Feeding problems in infants

Infant feeding problems are a common reason for parents to present in general practice. Differentiating between variants of normal and true pathology can be difficult. Parental anxiety and health beliefs can also add complexity to the consultation. Some of the more common feeding problems arising in very young children are cow’s milk allergy, lactose intolerance, gastro-oesophageal reflux disease (GORD) and colic.

Cows’ milk allergy

Cows’ milk allergy (CMA) is one of the most common childhood allergies in the developed world. It is an immune-mediated response to the proteins in milk and can present with a variety of symptoms. There are two types of CMA: IgE mediated and non-IgE mediated. IgE mediated symptoms start acutely, usually within two hours of ingesting food. Non-IgE mediated reactions have a delayed onset and may not present for 48 hours or even up to seven days.

The key to diagnosing CMA is taking a thorough history. A family history of allergy or atopy is commonly found and should be specifically asked about. It is important to check the child’s feeding history, such as whether they have been breast- or bottle-fed, whether have they been weaned, and their likes and dislikes.

When speaking to the carer it is always important to find out who has raised the concern about allergies - the parents, other carers or nursery staff. Ask about symptoms the child is experiencing and speed of onset. It is helpful to have a history of reproducible symptoms and also an idea as to how much of the food is required to cause a reaction.

A full physical examination along with weight and height is appropriate. Check for comorbidities such as eczema and obviously signs suggestive of an alternative diagnosis.

The symptoms of CMA are multiple and multisystem. The following table gives an overview of the most common symptoms reported.

IgE-mediated CMA is diagnosed via skin prick testing or specific IgE antibody testing (previously known as the RAST test). It may often be appropriate to refer children with suspected IgE-mediated CMA to secondary care for these tests.

Non-IgE CMA is diagnosed via clinical history followed by a successful dietary elimination trial. Totally excluding cows’ milk from the child’s diet (or mother’s diet if the child is breastfed) for a period of two to six weeks should see a marked improvement in symptoms.

NICE guidance suggests reintroducing cows’ milk after this initial period to confirm the diagnosis.¹ Unless there are growth issues, multiple systemic reactions, severe eczema or significant parental concerns this can usually be managed within the primary care setting.

Management of CMA involves maintaining a diet free from cows’ milk for a minimum of six months. Dietitians can support the family with these changes and to ensure the child (or mother in the case of breastfed babies) consumes a balanced diet.

Formula-fed babies should be switched to appropriate alternatives, usually in the form of extensively hydrolysed formulas (eHFs), which are whey or casein based. Around 90% of children with CMA can tolerate these formulas. Amino acid formulas, such as Neocate, are alternatives for those with severe forms of CMA. Soya milk, rice, oat or coconut milk are not recommended as first-line milk alternatives until children are at least 24 months.

Once a six-month period has elapsed it is advised to slowly reintroduce cows’ milk protein gradually. Dietitian input at this stage is enormously helpful, as are tools such as the ‘milk ladder’ for reintroducing. If symptoms recur, cows’ milk should be re-eliminated and the child reassessed in a further six months.

Most children with non-IgE mediated CMA will have outgrown it by the time they are three. In the case of IgE-mediated CMA, at least 50% of children should be symptom-free by the age of five years.

Gastro-oesophageal reflux disease

Gastro-oesophageal reflux is extremely common in infants and is described as the passage of stomach contents proximally along the upper GI tract due to transient lower sphincter relaxation. ‘Posseting’ is a symptom of simple reflux and usually does not warrant medical intervention. Sometimes infants can display additional troublesome symptoms or complications, and this is known as gastro-oesophageal reflux disease or GORD.

GORD usually starts before the infant reaches eight weeks of age, and typically 90% of cases have resolved by one year. It should be considered if symptoms of regurgitation are accompanied by distress, hoarseness of voice, a chronic cough or feeding problems. A single episode of pneumonia should alert a clinician to the possibility of reflux disease, and in severe cases it can result in failure to thrive.

Breastfed babies where GORD is suspected should be given a two-week trial of alginate therapy in the first instance. For formula-fed babies it is worth initially decreasing the volume but increasing the frequency of feeds. Should this fail to improve symptoms, thickening feeds with products such as Instant Carobel may be effective.

NICE guidance suggests only prescribing alginate therapy once these measures have been attempted. Second-line treatment consists of a four-week trial of either ranitidine or omeprazole. Secondary care referral would then be appropriate if the child remained symptomatic.

Colic

Colic is a term often used by parents, yet the true causes or underlying aetiology are not truly understood. It is hypothesised to be a mixture of GORD, CMA and constipation and affects 5-20% of infants.

Symptoms usually start as early as week one of life and typically persist until the third or fourth month. Features usually include crying in the late afternoon and early evening, and classically the drawing up of knees and arching of the back is described.

