grondboontjiebotter wat ekstra bygevoegde suiker, sout en gehidrogeneerde olies (‘hydrogenated fats’) bevat – hierdie minder gesonde olies keer dat die natuurlike olie van die grondboontjiebotter skei en dit verhoog die transvetsuur-inhoud.
(👉Lees die ‘labels’)

Die gesondste bly maar die suiwer gemaalde neute (met of sonder ‘n bietjie olyfolie – geen ander byvoegings!)
Kyk hieronder vir ‘n maklike resep. 🥣🥄

Die porsiegrootte vir grondboontjiebotter wat aanbeveel word is ongeveer 2 eetlepels & indien dit saam met ‘n gebalanseerde diëet geniet word, dra dit by tot ‘n gesonder jy! 😁

TRIPPE TRAPPE TONE

Ek’s seker ek hét gekyk waar die eerste trappie is. Ek’s amper 100% seker…

Hierdie mamma het heel Vrydag soos ‘n absolute vrot ma gevoel! Ek het met baba en al by ons boonste verdieping se trap afgeval. Darem net tot in die helfte van die trap…maar nogsteeds… 😬 Eina.

Met my baadjie onder die een arm, dummy & Telement in die hand, selfoon in die gatsak en baba op die heup, het ek aan die bopunt van die trap gestaan en vlugtig afgekyk. Ek was haastig. Ek misgis toe die tweede trap vir die eerste een, en daar steier ek vooroor, met enkels wat swik en voete wat skraap, soos ek probeer om vastrapplek te kry! Toe ek die teëls sien nader kom, en ons 2 aanhou gly, besef ek ons ontmoeting met die grond is onvermydelik. Ek probeer vir boetiebaba nader trek, maar met die momentum (en sy 10kg lyfie) “ka-plaks” ons boude-eerste op die harde teëltrap. Ek kreun, en boetie snak na sy asem – toe begin hy hartverskeurend huil. Gelukkig hou ek hom steeds vas (hy het genadiglik nie uit my arms geglip nie!) en alhoewel hy opsigself ‘okay’ lyk, kan ek hoor hy’s in pyn. Ek gil histeries vir my man om te kom help, en soos hy vir baba uit my arms tel, voel ek my eie seer: my elmboog, my linkerboud, my enkel (díé het alreeds ‘n golfbal-swelsel aan die vorm).

Ons uitstappie na Ongevalle en X-strale bevestig: geen gebreekte/gedislokeerde bene. Dankie, Vader. My enkel is net sleg verstuit. Maar boetiebaba het ‘n diep sny onder sy 3de toontjie… Só wag ons toe vir die chirurg wat hom heelmoontlik teater toe sal moet neem vir narkose en steke…

Die chirurg kom sien ons toe ‘n paar uur later in die kindersaal (genade, maar dis sleg om ‘n kind – wat nog te sê van ‘n borsvoedende baba – nil per mond te hou! Ek’t as dokter-mamma beslis nuwe perspektief en empatie bygekry). Steke is toe nie nodig nie! Ons kan sy voetjie konserwatief met verbande behandel – halleluja!

Oudste, met sy klein hartjie en kinderlike geloof, het by die huis al vir mamma en boetie se voete gebid. Pappa noem na die hele gedoente hoe hy tóé al gesien het hoe die voetjie se swelling sak…

Boetiebaba se naam-betekenisse het in hierdie (kort) 7 maande vir my werklik “lewendig” geword: Kampioen en God is genadig. Deur al die “trials & tribulations”…deur septiese skok en breinvliesontsteking en brongiolitis…en sy ma wat heel simpel was om nie aan die trapreëling vas te hou nie… Hy is ‘n dapper klein mensie & God is altyd genadig.

DIE “REGTE” DING

Hoe weet jy wat is die régte ding om te doen? In ‘n wêreld waar alles RELATIEF geword het: mý waarheid, jóú waarheid?

Hoe kies jy? Waarop maak jy staat? Intuïsie? “Gut” gevoelens? Besluite gebaseer op vorige ervarings? Wat sê die samelewing?

Ek besef net weer op hierdie vars nuwe Maandagoggend: my emosies kan my om die bos lei…dan voel ek sus en dan voel ek so. My vorige besluite was nie noodwendig die beste besluite nie…En die samelewing word tans ongelukkig met ‘n “anything goes”-uitkyk aan die slaap gesus…

Mag die Heilige Gees my hierdie week lei (en elke week wat kom!). Mag Hý my ware Noord wees. En mag ek werklik stil word…en na Sy stille fluisterstem lúíster. Sodat ek regtig kan weet wat die regte ding is om te doen.

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.