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DIARRHOEA IN KIDS

~ All you need to know…

Written by Dr Nické Theron, Pediatrician.

When Eran was 8months old we woke one night to a cot full of vomit. Things deteriorated from there… Two days of diarrhoea (with stools leaking through everything) and vomiting with a mild fever followed. I am grateful that it was a very mild episode and he was never dehydrated, but I still had a lot of worry and washing! I have spent many nights admitting children to ICU with severe dehydration and I know how fragile they are, but there is a lot you can do at home to prevent a crisis.

Let us look at the how and why of diarrhoea.
According to the WHO the definition of diarrhoea is 3 or more loose or watery stools per day, or any change from the child’s usual stool patterns. Diarrhoea is still one of the top 5 causes of childhood death in children under 5 years in the developing world and should always be taken seriously.

“Looking after a very sick child was the Olympics of parenting.”

Chris Cleave

Diarrhoea can be divided into acute (continues for less than 5-7 days), intermittent (7-28 days) and chronic (>4weeks).

  1. Acute diarrhoea in children is mostly caused by viral infections (up to 60-70% of moderate to severe cases of diarrhoea in children under 2years). The children usually have some vomiting, watery stools and a mild fever (38-39°C). Most children with a viral diarrhoea only need supportive treatment and the disease usually clears up spontaneously within a few days.
    Bacterial infections are the cause of diarrhoea in 30% of cases in children between 2-5years. These kids are almost always more toxic (high fevers above 40°C, looks ill, severe stomach pain, blood or mucous in the stools). The diagnosis can be made with stool or blood cultures.
    Another common cause of acute diarrhoea is antibiotic-associated diarrhoea. It usually starts during or shortly after a course of antibiotics such as Amoxicillin or Amoxicillin with clavulanic acid. The diarrhoea is due to a disturbance in the microbiome in the colon as described or could be due to a secondary infection due to overgrowth of a “bad bacteria” because the antibiotic wiped out all the “good bacteria” from the colon.
  2. Intermittent diarrhoea (also called persistent diarrhoea if more than 14days) is mostly due to a combination of factors. When you have a severe bout of infectious diarrhoea the inflammation causes damage to the bowel wall, thus decreasing the absorption of sugars and water. Your child could thus have a type of “lactose intolerance” while the bowel wall is being restored and this causes a prolonged episode of diarrhoea.
  3. Chronic diarrhoea is diagnosed when your child has diarrhoea for most days for more than 4 weeks. That is not fun for anyone involved. Some rare causes of chronic diarrhoea are parasitic infections, inflammatory bowel diseases, malnutrition, or malabsorption secondary to diseases such as Cystic Fibrosis. Your doctor will probably request tests on the stool itself, and your child might need some blood tests.

Another more common cause is “Functional diarrhoea”, also named “Toddler’s diarrhoea”. This diagnosis is made when a child has more than 4 stools a day for more than 4 weeks, and more serious issues were excluded. It is often caused by a diet high in fruit-sugars or milk-sugars (or other nutrients that are not absorbed), thus pulling more water into the bowels, leading to diarrhoea. Functional diarrhoea should clear up after a visit to a dietitian.

When your baby starts to spew bodily fluids all over the place, I am sure you don’t really care so much about the cause, so let me tell you the things to look out for and when to start worrying.

⚠️If your child has any of the following symptoms when they have diarrhoea, please see a doctor as it could indicate a cause that need specific treatment:

  • Blood in the stools (could indicate a bacterial or serious gut disease that needs urgent treatment)
  • Mucous in the stools (usually indicative of a bacterial or parasitic infection)
  • Severe stomach pain, especially when it is concentrated in one area
  • Other infections that accompanies the diarrhoea such as pneumonia or ear infections
  • History of eating wild mushrooms or any other form of toxins

The severity of the diarrhoea and vomiting, and associated fluid loss, can vary greatly.

⚠️Here are some complications to look out for:
• Dehydration is the biggest complication associated with diarrhoea, so be sure to look out for the following symptoms:
Mild dehydration starts with the child feeling thirsty or drinking fluids eagerly, a dry mouth and passing slightly less urine. This can still be managed at home.
If your child loses more fluids, they could also have sunken eyes and a sunken fontanelle (soft spot on their head). They can be irritated and pass very little urine. At this stage (moderate dehydration) it is better to see a doctor to make sure you can keep up with the fluid intake.
If the fluid losses continue without replacement, children become sleepy or unresponsive, they pass no urine and they go into a state of shock where there is insufficient blood circulation to the important organs of the body. This is a medical emergency (severe dehydration) and they need intravenous fluids to catch up with the losses.
• Hyponatremia or Hypokalemia (too little salts in the blood) is another possible complication of severe diarrhoea because of the movement of water and salts over the bowel wall. This can cause muscle weakness, cramps, headaches, confusion, convulsions and heart dysrhythmias.
• Hypoglycaemia (low blood sugar) could complicate diarrhoea as the little ones often does not want to eat and does not absorb food well while their bowels are ill. This could also cause irritability, convulsions and loss of consciousness.

