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Consider nutrition first in the management of common infant functional gastrointestinal disorders (FGIDs) and cows’ milk protein allergy. Learn more about these conditions and find out when nutrition may be the best prescription.

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Summary

Swift identification of the signs and symptoms can help infants and families get the support they need.
1 in 50 infants allergic to Cow’s milk

Cows’ Milk Protein Allergy

1 in 50 infants are allergic to cows’ milk protein & symptoms can persist until 3 to 5 years of age2

The majority (92%)5 of children with cows’ milk protein allergy experience 2 or more symptoms, which may be6:

  • Skin related: including eczema, hives, swollen lips face or eyes
  • Gastrointestinal: including reflux, vomiting, diarrhoea, colic, back arching, not feeding
  • Respiratory: including wheezing or noisy breathing
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30% prevalence of reflux & regurgitation

Reflux and regurgitation

30% prevalence1
Up to 12 months of age

Common symptoms include3:

  • Vomiting or frequent spitting up
  • Regurgitating gastric contents into mouth
  • Regurgitating 2 or more times per day for 3+ weeks
  • Is irritable and hard to settle
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20% prevalence of colic

Infant Colic

20% prevalence1
Up to 12 months of age

Common symptoms include recurrent and prolonged periods of3:

  • Crying
  • Fussing
  • Irritability with no obvious cause and cannot be resolved
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15% prevalence of constipation

Constipation

15% prevalence1
Up to 12 months of age

Common symptoms include4:

  • Two or fewer defecations per week
  • Excessive stool retention
  • Painful or hard bowel movements
  • Large diameter stools
  • Presence of large faecal mass in the rectum
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Broader Impacts of FGIDs

Parental anxiety and stress
Parental anxiety and stress7
Feeding problems
Feeding problems8,9
Visits to GP or pharmacy
Numerous visits to GP or pharmacy1
Loss of parental workdays
Loss of parental workdays9
Strain on healthcare resources
Strain on healthcare resources10-12

Long-term impacts

Recurrent abdominal pain
Increase in recurrent abdominal pain13
Allergic disorders
Increase in allergic disorders13
Psychological disorders
Increase in the risk of psychological disorders in childhood13

Recommended Management

Guidelines emphasise the first line management of common infant feeding contitions should include:4

Parental education
Parental education
Parental reassurance
Parental reassurance
Nutritional solutions
Nutritional solutions

Current treatment practices

In treating digestive problems in infants, it is important to avoid the use of drugs and invasive procedures where possible. Nutritional treatments are generally the preferred option.
Vandenplas et al. 201518

Research suggests that prescribed medications and over-the-counter remedies are frequently used to manage the symptoms of FGIDs.4,14,15 While there is some evidence to support pharmacological interventions for functional constipation, pharmacological therapy appears to offer no benefit for other FGIDs that occur in early life.4,14,16As such, infants suffering from FGIDs receive a large number of medical treatments that may be contraindicated or not substantiated scientifically.14,17 There is broad consensus that there is no indication for pharmacological treatment (such as proton pump inhibitors) in infants with colic or regurgitation, with no evidence of effectiveness and significant risks or negative side effects.16Cows’ milk protein allergy can present with either immediate (mediated by immunoglobulin (Ig)E) or delayed (non-IgE mediated) symptoms. Non-IgE mediated cows’ milk protein allergy can be particularly difficult to diagnose as symptoms are often also associated with FGIDs such as increased regurgitation, irritable behaviours and diarrhoea.6 There is evidence to suggest that it can take up to 10 months for infants to be diagnosed with cows’ milk protein allergy.19

Guidelines and recommendations for management of FGIDs

Management of FGIDs

First-line management of the most common FGIDs, particularly infant colic and regurgitation, should focus on parental reassurance and nutritional advice.1,4,14,16 The latter includes recommendations on feeding volume, frequency and techniques for all infants, and considering specialty formulas with proven effects for formula-fed infants with persisting symptoms.4 With the exception of functional constipation, drug treatment is seldom required.4

By simply providing parental reassurance and nutritional advice, pharmacists and general practitioners can make a difference for families suffering with infant FGIDs, with the potential to alleviate costs from public healthcare systems whilst treating according to best-practice guidelines.

