Feeding problems

If you are worried about the growth, weight and feeding patterns of your baby or toddler, you should discuss the matter with your health care professional (i.e. maternal health nurse or GP). They will be able to provide you with guidance on feeding your baby and will investigate any health issues that may affect your child.

Allergy and intolerance

Allergies are very different from intolerances. The difference between the two is that an allergy involves the immune system and the triggering of an allergic response, whereas an intolerance does not. An allergy might be considered an ‘over-reaction’ of the body’s immune system to an ordinarily harmless substance. The symptoms that result can range from mild to moderate and severe and may even be life-threatening.

On the other hand, intolerance might be thought of as a non-allergic adverse reaction to substances and chemicals in foods and the environment. The body processes involved in intolerance responses are not fully understood but seem to involve metabolic, toxicological and/or pharmacologic reactions. While people commonly confuse symptoms of allergy and intolerance, a specialist allergy doctorwill confirm whether or not your child has an allergy in Australia or New Zealand.

Allergy

Allergic reactions can be caused by a range of substances called allergens, which are harmless for most people, but allergy causing in others. Allergens can be found in common places, including some foods, pollens, moulds, dust mites, insect venoms, medications and animal hair. The main food allergens include peanut, tree nuts, sesame, egg, wheat, fish, shellfish, cow’s milk and its products (including infant formula) and soy. When a person who is allergic to a particular allergen comes into contact with it, an allergic reaction occurs. This involves the body’s immune system generating an ‘attack response’ to an allergen, because it thinks the allergen is an enemy invader. All of this leads to allergic symptoms, which can include things like hives, swelling around the mouth and vomiting. The other thing about allergic reactions is that they will occur every time a baby or child comes into contact with the particular allergen that their immune system thinks is the ‘enemy’. In this way, allergic reactions are reproducible.

Some allergic reactions can take a bit of time to show up, with the body’s immune system taking several hours or even days to show symptoms. These more delayed onset allergic reactions are tricky to diagnose and advice from an expert allergy doctor is needed.

In other cases, a baby or child may have a more severe allergic reaction, called anaphylaxis. These anaphylaxis reactions occur soon after exposure to an allergen (i.e. usually within minutes) and involve the body producing large proteins called IgE antibodies, which the immune system then uses to recognise and deactivate the offending substances.

In the case of anaphylaxis, immediate lifesaving medical treatment is needed. The signs and symptoms to look out for are listed on the Australasian Society of Clinical Immunology and Allergy (ASCIA) website.

For more information about allergy, visit the ASCIA website

Dealing with anaphylaxis

If your child has had anaphylaxis, once you’re home again, you’ll need to see a specialist allergy doctor. This is because it is important to identify the cause of the anaphylaxis via allergy testing. This can be done using a skin prick test (SPT); or a blood test that measures the level of allergen-specific IgE antibodies in your child’s blood, called RAST (RadioAllergoSorbent test). The results of the allergy testing will help your doctor to know which allergens your child is reacting to, so that he or she can then provide you with the best treatment advice.

Once the allergen that triggered the anaphylaxis has been identified properly, it needs to be avoided or eliminated from the diet until further advice from your specialist allergy doctor. Detailed information and advice on avoiding allergens is available on the ACSIA website.

What is cow’s milk allergy?

Cow’s milk is one of the common food allergies and affects around 2% of Australian infants and children. If your child is diagnosed with cow’s milk allergy (CMA), they will need to avoid all foods and drinks containing cow’s milk, as even the smallest amount can set off a reaction. This includes certain infant formula* and toddler milk products such as a2 Platinum®. Some breastfed babies may also show sensitivity due to cow’s milk in their mother’s diet and, in such cases, one should seek help from a GP or Accredited Practising Dietitian (APD). While CMA is usually outgrown by around 4 years of age, in some cases it persists into adulthood. A specialist allergy doctor will determine whether a child has outgrown their allergy with a combination of a skin prick testing (SPT) or RAST blood test, together with a milk food challenge. This is because a positive SPT or RAST to milk does not confirm symptoms will develop on exposure to milk or milk products, so a food challenge with milk may be the only way to determine whether a child has outgrown their milk allergy. Milk challenges should be conducted by experienced specialist allergy doctors in the hospital setting. For more detailed information on CMA, visit the ASCIA website CMA section.