‘Do not be anxious about anything, but in every situation, by prayer and petition, with thanksgiving, present your requests to God.’

Phil 4:6

Treatment of Diarrhoea

“Prevention is better than cure” is one of my favourite mantras.

The World Health Organisation has a few recommendations to prevent diarrhoea:

  • Breastfeeding
  • Consumption of safe food and water. (We often take this step for granted, but many people do not have access to clean water. However, we should all boil any water given to a baby under the age of 6months (especially as part of their formula) and rinse fruit and vegetables well before eating it. Take note of the expiry dates on expendable foods and keep meat separately in the fridge.
  • Handwashing for everyone.
  • Sterilizing bottles and dummies given to babies under the age of 6months
  • Immunizations against the Rota Virus has sharply decreased the number of babies admitted with severe diarrhoea and dehydration.

Unfortunately it is almost inevitable that your children will get poonamies or vulcanic vomiting at some point.

Let me give you a strategy for when the poo hits the fan:

  • Offer fluids regularly. The main aim of treatment is to prevent or treat dehydration. The best fluids to use are a combination of pre-mixed electrolytes (such as Rehydrat), diluted with boiled, cooled water. These sachets have the correct ratio of sugars to carry the salts and water back into the body. Another study compared the use of diluted apple juice (1:1 diluted with water) to these sachets and found that in children with mild dehydration the outcomes were the same, making diluted apple juice a good alternative. Using water with no supplements could lead to low salt-levels in the blood, using chicken broth could lead to dangerously high levels of salts in the blood.
  • To prevent or treat mild dehydration (see previous post), you should give your child between 50-100mls of fluids/kg over 4 hours. Eg: Your child weighs 12kg. You should give 600-1200ml over 4 hours (150-300ml/hr). It works best if you give a spoonful/ a few sips every 5-10min. Big volumes can make them vomit again.
  • If your child has signs of moderate/severe dehydration, or they keep on vomiting the fluids that you give them, please go to the Emergency Unit asap.
  • Continue to offer food during snacks and mealtimes
  • It is important to continue breastfeeding and giving regular foods (even dairy products) during a bout of diarrhoea. Your child might not have a good appetite, so offer them foods that they usually like, and do not worry if they only take a few bites. It is important to keep the lining of the bowels healthy, or the diarrhoea might be prolonged.
  • Anti-diarrhoea medications: Never give children medication to stop the diarrhoea. This causes a build-up of the toxin/virus/bacteria in the bowels, causing it to push into the bloodstream, and this can make them really sick. Anti-vomiting medication is also dangerous as it can make them sleepy (thus they drink less) or have dangerous side-effects in children. Medications like Diosmectite (Smecta) can be really efficient as it binds the toxin/virus/bacteria and expells it. It also improves the consistency of the poo. It is not absorbed, thus is safe to give to babies over 6months. It does taste quite horrible, but we have managed to give it to Eran with a syringe while blowing on his face to distract him/ help him swallow.
  • Antibiotics: As most episodes of diarrhoea are caused by viruses, antibiotics are mostly not necessary. If your child has high fevers or bloody diarrhoea there is mostly a bacteria involved which needs to be treated with antibiotics as prescribed by your doctor.
  • Supplements:
  • ~ Zinc: Several studies have proven that Zinc supplements can decrease the severity and duration of diarrhoea in children under 5 years. Eg Zinplex syrup.
  • ~ Probiotics: The use of probiotics can help to restore the microbiome of the bowel and thus help to get the diarrhoea under control. Reuteri drops are safe to give even from birth and although researchers cannot prove which dose or strain gives the best results, we know it should not cause any harm.

And then, most importantly, give them a lot of TLC!

“The secret of the care of the patient is in caring for the patient.’

Dr. Francis Peabody

I hope these tips will help to get your kiddies eating and playing again sooner rather than later!

Let me know what food / fluids works best for you when your child has diarrhoea?

