Weaning and Allergies

Weaning a child with any type of allergies can be a stressful, traumatic and time consuming experience.  I have explained here about Allergies, Intolerances and the difference between IgE and non IgE responses. The difficulty with identifying a non IgE response is that you cannot test for it, and need to follow your child's responses carefully. Intolerances tend to build up later in life, so at the weaning stage the chances are that you are dealing with some type of allergic response.

Weaning a baby with Reflux

Many doctors increasingly believe that reflux is only a symptom either of immaturity, gut inflammation due to allergies or intolerances, or (rarely) as part of an underlying condition. Trying to understand why your child is refluxing is certainly helpful when offering solid food, but the connection between reflux and gut allergies is pretty high and caution is sensible.

Thickening feed, reducing feed volume and avoiding known trigger foods can help the symptoms of reflux, but to avoid exacerbating an underlying cause take weaning very slowly. Try one new food at a time, for several days and do not try and rush into another food trial before you are certain your baby is fine with that food.

A word of caution about thickened feeds - thickeners take longer to digest and fill a baby up for longer. This can impact on the volume of feed consumed, an important consideration if you are dealing with faltering growth as well. Perhaps more immediately noticeable is that as with early weaning, digestion slows and there is more in the stomach for a longer time which can make gut symptoms like reflux worse. Solids in particular are less calorie dense and before the age of one should ideally be for tastes and enjoyment rather than the main source of nutrition. Obviously every baby is different and you should always speak to a health professional and follow their advice on your own child.

Over many years on and running support forums the general consensus seems to be that reflux babies do not like "surprises". Either spoon fed ultra smooth purees or self fed solids when appropriate to your child. Choking is common with reflux which actually can desensitise the back of the throat and throw swallowing coordination. This happens to me as an adult at bad times too!

Our bodies often take time to adapt and there is a lot of good weaning advice on the web, or from health professionals. Babies with reflux often struggling with mixed consistencies too. They can often feel out of control over feeding and in my experience self feed safe solids more enthusiastically whilst enjoying very smooth and predictable consistency purees from a spoon. My four all enjoyed "suck and dissolve" textures safely but every baby is different. (My twins used to love self feeding Rice Krispies, excellent for their fine motor control too!) I support Baby Led Weaning but it should be exactly that - baby led, and a baby with reflux will most likely find a totally "free" approach stressful and challenging, even potentially dangerous. Persistent reflux can itself cause temporary swallowing difficulties such as delayed swallow and/or pooling of solids as the reflux desensitises the back of the throat, so your baby should be your cue. Purees can be easily bought in pouches now, or you can buy and fill your own. (see the "Portable Food" page.)

NEVER LEAVE ANY BABY ALONE WITH FOOD OR DRINK.

Food Allergies

The "Big Four" foods are best avoided for some time until you can assess how things are going. They are Milk/Dairy, Egg, Soya and Wheat and are the four biggest food allergens. This is thought to be because together they account for a very large proportion of the Western Diet. Cows Milk Protein Allergy is very common, there is an excellent piece by Dr Adam Fox, one of the top paediatric allergist in the UK in "Small Talk" here.

Some babies suffer from something called Eosinophilic Proctocolitis which seems to occur early on and is often related to milk allergy. It is thankfully easily treated and there is a high rate of children outgrowing the condition early on. Many children with gut issues are also hypermobile. Joint hypermobility is quite common and does not have to form part of another underlying condition. However, for some it does, and this is often Ehlers Danlos Syndrome, Hypermobility Type - or type 3. Children with this type of connective tissue disorder are at much greater risk of developing food allergies.

Skin "reactions" often make parents worry their child is have a negative response to a food, but are often just normal rashes so try not to get too hung up on superficial symptoms. It's more important to look for big increases in reflux and other gut symptoms and and possible new symptoms like constipation. (Many babies' bowels slow down as solids are introduced so it's really important to keep a level head, you won't be doing your child any favours by recording every slight change and excluding every food you suspect the slightest reaction from.)  Skin rashes are often histamine responses, particularly common on the cheeks which tend to be slightly dry and sometimes fragile in babies.