*For formula fed babies with CMA, speak to your healthcare professional as there are modified formulae that may be suitable. Your healthcare professional can advise you on alternatives that can be included in your baby’s diet. Partially hydrolysed (HA) formulas are not a suitable treatment for CMA.

Intolerance

Intolerance reactions can be caused by a number of substances and chemicals either added to or naturally present in foods or the environment. Intolerance reactions involve non-immune system mediated adverse reactions and while symptoms may be uncomfortable and bothersome, they do not usually constitute medical emergencies.

Intolerance reactions are highly individual and occur in those who are sensitive to intolerance causing substances. They are the result of a build-up or accumulation of the intolerance causing agent. This can occur through exposure to many different sources of the same intolerance causing thing, For example, salicylates are a common trigger of food intolerance responses in those who are sensitive and these substances are present in many different foods, so that a build-up of salicylates in one’s system can occur through eating a little of it at a time, across many different foods.

People have different tolerance threshold levels to intolerance causing triggers and once exposure to this threshold level is reached, an adverse reaction can occur. Reactions can occur within hours of exposure but may also take days to present, as the onset of symptoms will occur at the same time that an individual’s threshold level is reached. This can mean that it is really tricky to identify the intolerance causing substances, as people will often blame their intolerance reaction on their last meal or the last few things eaten, rather than understanding that it can be the result of the additive effect of exposure to the same offending substance across a range of sources.

Adverse reactions vary from person to person, but some of the common reactions include hives, headaches, stomach and/or bowel problems and in some cases, feeling generally unwell and run down. Allergy tests cannot be used to identify intolerance reactions, but importantly, an allergy specialist doctor can rule out allergic conditions. Once allergy has been eliminated as a cause of symptoms, intolerance responses can be investigated with the help of specialist dietitians.

Some breastfed babies may also show intolerance sensitivity due to exposure to offending substances in their mother’s diet and in such cases, one should seek help from their GP and/or an Accredited Practising Dietitian (APD) in Australia or NZ.

The World Health Organisation says that a person has diarrhoea when they pass 3 or more loose or liquid stools in a day, or more frequently than is normal for an individual. This is different from the frequent passing of formed stools, which is not diarrhoea. Additionally, passing of the looser, pale coloured stool types common to breastfed babies is not diarrhoea.

Diarrhoea is most often a symptom of some kind of gut infection, including infection caused by bacterial and viral organisms. Infection can be picked up via contaminated food and also passed around between people due to poor hygiene. This is a good reason to make sure you always wash your hands well with soap following a nappy change and also before feeding your little ones.

Diarrhoea can be dangerous for babies and young children because their smaller bodies are vulnerable to dehydration. When diarrhoea is present, body water and electrolytes (things like sodium, potassium and chloride) are lost and if these are not replaced, then dehydration can develop. Vomiting may also be present during a diarrhoeal episode and this can result in extra body water and electrolyte losses. These can be replaced with an oral rehydration solution (e.g. Hydralyte). With young children around, it is often a good idea to have a bottle of oral rehydration solution in the fridge: these also come in small ice-stick sizes, which allow toddlers to suck on the icicles when they are not feeling so well.

The early stages of dehydration develop without observable signs and symptoms. However, moderate dehydration is accompanied by thirst, restless or irritable behaviour and perhaps sunken eyes. Other things to look out for as dehydration develops include drowsiness, decreased urine output and refusal to eat or drink.

Dehydration can develop quickly with little ones so it is always a good idea to contact your doctor immediately if you think your infant or child is becoming dehydrated.