Resources

  1. Jenkins R, Whyte LA; “Pathophysiology of diarrhoea”; Paediatrics and Child Health Volume 22, Issue 10, October 2012, Pages 443-447
  2. Elliot EJ; “Acute gastroenteritis in children”; BMJ; 2007 Jan 6; 334(7583):35-40
  3. http://www.uptodate.com
  4. WHO; “Preventing diarrhoea through better water, sanitation and hygiene: exposures and impacts in low- and middle-income countries”
  5. Freedman SB, Willan AR, Boutis K, Schuh S; “Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial.”; JAMA. 2016;315(18):1966.
  6. Lukacik M, Thomas RL, Aranda JV; “A meta-analysis of the effects of oral zinc in the treatment of acute and persistent diarrhea.”; Pediatrics. 2008;121(2):326.
  7. Lazzerini M, Ronfani L; “Oral zinc for treating diarrhoea in children.”; Cochrane Database Syst Rev. 201
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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
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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
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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.

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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
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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.
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ECZEMA – part 2

Written by Dr Nické Theron, Pediatrician.

Eczema is a chronic disease and sadly it is not (yet) curable. It is however possible to control the symptoms. The aim is to get the acute inflammation of the skin under control (usually with topical steroids added to your normal regime), and then maintaining a healthy skin barrier by keeping the skin hydrated. It is thus very important that you understand the disease and what causes flare-ups in your child (see previous post) so that you can create the best management plan with your doctor.


…being strengthened with all power according to His glorious might so that you may have great endurance and patience…

Col 1:11

General Tips and Tricks:

• Avoid triggers as far as possible. Triggers differ for each child and can be as simple as: extreme cold or dry environments, sweating, emotional stress or anxiety or exposure to certain chemicals or cleaning solutions eg soaps, perfumes, cosmetics, wool, synthetic fibres.

• Keep the skin hydrated:
This is a very important part of the management plan. It is not necessary to buy the most expensive ointments; research show they do not necessarily work better than the ones you can buy in Dischem.

Your moisturizer needs to tick the following boxes:

  • It must be an emollient or ointment, lotions can worsen the dehydration of the skin.
  • Contain cetomacrogol (emulsifier), urea or glycerol (locks in moisture on the skin)
  • Contain NO colourants or fragrants. Be careful of any ointments containing “Sodium Lauryl Sulphate” as this can also break down the natural skin barrier.
  • E.g. in South Africa: Cetaphil, Epimax, Epiderm
    Best results when applied twice a day. Important to apply directly after bathing.

Bathtime talk: Lukewarm baths / showers soothe the skin but avoid long (10-15min) baths. Use a non-soap cleanser sparingly (you can use the same ointment that you apply after bathtime). In some cases a specialist may prescribe a “bleach bath” to decrease the amount of bacteria on the skin. Use a ¼ cup of bleach in a full bathtub (+- 150L) twice a week. (Discuss this with your doctor first.)

Medical treatment

• Topical Steroids
Most children with eczema will use topical steroids at some point during the disease. The anti-inflammatory effect is very effective in the treatment of the itch and the inflammation of the skin and most mild and moderate cases of eczema respond quickly to these ointments.

There are many different types of topical steroids and they are classified according to their potency. Examples you may know is Hydrocortisone (Mylocort) which is a weak steroid, Methylprednisolone (Advantan) moderately strong, and Betamethasone (Repivate) one of the strongest steroids available to use on the skin. Your doctor will help you to weigh up the risks and benefits to decide which steroid cream to use.

When there is a flare-up of the eczema, use a stronger steroid cream once daily for 7-14 days, then switch to a weaker steroid until the lesions are gone

Steroids in general has a bad reputation because they have the potential to cause some nasty side effects. However, only 2% of the topical steroid is absorbed, and if you use it safely it can bring a lot of relief to your child. It is important to use the ointment sparingly (apply only a pea-size per affected area), apply only once a day, limit the duration of strong steroids to 14 days, use the weakest effective ointment, be careful in the face and skinfolds as these areas are more prone to side effects. Long term use of strong steroids may cause a steroid-crisis because the body stops making its own steroid-hormones that are vital in times of illness / surgery / injury.

Common side effects can be thinning of the skin (atrophy), small red / purple spider-veins (telangiectasia) or stretch marks may develop in the affected area or the steroid can irritate the skin causing a contact dermatitis.

Once you have control of the acute flare, it is important to maintain the control by using emollients consistently and in moderate / severe eczema you can also use intermittent topical steroids for 2 days in a week to minimise the side effects.

Sometimes it may be necessary to give a short course (3 days) of oral steroids to get control of a severe eczema flare, but this should be the last resort!

• Topical calcineurin inhibitors
This is a relatively new class of treatments that are very expensive. Tacrolimus ointment (Protopic) / Pimecrolimus cream (Elidel) are effective to manage eczema and it has fewer side effects, but it does not work as quickly as steroids. It is better to use in sensitive areas such as the face and groin in children over 2yrs. There are still some concerns about long-term use (possible link to cancers later in life, this is still being investigated) and it is thus mostly used as a second line of therapy for children who does not respond to topical steroids.