Guidelines and recommendation for cows’ milk protein allergy2,6,20–23

Guidelines for cows’ milk allergy

For infants where there is a strong suspicion of cows’ milk protein allergy, an elimination diet is required to confirm diagnosis. For breastfed infants, the mother will usually need to exclude cows’ milk protein from her own diet. For formula-fed infants up to 6 months old with mild to moderate cows’ milk protein allergy (not anaphylaxis), a cows’ milk based extensively-hydrolysed formula is generally the first-choice recommendation.

For infants who do not tolerate an extensively hydrolysed formula or for anaphylaxis, an amino acid-based formula is a suitable alternative. Soy formulas are usually not recommended for infants under 6 months old. Soy formulas may be tried in infants over 6 months old where soy is tolerated. A rice milk-based formula can also be recommended for children with cows’ milk protein allergy.

Nutritional management for common infant feeding issues

Nutritional management

Nutricia has a wide range of products that are suitable for different feeding needs.

Reflux & regurgitationInfant colic or constipationCows’ milk protein allergy

Our products contain Nutricia’s unique prebiotic oligosaccharides blend

BREASTMILK IS BEST FOR BABIES

Learn more

Earn CPD points

Earn CPD points

Learn more by completing accredited CPD modules on Cows’ Milk Protein Allergy & FGIDs.

Earn CPD Points

Resources

Nutrition Prescriptions resources

Nutrition Prescriptions is a reliable source of current information on nutrition-led infant health management.

Below are key take-outs adapted from a recent review article4 on best practice in managing common infant FGIDs.

Infant reflux & regurgitationInfant colicInfant constipationCows’ milk protein allergy

Expert advice and opinion

Expert advice

Infant nutrition expert, Dr Thomas Ludwig, gives an overview of infant FGIDs, their impact on children and their families and the case for managing them with a nutrition-first approach.

You can find more videos featuring infant nutrition experts and key opinion leaders here.

Watch more

References

1. Vandenplas Y et al. JPGN 2015;61(5):531–537.
2. Australasian Society of Clinical Immunology and Allergy (ASCIA) 2019. Information for patients, consumers and carers: cow’s milk (dairy) allergy. Available at: www.allergy.org.au.
3. Beninga MA et al. Gastroenterol 2016;150:1443–55.
4. Salvatore S et al. Acta Paediatr 2018;107:1512-1520.
5. Host A and Halken S. Allergy 1990;45:587–596.
6. Koletzko S et al. JPGN 2012;55(2):221–9.
7. Hyman PE et al. Gastroenterol 2006;130:1519–1526.
8. Miller-Loncar C et al. Arch Dis Child 2004;89(10): 908–912.
9. Indrio F et al. Eur J Pediatr 2015;174(6):841–842.
10. Iacono G et al. Liver Dis 2005; 37(6):432–38.
11. van Tilbur MA et al. J Pediatr 2015;166:684–89.
12. Morris S et al. Arch Dis Child 2001;84:15–19.
13. Savino F et al. Acta Paediatr 2005; 94(suppl 449):129-32.
14. Mahon J et al. BMJ Open 2017;7:e015594.
15. Saps M et al. J Pediatr Gastroenterol Nutr 2009; 48(Suppl 2): S101–3.
16. Glanville J et al. BMJ Open 2016;6:e011475.
17. Headley J & Northstone K. Eur J Clin Pharmacol 2007;63:189–95.
18. Vandenplas Y et al. Gut health in early life: implications and management of gastrointestinal disorders. Essential Knowledge Briefing. Wiley, Chichester (2015).
19. Nutricia. Data on file.
20. Fiocchi A et al. World Allergy Organ J 2010;3:57–161.
21. Fox A et al. Clin Transl Allergy 2019;9:40.
22. Kemp AS et al. MJA 2008;188(2):109–112.
23. ASCIA. Guide for Milk Substitutes in Cows’ Milk Allergy. Available at: https://www.allergy.org.au/hp/papers/guide-for-milk-substitutes-cows-milk-allergy.

FOR HEALTHCARE PROFESSIONALS ONLY