Many babies outgrow their allergies, the age of 2 is often quoted, the next "bench mark" I have heard frequently is 7-8 years. You might be in it for the long haul but do remember, this is relatively rare.

Years ago I wrote a piece on Breastfeeding children with Reflux. It's reproduced below. Whilst I still stand by what I wrote, having learned so much more about gut allergies over the years I felt it's time had come to be at the bottom of this page - rather than a page of its own. Breastfeeding is best for so many reasons, but certainly complicates matters with severe gut allergies. no mother should ever feel guilty for choosing formula based on informed discussions and decisions but the information below is not unhelpful in that context:-


Why breastfeed your baby with Reflux?

Breastmilk is the perfect milk for nearly all babies, but is especially good for babies with reflux.

Breastmilk is highly digestible so will not sit in the stomach, putting pressure on the sphincter and possible worsening reflux. It is digested rapidly so hopefully there is less milk vomited back up. The intake at each feed is likely to be less than via a bottle and vomiting is less likely therefore. (That said, each growth spurt produces and an increase in milk supply and very often an increase in vomiting.)

Breastfed babies almost never get constipated, which really aggravates reflux.

Breastmilk is hypoallergenic, although your baby may well react to foods YOU eat if you are breastfeeding. Cutting out dairy and soya made a huge difference to my twins when I was breastfeeding them - but you should never do this without the advice of a health professional. Caffeine in mum's diet can also aggravate reflux.

It is easy to comfort your baby when distressed or in pain with a breastfeed. Breastfeeding soothes painful throats when a baby is suffering from reflux.

The 4 month stage is often difficult.
Babies at 4 months are undergoing huge mental and physical growth and awareness and wake more, are harder to settle and often wake when they previously slept through the night. (Although "sleeping through" is rare so young in BF babies, they are not designed to do this and your milk is at its best in the middle of the night when you are resting!) This is nature's way to ensure a strong mother-baby bond as baby is more aware of his surroundings and an adequate milk supply. Reflux often peaks at this time too, and it is often difficult to determine what is going on, and whether this is a perfectly normal developmental stage or aggravated reflux. Many mums misinterpret this phase and start solids at this time, and it is the reason for previously recommending weaning at 4 months. Introducing solids too early to a baby with reflux can also bring more problems.

When your baby is a reluctant feeder
A baby suffering from Reflux will be unlikely to find feeding a totally stress free experience and some may develop an aversion to nursing. This does not mean breastfeeding is being rejected, far from it, is means your child is telling you – by arching backs, crying, turning away, fighting you trying to latch them on – that they are unhappy about feeding full stop. Try adjusting their position, almost sitting them on your lap so they are more upright. Try feeding in a carrier, or whilst in a different position yourself. Wind your baby before starting feeding – babies with Reflux can have trapped wind at any time! This kind of behaviour around feeding is NOT normal and you need to get advice, and hopefully medication from your GP or local paediatrician to alleviate the discomfort your baby is suffering. Don’t leave too long between feeds so the milk can soothe baby’s throat frequently.

Tips for Coping with Frequent Feeders
Babies with Reflux need to feed little and often, and breastmilk is digested extremely quickly. You cannot feed too often; following your baby's cues is the best way to establish successful breastfeeding. Since breastmilk is a natural antacid, babies often comfort feed very frequently, so here are a few tips for coping: -

Adjust your expectations
First of all, remember that frequent feeding is normal and expected in the early months - most newborns need to feed at least 8 - 12 times per day. Frequent demand feeding is also needed to avoid and reduce engorgement in the early days, to establish a good milk supply, and to help a baby adjust to life in the outside world.

Breastfed babies often wake more at night than bottlefed babies and there are several excellent reasons for this:-

· When you are well fed and rested your milk is at its best, its calorific content actually increases at  night.
· There are fewer distractions and babies feed well at night. Historically this was a “safe” time to feed without worrying about dangers.
· Breastfed babies are not designed to go for long periods without feeds.
· Formula is far less digestible and sits in the stomach for a long time – actually increasing the chances of pressure on the sphincter and therefore worsening reflux.
· Breastmilk is digested so quickly since it is the perfect food for babies that they need frequent small meals.
· Lastly, breastfeeding can help protect against cot death because babies do not fall into a long, very deep sleep since they are waking frequently for feeds. Keeping baby near you allows him to use your sounds and movements to regulate his breathing also.