• Relieving itching
It is important to relieve itching as this is usually the most bothersome symptom and keeps children awake at night. Scratching also worsens the eczema lesions, so keep finger nails short!

Oral antihistamines such as Hydroxyzine (Atarax) may cause drowsiness which will improve sleep. Cetirizine (Zyrtec) can also be used.

Wet dressings/wraps (the topical steroid and emollient is applied under a wet gauze covered with a dry dressing) is very effective to soothe and hydrate the skin, loosen crusts, reduce itching and prevent scratching.

Alternative treatments:

  • Probiotics – research shows a small reduction in the symptoms which is not statistically significant. No serious side effects were noted so it may be worth it to test it in your child.
  • Melatonin – In two small randomized trials, melatonin supplementation reduced disease severity and improved sleep in children with eczema. Melatonin is a hormone and as such has its own risks and side effects. Please discuss with your doctor

Prevention of Eczema:

  • Use of emollient therapy from the first week of life has proven to reduce the risk of developing eczema before 1yr of age. This is a safe, cost-effective measure to use if you know your baby may be at risk.
  • Use of probiotics in the mother and the baby may prevent the development of eczema but more studies are necessary. This is also a relatively safe precaution to take.

Life with a child with eczema can be hard, but if you stay positive, build treatments into a fun routine and walk this road with your health care provider, there is light at the end of this tunnel.

Worry does not empty tomorrow of its sorrow. It empties today of its strength.

Corrie ten Boom

♡

Pediatrics and Playdough & Medicine Mommy

Resources:

  • Miller DW, Koch SB, Yentzer BA, Clark AR, O’Neill JR, Fountain J, Weber TM, Fleischer AB Jr; “An over-the-counter moisturizer is as clinically effective as, and more cost-effective than, prescription barrier creams in the treatment of children with mild-to-moderate atopic dermatitis: a randomized, controlled trial.”; J Drugs Dermatol. 2011;10(5):531
  • Coondoo A, Chattopadhyay C; “Use and abuse of topical corticosteroids in children”; Indian J Dermatol. 2014 Sep-Oct; 59(5): 460–464.
  • Michail SK, Stolfi A, Johnson T, Onady GM ; ”Efficacy of probiotics in the treatment of pediatric atopic dermatitis: a meta-analysis of randomized controlled trials.”; Ann Allergy Asthma Immunol. 2008;101(5):508.
  • Chang YS, Lin MH, Lee JH, Lee PL, Dai YS, Chu KH, Sun C, Lin YT, Wang LC, Yu HH, Yang YH, Chen CA, Wan KS, Chiang BL; “Melatonin Supplementation for Children With Atopic Dermatitis and Sleep Disturbance: A Randomized Clinical Trial.” JAMA Pediatr. 2016;170(1):35
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ECZEMA – part 1

Written by Dr Nické Theron, Pediatrician

Red rashes… there are so many things that could look the same, and each child’s rash reacts a little differently. Even in the Bible many chapters in Leviticus was devoted to different skin lesions. There is only a small amount of treatments available…but oh so so soooooo many “boererate” and little ointments, potions and lotions that everybody swears worked for their child. Luckily eczema is one of the rashes we actually do have some answers for, so let me share what I do know:

What is Eczema?

Eczema (also called atopic dermatitis) is a chronic inflammatory skin disease that usually starts before the age of 5 years. It affects up to 1 in 5 children worldwide, and it seems as though it is becoming even more common in developed countries. You are not alone in your struggles!

Genetics play a strong role so there is usually a family history that one or both parents have atopy (this means they are prone to food-allergies, eczema, allergic rhinitis and asthma). An abnormality in the outer barrier of the skin, the epidermis, leaves the skin vulnerable. Environmental irritants (such as grass, dust, heat, cold), allergens and microbes (such as bacteria and fungi) can now pass through, and the skin loses more water. Some children also have an abnormal immunological response to foreign proteins, worsening the inflammation of the skin. This cycle is a little like the debate about who comes first, the chicken or the egg. It is still unsure whether eczema starts “inside-out”, or “outside-in” and although specific food or aero-allergens can make it worse, it is not always the cause of eczema.

There is evidence that the microbiome on the skin (the “normal” bacteria and fungi that live on your skin in harmony) is disrupted in a child with eczema. This causes an overgrowth of bacteria (usually Staphylococcus Aureus) which could worsen the inflammation of the eczema. It is thus not a cause of eczema, but it can make it worse.

Although tonsils play a part in the immune system of the body, I could not find any information suggesting that it could play a role in the development of eczema.