Prevent the spread of infection

If your child has diarrhoea, it is important to take the following steps to prevent others from also becoming ill:

  • keep your child away from other children until she or he has recovered.
  • do not allow your child to share her food and drinks with others.
  • wash your hands thoroughly after changing nappies or assisting with toileting.
  • wash your hands before handling food and drinks.
  • health education about how infections spread.

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What is colic?

One in three babies cry for three hours or more each day and are very hard to settle. Such babies are often said to have “colic”. There are many theories about what causes colic. Crying and unsettled behaviour usually occurs in the late afternoon and evening and is most common in infants from two weeks to four months. This behaviour is found in in babies throughout the world. Cuddling and other calming techniques often do not help. The behavior often settles after a few weeks, and is very stressful for the parents. It is important for babies to be seen by a health care professional to rule out any medical causes for their unsettled behaviour.

Symptoms of colic

Symptoms for colic peak around the six to eight week mark. Besides excessive crying, symptoms include:

  • Reddening, frowning and grimacing face.
  • Pulling up of legs.
  • Noisy stomach noises.
  • Passing wind or faeces when the crying stops.

Causes of colic

There are many theories as to what causes colic. These include maternal diet (e.g. cow’s milk protein intolerance or allergy), maternal drug taking (e.g. nicotine and caffeine), unfamiliar gut sensations (gas or fullness), or general immaturity and adjusting to life out of the womb.

Treatment for colic

Unless there is a medical cause found for colic, such as behavior (e.g. reflux), there are no specific medications recommended, nor found to be useful.

Advice for parents

  • Try to stay calm.
  • Help your baby to cope with their distress by cuddling or feeding.
  • Let your baby suck at the breast or bottle. Your nurse or doctor can advise you on feeding and the amount of milk your baby needs.
  • Offer a dummy. Sucking may provide comfort and help your baby to settle.
  • Gently rock or hold your baby in your arms or in a baby carrier or sling.
  • Continue to speak softly to your baby. Your voice and presence may help soothe them.
  • Try playing some soft music.
  • Try giving a warm bath.
  • Try a nut-free baby massage oil. This may calm the baby and also help you to relax

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What is constipation?

Constipation is the difficult passage of hard, dry, or crumbly bowel motions, which often cause discomfort. The motions can often appear as pellets.The frequency of bowel motions, although relevant, is not the main factor as this varies greatly between healthy infants.

Constipation can cause pain, discomfort and bloating, and parents should always access medical advice for an infant with constipation. When bowel motions are difficult to pass, they may cause pain and create a small tear in the anus, known as an anal fissure. The infant may hold on to subsequent motions to avoid further pain, which exacerbates the constipation.

If constipation persists in children, faecal incontinence can be seen, whereby the child involuntarily defacates in an inappropriate place. This is when stools leak out for the anus around a solid lump of faeces. It is thought that when the rectum and anal canal are chronically impacted, this prevents the external sphincter from contracting as expected.

If your child is constipated it is important to seek the advice of your health care professional.

What are the signs and symptoms of constipation?

These can vary between infants but often include the following:

  • Hard, dry, crumbly, pellet-like poo.
  • Bloating.
  • Stomach cramps (pain may be intermittent).
  • Reduced appetite.
  • Squatting, crossing legs, or refusal to use bowels, known as “holding-on” behavior.
  • Anal fissures, and some anal bleeding when bowel motions are passed.
  • Irritable behavior.
  • Recurrent urinary tract infections.

What frequency and consistency of bowel motions are normal for infants?

This can vary greatly between infants. Breastfed infants may use their bowels after each feed, or as little as once a week. Formula fed infants tend to use their bowels less often and their stools are bulkier and firmer, as is the case when breastfed infants also receive some formula. If stools are not passed frequently, but when passed cause no pain and are not hard or dry, there is no problem. Babies may go red in the face and strain, but as long as the stool is not hard, there is no reason for concern. When solids are introduced, the stools do change form and generally become more solid in nature.