Many totally well and healthy babies feed VERY frequently, particularly around the big growth spurt ages - 3 weeks, 6-8 weeks, 12 weeks, 16 weeks - and anytime in between! Your baby is trying to build up a good milk supply and the only way he/she can do that is by feeding frequently. A baby with reflux has comfort as a high priority too; I found if you accept frequent feedings then they are easier to deal with.

Check your latch and positioning
The general advice is that if you are getting plenty of wet nappies (sometimes difficult to tell with disposables), your baby is gaining weight and is generally happy and healthy, then the frequent nursing is unlikely to be a sign of a problem. However with a baby with reflux, you might have an excellent supply, but due to vomiting your baby is not gaining and is far from happy! You still need to watch for sufficient wet nappies so your baby does not become dehydrated, but remember switching feeding methods is unlikely to change the situation and will probably bring more problems.

Learn to feed lying down - then you get some rest too. Whilst Co-sleeping has its dangers, it is often recommended by health professionals to promote breastfeeding. Breastfed infants are supposed to feed at night; your baby gets his/her "gold top" feed at 3am!! It is essential to follow safe co-sleeping guidelines listed here: -


Guidelines for Sleeping with Your Baby

1. Always place baby to sleep on their back.
2. Baby should sleep next to mother, rather than between mother and father.
3. Take precautions to prevent baby from rolling out of bed. Use a mesh guardrail and be sure the guardrail is flush against the mattress and fill in any crevice with a rolled-up baby blanket or towel.
4. Use a large bed with a mattress that fits snugly against the rail or is flush up against a wall. Don't use fluffy bedding or cover baby with comforters, etc.
5. Do not sleep with your baby if you are under the influence of alcohol, drugs, or sleep-inducing over-the-counter medications or if you are overly exhausted from sleep deprivation
6. Do not allow baby-sitters or older siblings to sleep with baby.
7. Don't fall asleep with baby on a couch, bean bag chair or waterbed.
8. Do not let baby sleep unattended on an adult bed.
9. Don't overly bundle baby, because they get additional warmth from the mother's body. Overheating can be dangerous to infants.

When it works, Co-sleeping means you get some sleep too - a rare thing with small babies suffering from reflux!

Invest in a good baby carrier.
 There are several baby carriers and slings in which you can breastfeed whilst having at least one, sometimes two hands free! For smaller babies try the Coorie pouch sling or a tie on sling like the Wilkinet adjusted to get baby into position. I also used an Ellaroo wrap sling but these slings can take a bit of practice to learn to put them on quickly. Wrap slings are excellent for tiny babies, and can be used from birth even with premature babies. Check out the Kari-me at http://www.littlepossums.co.uk/slings/wrap-slings.htm Later on something like the Connecta Baby Carrier is perfect, holding the babyclose and distributing their weight well. There has been a surge in real slings on the market in recent years with lots to choose from. Avoid the mass produced ones in which the baby hangs "off" you, not distributing the weight as well and making even a small baby feel overly heavy.

Breastfeeding and Food Intolerances and their relationship with Reflux
Babies under 6 months of age have "leaky" or permeable guts to allow the free passageway of maternal antibodies, helping boost their immune system. This is why introducing formula or other foods before 6 months of age - especially if there is a history of allergy in the family - can prompt the baby's immune system to react and develop an allergy towards them. Babies with Reflux seem to be more prone to allergies too, even when there is little or no family history. One of the best ways to protect your baby against food allergies and intolerances is to exclusively breastfeed for the first six months of life as recommended by the World Health Organisation.

Babies really do not need any other food until this age, although the huge growth and developmental spurt of 4 months is all too often misinterpreted as readiness for weaning. Babies this age often start to sleep less well generally, demanding frequent feeds. We now understand these behaviour changes are due to growth rather than readiness for weaning, and since a baby's gut is permeable until 6 months (to allow maternal antibodies to cross from breastmilk) giving other foods before this time dramatically increases the likelihood of your baby developing allergies since the foreign proteins cross into the baby's blood stream. Remember too this is the time when reflux often peaks.