Symptoms:

Dry skin, intense itching, patches of red skin with small bumps and some flaking of the skin can be seen in children with eczema. There can also be some blistering and watery fluids leaking from the lesions, causing crusts on the skin. Itchiness is often worse at night. Scratching can worsen the inflammation and introduce infections. The skin can become thickened or darkened or even scarred from the constant inflammation and scratching.

Eczema usually start before one year of age, and the area of the body affected by the eczema can differ between children but can also change in the same child over time. Infants most commonly have patches on their arms and legs, their cheeks or scalp. Older children are more affected on their backs and the creases of their elbows and knees. Some children are only affected on their hands, or around their eyes or lips.

The Eczema Journey:

Most children will outgrow their eczema by late childhood (80% clears up by 8years of age). If your child has a mild eczema and was diagnosed before 2yrs of age, the chances are good that your child will be eczema free soon.

However, if the eczema started before 2yrs of age, your child has a higher risk of developing other allergies and asthma. We call it the “allergic march”, meaning that if your child’s immune system is prone to over-react to foreign proteins encountered via the skin as a baby (resulting in eczema), it will probably overreact to food proteins encountered via the gut (resulting in food allergies), pollen proteins encountered via the nose (resulting in allergic rhinitis) and proteins encountered via the lungs (resulting in asthma) as your child grows. This does not mean that every child will develop all of the above, but we need to keep our eyes open for the signs and symptoms.

Children and adolescents with eczema can also develop ADHD, depression or anxiety disorders. This is thought to be caused by the lack of sleep due to night-time itching, the psychological stress of having a chronic disease as well as the effect of chronic inflammation on the developing brain.

There is also an association between Autism Spectrum Disorders and eczema. Children diagnosed with eczema before the age of 2 has a slightly higher risk to be diagnosed with autism later in life. This relationship is still being investigated, but it is thought that the different inflammatory markers (especially the cytokines) may play a role.

Eczema can thus affect all areas of your child’s life and they need close follow-up and care.

“Cast all your anxiety on him because he cares for you.”

1 Peter 5:7

Making the Diagnosis:

Your GP can make the diagnosis by taking a good history and doing a quick examination of the skin. General practitioners should be able to treat mild cases, but if initial management does not work, it is better to follow up with a dermatologist and/or pediatrician to ensure good control of the disease.

Some diseases that could mimic eczema or that should be excluded are:

  • Allergic or Irritant Contact dermatitis: This is when the skin reacts to a known allergen (eg a piece of fish touches your child’s hand he will get a rash only on his hand) or an irritant (eg your child wears new shoes and the rash is only visible where the shoe touched the foot.)
  • Seborrheic dermatitis: mostly in infants. They develop a greasy red rash with scales on their scalp, eye brows and in their skin folds that is not itchy.
  • Psoriasis: chronic auto-immune skin disease with red skin patches with a silvery scale. Rare in children
  • Scabies: infection of the skin, very contagious, also very itchy. Usually there is a specific rash on the palms or in between the fingers.
  • Certain drug reactions
  • Primary immunodeficiency syndromes: here a lack of a certain part of the immune system may result in a rash on the skin.

Thank you for all your questions that helped me to write this post, I have also learned a thing or two while reading the latest research. I hope that you will feel more confident in understanding what eczema is and how it works and that this will empower you to tackle this journey with your child. Find a caregiver that you trust and will take alongside you on this journey. Treatment is available, and we will discuss it in tomorrow’s post.

“He who has a why to live can bear almost any how.”

Friedrich Nietzsche

♡

Pediatrics and Playdough & Medicine Mommy SA

Resources:

  • Thorsteinsdottir S, Stokholm J, Thyssen JP, Nørgaard S, Thorsen J, Chawes BL, Bønnelykke K, Waage J, Bisgaard H; “Genetic, Clinical, and Environmental Factors Associated With Persistent Atopic Dermatitis in Childhood.”; JAMA Dermatol. 2019;155(1):50
  • Kim JP, Chao LX, Simpson EL, Silverberg JI; “Persistence of atopic dermatitis (AD): A systematic review and meta-analysis.”; J Am Acad Dermatol. 2016;75(4):681. Epub 2016 Aug 17.
  • Wan J, Mitra N, Hoffstad OJ, Gelfand JM, Yan AC, Margolis DJ; “Variations in risk of asthma and seasonal allergies between early- and late-onset pediatric atopic dermatitis: A cohort study”; J Am Acad Dermatol. 2017;77(4):634. Epub 2017 Aug 14.
  • Yaghmaie P, Koudelka CW, Simpson EL;” Mental health comorbidity in patients with atopic dermatitis”; J Allergy Clin Immunol. 2013 Feb;131(2):428-33. Epub 2012 Dec 13.
  • http://www.uptodate.com
  • Thank you to the “National Jewish Health” site for the illustration.
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REFLUX – part 2

