Breast- feeding Abstracts: Lactose Intolerance, Diarrhea, and Allergy

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Breast- feeding Abstracts: Lactose Intolerance, Diarrhea, and Allergy

 

Lactose Intolerance, Diarrhea, and Allergy

Maryelle Vonlanthen, MD

from Breastfeeding Abstracts, November 1998, Volume 18, Number 2,

pp. 11-12.

http://www.lalecheleague.org/ba/Nov98.html

 

Signs and symptoms of lactose intolerance, diarrhea, and allergy may

occur in exclusively breastfed infants. These problems may be the

result of sensitivity, intolerance, or allergy, terms not always

defined correctly in the literature. An adverse reaction is any

abnormal reaction to food or additives; food intolerance is any

abnormal physiologic response to ingested food; and food

hypersensitivity (true allergy) involves an immune reaction to

ingested substances, often synonymous with IgE-mediated reactions.

 

Immune reactions to ingested substances are classified into two

broad types: IgE, with involvement of the cardiovascular system,

respiratory system, and/or skin; and milk protein enterocolitis,

limited to gastrointestinal involvement.

 

The top three food antigens are cow's milk protein (mostly the beta-

lactoglobulin component), soy bean protein, and egg white, followed

by peanuts, meat, and fish, especially cod. About 50 percent of

infants allergic to cow's milk protein will also be allergic to soy

bean protein, and soy is virtually everywhere in processed foods.

Allergens can be hidden in minute amounts, even occurring as cross

contamination during food processing.

 

Diagnosis

A complete allergy history of the parents is important in the

diagnosis of infant food allergy. If one parent has allergic

disease, the infant has a 30 percent risk of developing allergic

disease. This risk doubles if both parents have allergic disease.

 

In families with a high risk of atopic disease, the cord blood can

be examined for high IgE levels. The presence of high levels of IgE

may correlate with the occurrence of IgE-mediated disease. There are

a number of studies in the literature which suggest that babies may

become sensitized in utero if there is a strong family history of

allergies.9

 

Mothers may be advised to avoid suspect foods during all or part of

their pregnancy and to continue to avoid these foods during

lactation. The research indicates that this practice does not

decrease the incidence of allergy by two years of age, but it does

delay the onset of allergy.

 

For a baby, just about anything can be a symptom of allergic

disease. IgE-mediated reactions can include symptoms in the upper

gastrointestinal tract such as nausea, vomiting, reflux, refusal to

eat, and eating ravenously; lower GI symptoms may include blood in

stools and diarrhea.

 

IgE-mediated disease can also cause respiratory symptoms such as

wheezing and perpetual congestion; atopic dermatitis, eczema, and

various rashes; an extreme reaction is anaphylaxis which leads to

cardiovascular collapse and shock.

 

Symptoms of non-IgE-mediated allergic disease (or cow's milk

colitis) are usually limited to the lower GI tract, causing diarrhea

and blood in the stools. The presence of symptoms outside the

gastrointestinal system generally indicates IgE-mediated

hypersensitivity.

 

Research has shown that foreign proteins do pass into breast milk

and can cause allergy.1, 3 There are case reports in the literature

of cow's milk protein in breast milk causing anaphylactic shock in

infants.4 The possibility of allergic disease should be considered

when a breastfeeding baby is not acting quite right, especially if

the baby is not growing well.

 

In diagnosing allergy, a complete history, including information

about the baby's behavior, is important. Sleeping patterns, colicky

behavior, and crabbiness may be signs of allergy. A complete

physical is also important. Sometimes it is helpful to examine a

baby just after a feeding because some babies will react

immediately, providing clues to the practitioner.

 

Laboratory data may show an elevated white blood cell count,

peripheral eosinophilia, and/or blood in stools. GI endoscopy with

biopsies and skin tests can also be useful. It is important to note

that these symptoms of atopic disease such as diarrhea or rectal

bleeding can have other causes such as lactose intolerance, rectal

fissures, Crohn's disease, infectious etiologies, and clostridium

difficile colitis.

 

Identify patients at risk and weigh options based on family history.