While taking a history it important to ask about the general health of the baby, as well the antenatal and perinatal history. Asking specific questions regarding feeding, vomiting and stools is vital to help exclude alternative diagnoses. An allergy history should also be taken, as well as asking about exacerbating or relieving factors.

Management of colic usually involves support and reassurance to the parents. Input from the health visitor may be helpful. Occasionally oral treatments may be required and a one-week trial of simeticone drops may be advised, followed by a one-week trial of lactase drops if that proves unhelpful. Drops may be continued until the age of 3-4 months and then weaned off over a seven-day period.

Referral is not usually warranted, but can be considered if the diagnosis is unclear or there is significant parental anxiety.

Lactose intolerance

Lactose is a disaccharide found exclusively in milk, and lactose intolerance is a condition that parents often raise concerns about. It typically causes lower gastrointestinal symptoms such as bloating, flatus, loose stools and abdominal pain.

There are a number of different subtypes of lactose intolerance. Primary lactose intolerance is an autosomal recessive condition and can present at any age. It is very common in some populations such as Hispanics, but relatively unusual in Northern Europeans. It typically presents over the age of five in Caucasians, but earlier in Asian and Afro-Caribbean children. A family history may be expected.

Secondary lactose intolerance is a consequence of damaged intestinal mucosa, classically by gastroenteritis infections.

Congenital lactose intolerance, affecting infants in the first days and weeks of life, is extremely rare. It presents with excessive diarrhoea and is an unusual cause of feeding difficulties in very young children.

Case Study 1

Mrs Jones brings her four-month old baby, Ella, to see you. She was born by normal vaginal delivery at 41 weeks and is exclusively breastfed. Mrs Jones describes her as having been a ‘sicky’ baby since birth, and for the past three to four weeks she has been having increasing numbers of loose and foul-smelling stools. For the past week Mrs Jones has noticed some fresh blood present in her nappies. Ella’s weight gain is steady along the 75th centile. She has an older sister who is asthmatic and Mrs Jones has a history of eczema.

Examination is normal. What is the likely diagnosis? What advice would you give Mrs Jones?

Discussion

With a normal examination and steady weight gain, this history would suggest a possible diagnosis of cows’ milk allergy. Given that there does not appear to be a direct correlation with feeds, this is most likely to be a non-IgE mediated reaction.

Diagnosis would be made by strict cows’ milk exclusion from Mrs Jones’ diet for two to six weeks. A challenge test could then be carried out to confirm the diagnosis. Specialist dietitian advice would be useful to guide the parents through the weaning process, allowing gradual reintroduction of cow’s milk after a six-month period. You could also consider suggesting Mrs Jones takes calcium and vitamin D supplements while she continues to breastfeed.

Case Study 2

Mr and Mrs Parkins bring five-week-old Jack to see you. He was breastfed for the first two weeks of life and is now formula fed. Mum describes him vomiting after each bottle and being distressed, especially when being settled in his cot. He opens his bowels every other day and has regular wet nappies.

Examination is normal, weight gain satisfactory and there is no significant family history.

What is the likely diagnosis? What management plan would you initiate with Jack’s parents?

Discussion

A diagnosis of GORD would be high on your list of differentials given this history.

Since he is formula fed, simple measures could be suggested in the first instance. Reducing the feed volume and increasing the number of feeds may ease Jack’s symptoms considerably. Thickening agents may also be of use and are worth considering. A two-week trial of alginate therapy, followed by a four-week trial of either ranitidine or omeprazole would then be indicated.

Reassuring the parents that Jack is likely to have outgrown these symptoms by his first birthday may be helpful.

Case Study 3

Harry’s mother brings him to surgery one afternoon, as she is worried he may have lactose intolerance. Harry is a three-week-old breast-fed baby, who was born at 41+4 weeks’ gestation via emergency C-section. He had good Apgar at delivery and was discharged from hospital at day 3. Since then he has been irritable and fussy with feeds. He takes a long time to feed and his mother struggles to settle him in his Moses basket. He possets after most feeds and opens his bowels three times per day. There are no concerns regarding weight gain.

Mum suffers with IBS and dad has mild asthma. Examination is normal.

What is the likely diagnosis? What advice would you give Harry’s mother?

Discussion

The history is suggestive of colic symptoms and his steady weight gain is reassuring. Reassuring Harry’s mother and giving some practical advice may be the best management plan. Involving the health visitor may also be helpful. You could make her aware of other options such as simeticone drops to consider at a later date. With such a young infant, clear safety netting is important.

• Dr Garner is a GP in Worcester

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References

1. NICE. Food allergy in children and young people. CG116. London, NICE 2011.
2. NICE. Gastro-oesophageal reflux disease in children and young people: diagnosis and management. NG1. London, NICE 2015.