Tips & Tricks for the Management of Reflux in Babies, by Dr Nické Theron

In the last few weeks I have spoken to many moms and read many blogs to do some more research regarding reflux in babies. (SEE THE PREVIOUS POST to learn more about what reflux is). There are some interesting and scary treatments suggested out there! As a mom I wish I could give you a miracle-cure that would help your baby sleep better, cry less, spit up less. Unfortunately I know such a cure does not exist, no matter how alluring some moms on social media make it sound. As a pediatrician I would like to stick to what has been proven to work and what is safe for your precious baby now and in the long run. So here goes:

General management for all babies with reflux (GER and GERD):

• Upright positioning (90°) for 20-30min after feeds.
Babywearing keeps your hands free and keeps baby happy and safe.
“Reflux pillows” that elevates your baby’s head while sleeping has not been proven to make a big difference. Please remember the safest sleeping position for a baby is flat on his back to reduce the risk of SIDS (Sudden Infant Death Syndrome).  Even though babies with reflux sleep better on their stomach or left side down, I cannot recommend this if your baby is not monitored continuously.
Placing your baby in a rocker or car seat can worsen reflux due to the scrunched up positioning and increased pressure in their stomachs.

• Feeding volume and frequency:
It helps to give smaller feeds (so that you do not overly distend the abdomen) more frequently. Working out the smaller volumes if you are bottle feeding also prevents over-feeding and unhealthy weight gain.
Breastfeeding moms can feed on demand, but try to help soothe baby in other ways (baby-wearing, sucking on your fingers or a dummy) if the previous feed was less than two hours ago so that you do not worsen the reflux symptoms. Breast milk has a protective effect against reflux, so you are doing a great job!

• Thickening of feeds:
Studies have proven that this can decrease the episodes of spitting-up, but it is a very laborious process. Formula or expressed breastmilk can be thickened with rice or oatmeal-porridge or Maizena.

• Trial of a milk-free diet:
If you are breastfeeding, you can cut out all dairy and beef products from your diet for 2 weeks to see if there are any change in symptoms. You might have to cut out soy-products too.
If you are formula feeding, you can try a trial with an “extensively hydrolyzed formula” (also called hypo-allergenic such as Neocate or Similac Alimentum). It is not recommended to change to a soy-based/ goats-milk based / lactose free formula for this trial as there can be a cross-reaction to the allergens. Once baby is diagnosed with a milk-allergy you can try these substitutes under guidance of your doctor and dietitian.

• Avoid exposure to tobacco smoke as this can further decrease the pressure in the lower esophageal sphincter (see previous post), causing more frequent episodes of reflux.

• Adding probiotics has been suggested, but there is not enough evidence to prove if it will help.

• The use of a Chiropractor is not recommended as most of their procedures are not evidence based. “Subluxations of the spine after birth” mostly cannot be proven, will not cause reflux and the interventions they apply are either too delicate to really change anything in the bony structure, or too rough to be safe for the developing spine of your child. Please be careful.

If you have tried all of these tips and your baby still shows SIGNS OF GERD (as discussed previously) you can discuss the following steps with your doctor:

1. Is it really GERD?
Many diseases can mimic reflux and will not respond to reflux medications:
• Cow’s milk-protein allergy: this is a type of food allergy that can best be diagnosed by an exclusion diet.
• Eosinophilic esophagitis – this is inflammation of the esophagus due to an allergic reaction involving a specific type of white blood cells. These babies can have trouble swallowing, vomiting and chest pain. Diagnosed with a biopsy during an endoscopy.
•  Anatomic abnormalities of the esophagus – sometimes there is a connection between the esophagus and trachea (air pipe), or a web of veins causing a partial occlusion of the esophagus. This can be diagnosed with the help of a contrast swallow.
• Celiac disease – allergy to gluten causing inflammation in the esophagus, stomach and intestines, can also have many other symptoms. Diagnosed with an exclusion diet and can be confirmed with a blood test.

👉As you can see an endoscopy (looking at the esophagus and stomach from the inside with a camera, your baby will need sedation or anesthesia) can help to clarify the diagnoses. It can also evaluate for inflammation and check the response to treatment with PPI’s.

👉Another diagnostic test often used is Ph monitoring where the height of the acid reflux and the amount of episodes over 24hours are tested. Because reflux can also happen in normal infants this test cannot give us a definitive answer.