A study of positive predictive values (ppv) of various indicators of

allergy shows that peripheral eosinophilia had a 10 percent ppv, low

hemoglobin had a 48 percent ppv, and low albumin had an 81 percent

ppv.5

 

Measuring albumin is an effective tool for the practitioner

especially when endoscopy is not available. The gold standard of

allergy testing remains a food challenge demonstrating the return of

symptoms following the reintroduction of food after an improvement

during elimination diet.7

 

Treatment

 

If the only symptom is colicky behavior, fussiness, gas, and/or

loose stools, it can be helpful to examine the feeding pattern

before starting an elimination diet. Woolridge10 noted that when

mothers fed from both breasts at each feeding, infants experienced

overconsumption of foremilk, receiving large amounts of skim milk

and lactose.10

Overconsumption of lactose caused green, watery, loose stools,

gassiness, and colicky behavior. Most mothers gave a history of

limited time at the breast and/or very forceful milk ejection that

forced the baby to pull off the breast to keep from choking. When

the feeding pattern was changed to nursing fully on one breast,

offering the second breast only if the baby wanted to continue, the

babies improved.

 

If an elimination diet is necessary, it should begin with the top

offender, cow's milk protein. Once the mother's elimination diet has

started, it can take anywhere from a few days to six weeks for an

infant to show improvement, making it difficult to use elimination

as a " test " to prove or disprove allergy to a particular protein.

 

Many infants will outgrow their allergies by about 6 to 18 months.

After a period of elimination, infants should be rechallenged with

the offending protein to determine the need to continue with the

diet.

 

Research has shown that allergy injections are not an effective

treatment for food allergies.6 The best treatment is prevention.

 

Conclusion

Food allergies in breastfed infants are usually to substances

passing into breast milk, not to breast milk itself. There are

different types of allergies which may present multiple symptoms.

Many symptoms are non-specific which may lead to over- or under-

diagnosis. Most infants will respond to elimination of cow's milk

from the mother's diet. It is not necessary to use elimination of

multiple foods as a first line of therapy.

 

This article is based on a presentation given by Maryelle

Vonlanthen, MD at LLLI's 1998 Seminar for Physicians on

Breastfeeding. Dr. Vonlanthen, a gastroenterologist, is Assistant

Professor of Pediatrics, University of Arkansas Medical Sciences,

and is a member of LLLI's Health Advisory Council.

 

Cant, A., R. A. Marsden, and P. J. Kishaw. Egg and cow's milk

hypersensitivity in exclusively breastfed infants with eczema and

detection of egg protein in breast milk. Br Med J 1985; 291:932-35.

de Boissier, D. et al. Multiple food allergy: A possible diagnosis

in breastfed infants. Acta Paediatr 1997; 86(10):1042-46.

 

Lake, A. M., P. F. Whitington, and S. R. Hamilton. Dietary protein-

induced colitis in breastfed infants. J Pediatr 1982; 101(6):906-

10.

Lifschitz, C. H., H. K. Hawkins, C. Guerra, and N. Byrd.

 

Anaphylactic shock due to cow's milk protein hypersensitivity in a

breastfed infant. J Pediatr Gastroenterol Nutr 1988; 7(l):141.

Machida, H. M., A. G. Catto Smith, D.G. Gall et al. Allergic colitis

in infancy: Clinical and pathological aspects. J Pediatr

Gastroenterol Nutr 1994; 19(1):4-6.

 

Osvath, P., K. Kelenhegyi, and E. Micksey. Comparison of ketoifin

and DSCG in treatment of food allergy in children. Allergol

Immunopathol 1986; 14:515-18.

Powell, G. Milk and soy induced enterocolitis of infancy. J Pediatr

1978; 93(4):553.

Sorva et al. Beta lactoglobulin secretion in human milk varies

widely after cow's milk ingestion in mothers of infants with cow's

milk allergy. J Allergy Clin Immunol 1994;93:787.

Wilson et al. Severe cow's milk induced colitis in an exclusively

breastfed neonate. Clin Pediatr 1990; 29(2): 77

Woolridge, M. W. and C. Fisher. Colic, overfeeding, and symptoms of

lactose malabsorption in the breastfed baby: A possible artifact of

feed management. Lancet 1988: 2(8607):382-84.

Last edited Friday, May 9, 2003 11:00 AM by sak.