Causes of constipation in infants and toddlers

The majority of the time, constipation is functional (i.e. not related to a medical condition). Functional constipation is usually caused by both the drying of faecal mass in the large bowel, as well as difficulty expelling the stool. However, 5% of infants do have a pathological cause for their constipation so medical assessment by a health care professional is recommended.

Constipation is less commonly seen in breastfed babies, as breastmilk is more easily digested than formula due to multiple natural ingredients occurring in breastmilk. If it does occur, it may be due to inadequate fluid, so offering the breast more often can resolve this. In formula fed babies, making up the formula incorrectly (i.e. too much powder for too little water) and dehydration are common causes of constipation. Nappy rash can lead to painful defecation and, hence, promote constipation due to withholding faeces to avoid further pain. It is possible, too, that a baby receiving formula may be reacting to the milk protein in the formula and may improve on a different formula.  It is important to seek the advice of your health care professional in advance of introducing a different formula.

Treating constipation

  • Offer extra breastfeeds if breastfed, or bottles of cooled, boiled water if formula fed.
  • If formula fed, check to ensure formula is being correctly made up, with the right volume of water and correct number of scoops as specified on the side of the can.
  • Some babies enjoy and benefit from baby massage.
  • For toddlers, gradually including additional fruit, vegetables, whole grains and other high fibre foods into their diet may help.

There are many myths on how to treat constipation in babies. Prune juice is not suitable for infants less than nine months of age, even when diluted, as it contains a natural bowel irritant. In addition, sugar or rice cereal should not be added to formula and will not relieve constipation.

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Reflux, gastroesophageal reflux (GOR), regurgitation, or “spilling” of gastric contents in babies is when the stomach contents effortlessly enter the oesophagus or the mouth. Usually, it is swallowed, but sometimes it spills out of the mouth. Reflux is very common, with around two thirds of babies under the age of 4 months having at least one episode daily. From 4 to 8 months this decreases to one third of babies, and by 12 to 14 months of age, almost all babies no longer overtly regurgitate. For distressed parents dealing with a very unsettled infant, this may be reassuring to know.

Why does reflux occur in babies?

Babies have a shorter oesophagus than older children, and when this lengthens over time, symptoms often subside. In addition, the sphincter between the stomach and oesophagus (lower oesophageal sphincter) matures as infants grow, again reducing reflux episodes. Finally, babies spend a lot of time horizontal, hence the developmental milestone of sitting often assists to alleviate reflux.

Other signs and symptoms of GOR

Besides regurgitation, babies with GOR may exhibit:

  • Back arching
  • Abdominal pain
  • Oesophagitis
  • Excessive screaming and irritability
  • Gulping
  • Recurrent chest infections due to aspiration
  • Feed refusal
  • Inadequate weight gain

These symptoms are either due to the volume regurgitated, or the acidity of the refluxed contents.

Diagnosis of GOR

If your baby exhibits symptoms of GOR it is important to seek the advice of your health care professional.

Management of GOR

  • Small regular feeds of breastmilk or formula are better tolerated in some infants, rather than over-feeding.
  • The use of thickened feeds may assist some infants with volume-related reflux, but doesn’t typically assist acid related reflux.
  • Keeping infants upright for 30 minutes post feeds, and tilting the cot can assist to reduce symptoms.

Gastroesophageal reflux disease

Gastroesophageal reflux disease (GORD) often presents with the more troublesome and severe symptoms of GOR, and may be diagnosed when GOR does not resolve over time. It is important to seek the advice of your health care professional for diagnosis and management of GORD.

Where to get help and support for parents?

Failure to thrive is the term used for infants and young children under the age of five, who fail to achieve normal growth. Failure to thrive is defined as weight that falls under the third percentile on at least two separate occasions.

It must be acknowledged that some children are just naturally small and, as long as other neuro-developmental milestones are being met, it may just be their genetic pattern. A failure to thrive can be monitored by recording your infant’s height and weight on their growth chart over a period of time.

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