2. Does my baby need acid suppressing medication?
PPI’s (Proton Pump Inhibitors for example Nexiam, Losec) are used to suppress the amount of acid formed in the stomach. It will NOT decrease the number of reflux episodes or the amount of vomiting, but it could make your baby more comfortable if there was inflammation and pain due to the acid.
The acid in your stomach is actually very important for your baby’s digestion and immune function, and decreasing the acid content certainly does have risks.

👉Who should get PPI’s and for how long ?
• Babies with proven esophagitis seen on endoscopy (use for 3-6months and then re-asses)
• Babies with severe symptoms of GERD that does not respond to conservative measures can be given a trial of two weeks. If there is a definitive improvement, medication can be continued for 3-6months and then re-assessed.

👉Possible complications of PPI’s:
• Higher risk of acute diarrhoea and pneumonia because you remove a line of immunity defence. This can also lead to infection of the gut with Clostridium Difficile.
• Interferes with the absorption of Iron and Vitamin B12 and lead to anemia (low red blood count).
• Can affect calcium absorption and lead to increased risk for fractures.
• Allergic sensitization – there is a link between using acid suppression in infancy and later development of allergies.

When you want to stop the PPI, it is important to wean it slowly as there can be a rebound higher acid production for the first few days after stopping the medication.

3. Are there other medications that could help?
• Antacids such as Gaviscon have been shown to provide some relief in the symptoms of reflux. It works by coating the stomach contents with an alkaline layer which makes it more difficult to push back and less painful to the esophagus. It can be used in the place of thickening feeds in breastfeeding babies. Although there are not a lot of studies done in babies, it seems safe to give for short periods (less than two weeks) or on occasion. Using it for longer periods could lead to aluminium toxicity or rickets (Vitamin D deficiency).
• Prokinetics such as Domperidone (Emex), metoclopramide or erythromycin could help to speed up the passage of feeds through the esophagus and stomach. They could however have many unpleasant side-effects affecting your baby’s movement, brain and heartrate.

4. Will surgery help?
Surgery is usually not indicated in children under 1 year of age. Even in older children and adults the results of a Fundoplication surgery are not very satisfactory.

“Be joyful in hope, patient in affliction, faithful in prayer”

Romans 12:12

If you have read all the way to here you must truly have many questions! I hope that I could give you some answers, some advice and some hope. Remember that you are not alone. Talk to other moms and share the burdens and the joys. Talk to your doctors and walk the road with them, they want to help you.

These days feel long, but the years are short and before you know it your child will be waving goodbye on their first day of school (without vomiting all the milk from their morning porridge)!

♡
Pediatrics and Playdough
Medicine Mommy

Resources:

1. Rosen R, Vandenplas Y, Singendonk M, Cabana M, Di Lorenzo C, Gottrand F, Gupta S, Langendam M, Staiano A, Thapar N, Tipnis N, Tabbers M; “Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)”; J Pediatr Gastroenterol Nutr. 2018 Mar; 66(3): 516–554. ; doi: 10.1097/MPG.0000000000001889
2. Rybak A, Pesce M, Thapar N, Borelli O; “Gastro-Esophageal Reflux in Children”; Int J Mol Sci. 2017 Aug; 18(8): 1671; Published online 2017 Aug 1. doi: 10.3390/ijms18081671
3. Campanozzi A, Boccia G, Pensabene L, Panetta F, Marseglia A, Strisciuglio P, Barbera C, MagazzùG, Pettoello-Mantovani M, Staiano A; “Prevalence and natural history of gastroesophageal reflux: pediatric prospective survey.”; Pediatrics. 2009;123(3):779.
4. Davies I, Burman-Roy S, Murphy MS, Guideline Development Group ; “Gastro-oesophageal reflux disease in children: NICE guidance”; BMJ. 2015;350:g7703. Epub 2015 Jan 14
5. https://www.mayoclinic.org/diseases-conditions/infant-acid-reflux/symptoms-causes/syc-20351408
6. Safe M, Chan WH, Leach ST, Sutton L, Lui K, Krishnan U; “Widespread use of gastric acid inhibitors in infants: Are they needed? Are they safe?”; World J Gastrointest Pharmacol Ther. 2016 Nov 6; 7(4): 531–539.; doi: 10.4292/wjgpt.v7.i4.531

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REFLUX

What is Reflux?

Dr Nické Theron, pediatrician, is here to empower our mommies with knowledge.

Most moms know the feeling of getting your little one all dressed up and ready to go, just to have them spit/vomit milk all over everything just before you leave!

