HEALTH Into the mouths of babes

Into the mouths of babes


Doctors insight
Dr Ronan Clancy

Feeding problems in the first year of a baby’s life include infant colic, lactose intolerance, gastroesophageal reflux disease and cows’ milk protein intolerance. They are common and distressing to parent and baby, but a little knowledge really goes a long way. Having experienced the sleep debt that a refluxing baby can inflict, and having recently become a proud father for the second time, it’s personal!

Infant colic
Infantile colic presents in the first few weeks of life with paroxysmal episodes of frantic crying or screaming, drawing up of legs, fist clenching and a refusal to be consoled. It’s really stressful for parents and tends to start at the same time every evening. Walking the halls for three to five hours is not uncommon! It occurs in up to 20 percent of all babies, and usually resolves by about the fourth month of life. Happily, it’s harmless. Its cause is poorly understood but may be associated with lactose and milk-protein intolerances, family stress levels and feeding technique (quantity and timing issues).
Lactose intolerance
If there is frequent diarrhoea, your infant may be lactose intolerant. Lactose is a disaccharide sugar present in breast milk (9 percent), animal milks (< 4.7 percent) and as an additive in non-dairy products. When not digested due to a deficiency of lactase enzyme, lactose ferments in the gut producing large amounts of gas and lactic acid. This causes characteristic explosive gaseous and watery stools in a usually happy infant. It can, however, cause bloating, crying and pain, thus making diagnosis more challenging.

Gastro esophageal reflux disease
The passage of stomach contents into the oesophagus (gastro esophageal reflux) is a normal physiologic process that occurs in healthy infants when the infantile valve separating the oesophagus (food pipe) from the stomach is not yet fully functional. In most cases, the infant is happy and feeding well. Conversely, it can cause upset and crying, difficult winding, dribbling and persistent vomiting after feeds. When there is sufficient vomiting to stall weight gain, the condition is termed gastro oesophageal reflux disease. It may be associated with intolerance to proteins found in soy and mammalian milks.
Sandifer syndrome is the classic physical presentation of reflux; arching of the back, torting of the neck and chin lifting during upset. This can be very helpful in distinguishing reflux from colic, whereby infants display discomfort by pulling knees up. Fortunately, most children outgrow this condition within the first year of life as the digestive system matures.
Cows’ milk protein intolerance
Cows’ milk protein intolerance (which I will discuss in the next article) can cause some or all of the symptoms described in this article so far. Confused yet?!

Treatment options
Because there is so much symptom crossover in infant feeding disorders, diagnosis can be difficult or vague. Trial treatments for the various disorders are often necessary to find a solution – and regain sanity!
Colic treatments include simethicone (Infacol), gripe water and probiotics (Lactobacillus). Anecdotally these can be beneficial but lack evidence. Common treatment options for both colic and lactose intolerance include lactase drops (Colief) added to the milk feed (breast or bottle). These have shown evidence for reducing crying times in colic. Low-lactose and lactose-free formulas are the treatment of choice for bottle fed babies with suspected lactose intolerance. They are unsuitable for babies who require a galactose- or cows’-milk-protein-free diet.
Nursing mothers can try hypoallergenic diets. These include strict avoidance of dairy products (cows’ milk, yoghurt, cheese and beef). Avoiding chilli, coffee, chocolate, citrus fruits and dark green vegetables such as broccoli may also reduce colic symptoms. Note, it takes a few days for these proteins to clear after the diet has begun.
Parental stress-level management, relaxation, burden sharing and team work are important. Vented bottles (Dr Brown brand) aim to reduce swallowed gas in colicky infants.
If gastroesophageal reflux is suspected, thickened feeds, such as Enfamil AR and SMA Staydown and upright positioning, of infant after feeds and upward tilting of cot are the first intervention. Breast feeding mums can try also try the hypoallergenic diets. Failing this, anti-acid medications, such as Gaviscon Infant, can be tried. Other medications may be prescribed if there is evidence of weight loss.
Importantly, if basic measures fail, or if there is bile or blood in vomits or stools, persistent forceful or projectile vomits, weight loss, severe upset/pain/constipation or abdomen swelling, your doctor should be contacted without delay, as these symptoms can suggest more-serious underlying disease.

Dr Ronan Clancy is a GP at the newly opened Clancy Medical Practice, James street, Westport (www.westportgp.ie). He is in practice with Sarah Kavanagh, chartered physiotherapist.