Allergens in breastmilk
Some babies react adversely to allergens in your breastmilk. Of these, Dairy and Soya proteins are the most common and Cow’s milk and Soy protein intolerances are very common in infants under two (often abbreviated to MSPI - Milk and Soy Protein Intolerance) and it is really not too hard to cut both out of your diet to see if it helps with reflux. Soya is highly allergenic, many people (me included) quickly become intolerant when exposed to a higher intake so even if your baby appears to tolerate Soya, be wary of swapping dairy for soya substitutes in your diet. Soya is also high in oestrogens and for this reason is not idea, and no longer recommended for infants under six months. It sometimes takes a fortnight for all traces to leave your breastmilk and your baby's gut so a day without won't probably make a huge difference. Some infants develop gut allergies, true allergic responses but in a local immune response to food proteins. There is more info on this here


CONCLUSION
Simple measures to help your child
  • Breastfeeding is usually best for a baby with reflux because it is more hypoallergenic than most formula and is digested twice as fast as formula. It is also great for reflux due to its natural antacid properties.
  • Feed little and often, on demand.
  • Positioning your baby as upright as possible will help. Many babies with reflux struggle with a forceful letdown, there are excellent tips on coping with this and many other breastfeeding issues on www.kellymom.com/bf/index.html
  • Try eliminating the foods that can make reflux worse but consult your doctor first. Dairy products are a big offender, as is caffeine, fatty foods, spicy foods, citrus fruits.
  • Wind your baby well after each feed, and if necessary between feeds too.
  • Never lay your baby down flat, prop the cot up with books at approx 30 degrees (take care they cannot climb out) and always place something under their heads when nappy changing or dressing.
  • Keeping babies upright whenever possible helps, slings and carriers are a great way to do this, especially traditional type carriers. Baby walkers and gyms put extra pressure on the stomach sphincter and aggravate reflux. Tight clothes do the same so dress your baby in loose clothing.
  • Sucking on a pacifier or dummy, can increase saliva production. Saliva is alkaline which can help neutralize some of the acid that may come up. Not often recommended for breastfed babies, a dummy or soother can really help gain some kind of routine when used discriminately as a pacifier.
  • Avoid long spells in car seats. Some car seats position babies so they are slouched over, putting added pressure on their tummies. Look for a car seat that allows baby to be reclined enough that they aren't slouched yet, inclined enough that they are fairly upright.


Obviously, not everyone takes to breastfeeding and for some there is little choice. You have to choose the method of feeding which works best for you and your baby. Caring for a baby with reflux can be incredibly demanding and if you are breastfeeding there is little respite. Expressing is never recommended before 8-12 weeks when your milk supply is better established.

If you have a very sick baby who is extremely allergic to a multitude of foods and is not doing well on your milk, there are some excellent hypoallergenic formulas around. Making a well-informed decision either way is what matters. However when you are tired from lack of sleep and struggling with a baby with Reflux who does not want to be put down, a food that is available 24/7 without any preparation can make all the difference!



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2 comments:

  1. Hi,

    Thanks for sharing this article. It is extremely helpful and I can relate almost everything with my 4 four year old boy suffering from acid reflux since birth.

    He still can not swallow solids and I've to puree everything. He vomits alot and always refuses to eat. Now he has started loosing weight fast and I am worried. Please suggest what should I do? :(

    ReplyDelete
    Replies
    1. Hi- I'm so sorry to hear your son is struggling still :( You need to see your GP to get his weight heckled and discuss a referral to a paediatrician. They can fast track you if appropriate. It's not unusual to have issues until 7 or 8- after that is less common. The important thing is to discover the reason for reflux- it's a symptom not a disease in its own right. It might be developmental, linked to an underlying condition eh a connective tissue problem or be due to inflammation anywhere along the gut. I really hope you get some help- of you want to chat to others for support (we can't give medical advice) do join our Facebook group :)

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Many thanks for taking the time to comment!

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