Thank you for all your questions and comments about your journey with reflux. I will try to answer most of you in the next few paragraphs while I explain more about the what, why and how of reflux:

Gastro-Esophageal Reflux (GER) is a 100% physiological (natural) occurrence in healthy babies, children and adults where the contents of the stomach push back into the esophagus (swallowing tube). It is more prominent in babies (40-60% of healthy babies struggle with reflux) because of their immature lower esophageal sphincter (the gate that is supposed to contract to keep the stomach content inside), fluid diets (fluids push back easier), slower passage of food through the stomach and the fact that they are mostly laying down (yes, gravity does play a role here).

Preterm babies have even more trouble with reflux because the esophagus is still too immature to “swallow” the milk down and they are often fed via feeding tubes (which opens up the lower esophageal sphincter even more).

“So do flux and reflux–the rhythm of change–alternate and persist in everything under the sky.”
― Thomas Hardy, Tess of the D’Urbervilles

Symptoms of reflux can start from the first few days of life when they start drinking larger volumes of milk, and usually subside by the age of 12-18months. This is due to a combination of all the factors mentioned above improving. There are some studies that show that children who had reflux as a baby are more prone to struggle with it as they get older.

Babies who have reflux (GER) usually spit/vomit up milk after feeds (yes, it can come up through their noses), (yes, it can be quite a lot!), they can also be irritable after feeds or arch their backs. They often sleep for shorter stretches and want to feed often (the milk actually soothes their throats, but more milk can also cause more trouble). Remember this is still NORMAL baby-behaviour!

“Silent reflux” is a non-medical term applied when a baby has episodes of reflux into their esophagus and airways without vomiting it out. (Making it more difficult to diagnose). In the end the same diagnostic and treatment rules apply.

Most babies with reflux grow well, feed well, are not extremely irritable and do not have any danger signs. These babies are often referred to as “happy spitters” and do not need any further medical intervention. It is very rare for the stomach contents to contain enough acid to cause discomfort or damage to the esophagus / airways. Even in studies where they monitored the reflux episodes by pH monitoring, they often could not associate the episode with the baby being unhappy or waking up from the reflux.

If your baby is failing to thrive (not gaining weight, not reaching developmental milestones), is refusing feeds (turning away his head while arching his back – Sandifer syndrome) or has signs of esophagitis (this is painful inflammation of the esophagus that can only be diagnosed with a gastroscopy, clues will be excessive crying and irritability when lying flat, shortly after feeds and while refluxing) your baby has Gastro Esophageal Reflux DISEASE (GERD). This is pathological and should be treated.

There are many other causes for the symptoms of reflux. Your baby could be going through a growth spurt or be overstimulated or have flu or gastro-enteritis, but if your baby has any of the following Red Flags, please see your doctor asap to exclude more sinister diseases:

  • Recurrent projectile vomiting (when the vomit hits the other side of the room)
  • Yellow bile or blood-stained vomiting
  • Any other abdominal signs: distension or pain of the stomach, constipation or diarrhoea
  • Fever
  • Any seizures, abnormal movements, abnormal head size or other neurological signs
  • Recurrent pneumonias (lung infections)

When you visit your doctor with symptoms of reflux they will probably be able to exclude most of the dangerous conditions by taking a history from you and doing a good examination. Hopefully this, together with the knowledge you were armed with in this article will help you cope with the day-and-night realities of reflux.

I know the mountains of milk-stained washing and sleep deprivation are tough – check back tomorrow to see what you can do to make your little one a little more comfortable.

♡

Resources:

  1. Rosen R, Vandenplas Y, Singendonk M, Cabana M, Di Lorenzo C, Gottrand F, Gupta S, Langendam M, Staiano A, Thapar N, Tipnis N, Tabbers M; “Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)”; J Pediatr Gastroenterol Nutr. 2018 Mar; 66(3): 516–554. ; doi: 10.1097/MPG.0000000000001889
  2. Rybak A, Pesce M, Thapar N, Borelli O; “Gastro-Esophageal Reflux in Children”; Int J Mol Sci. 2017 Aug; 18(8): 1671; Published online 2017 Aug 1. doi: 10.3390/ijms18081671
  3. Campanozzi A, Boccia G, Pensabene L, Panetta F, Marseglia A, Strisciuglio P, Barbera C, MagazzùG, Pettoello-Mantovani M, Staiano A; “Prevalence and natural history of gastroesophageal reflux: pediatric prospective survey.”; Pediatrics. 2009;123(3):779.
  4. Davies I, Burman-Roy S, Murphy MS, Guideline Development Group ; “Gastro-oesophageal reflux disease in children: NICE guidance”; BMJ. 2015;350:g7703. Epub 2015 Jan 14
  5. https://www.mayoclinic.org/diseases-conditions/infant-acid-reflux/symptoms-causes/syc-20351408