Guide to Managing Common Feeding Problems in Infants and Children
Feeding problems are common in infants and children. While some fussiness or occasional throwing up of food is not a cause for concern, it is important to seek medical advice when the child fails to put on weight. Some common problems include food allergies, intolerances, diarrhoea, constipation, reflux and colic. Consulting a General Physician or a maternal health nurse is the best way to address any kind of feeding problems.There baby formulas that are specifically produced for children who suffer from constipation, diarrhoea, food allergies or other issues.
All about constipation
According to North American Society of Gastroenterology, Hepatology, and Nutrition (NASPGHAN) constipation is defined as “a delay or difficulty in defecation, present for 2 weeks or more, and sufficient to cause significant distress to the patient.” Characterised by difficulty in passing stools that are dry, hard or crumbly. There is an infrequent passing of stools and they often resemble pellets.
The passing of dry stools is usually accompanied by discomfort, pain, bloating and sometimes blood in the stool. The best course of action is to consult a qualified medical professional if your baby or child has constipation.
Fissures or tears in the anal passage can be caused by repetitive straining to pass stools. Fissures cause burning and pain which further may result in the child avoiding defecation for fear of more pain. This exacerbates the problem in a vicious cycle. In children, faecal incontinence which refers to involuntary defecation may result from persistent constipation. This is characterised by stools leaking out of the anus along with a solid lump of dry faeces. This is because of ineffective contraction of the external anal sphincter that allows for normal passage of stools.
Consult a healthcare professional as soon as you notice constipation in your child.
Common symptoms of constipation
Although each child can experience different symptoms and their severity, some of the most common ones include:
- Passing pellets that are dry, hard and crumbly
- Cramps or intermittent stomach pains
- Lack of appetite
- “Holding on” or refusing to pass stools
- Fissures and bleeding along with bowel movement
- Urinary tract infections
Bowel movement in infants: When is it abnormal?
Frequent loose stools are more common among breastfed babies while bottle-fed babies tend to have less frequent stools. Infants who are on formula pass stools that is firmer or bulkier than breastfed babies. Even with slightly infrequent stools, if they are well-formed and not dry, with no pain or discomfort while passing stools, there is no cause for concern. Sometimes babies strain while passing stools while going red in the face. But as long as the stools are not pellet-like or hard, there is no need to rush to the doctor. There is a change in frequency and consistency of stools as babies are weaned on to solids and whenever their eating habits change.
What causes constipation in children and babies?
Most of the time, constipation in children is due to the faeces drying up in the colon accompanied by difficulty in opening the bowel. About 5% of babies may have a medical cause behind constipation. Getting a thorough evaluation to rule out pathological conditions is the best way to address the issue in children and infants.
Babies who are breastfed rarely experience constipation while it could be common in formula-
fed infants. This is because breast milk is easier to digest as compared to formula milk. Poor intake of breast milk may be the reason why breastfed babies experience constipation. Increasing the frequency of feeding may resolve the problem.
If your baby is on formula, make sure adequate water is added and the formula is at the right consistency. Too much formula and very little water can be one of the causes of constipation in formula-fed infants.
At times a diaper rash can also result in pain while defecating. Because of the pain, the infant may withhold the faeces resulting in hard stools. Intolerance to lactose or allergy to formula milk protein may also cause changes in the consistency or frequency of faeces. Consult a qualified medical professional for any concern related to constipation in your child or infant.
How to treat constipation?
For babies on breastfeed, encourage more feeding. For infants on formula, give boiled and cooled water in-between feeds.
Check if you are adding the right amount of formula. Follow the instructions on the formula to see that the number of scoops and the water volume are as per the recommended amounts.
Massage can help relax the muscles and aid in smoother bowel movement
Fibre-rich foods such as fruits, vegetables, whole cereals and grains may help add bulk in toddlers and older children.
Many misconceptions surround constipation and its treatment. While some recommend giving prune juice, others advise sugar or rice. Prune juice may actually irritate the bowel and is not advisable for infants and children. Sugar and rice also are not effective in relieving constipation as they do not contain fibre
Allergy and food intolerance
Infants can sometimes experience a negative reaction to milk or other substances. The reaction could be either due to intolerance or allergy. Food intolerance is not the same as a food allergy.
An allergy is the result of an overactive immune system that is triggered by certain types of substances. An allergic reaction can involve multiple organs and can cause a wide range of symptoms. Some common symptoms include itching, rashes, hives, diarrhoea, and vomiting. The allergic reactions are mild to moderate in most cases. Rarely, the allergic reaction may be severe enough to cause a condition called anaphylaxis which can be life-threatening. This is characterised by symptoms such as shortness of breath, wheezing, fainting or trouble swallowing.
Food intolerance is sensitivity to certain foods and does not involve the immune system. Symptoms are milder and do not progress to the severe stage of anaphylaxis. Food intolerances are usually caused by an inability to digest a certain food.
Many people get confused between allergy and intolerance as some symptoms could be common to both.
Consulting an allergy specialist in Australia or New Zealand is the best way to understand if your child is allergic or intolerant.
Allergies are triggered by “allergens” that are found in the environment in dust mites, hair of animals, pollen, insect venoms, some medications. About 10% of babies, according to studies, have food allergy. Food allergies are usually triggered by proteins in foods such as egg, milk, nuts, shellfish, soy or wheat. Although these foods account for 90% of food allergies, many other foods can cause the symptoms as well.
In babies who have an allergy, their immune system starts to respond in an exaggerated way when it comes in contact with any of these allergens. The body recognises these as “alien” or enemies and proceeds to attack them in a vicious way. The symptoms of this attack are vomiting, swelling around the mouth or tongue, and hives. The allergic response occurs every time the immune system comes into contact with the allergens.
Sometimes with milder forms of food allergy symptoms may not be as pronounced and result in milder colic, vomiting, diarrhoea and rash. Sometimes a skin rash or eczema may be the only symptom. Some studies have shown that food allergy accounts for at least half of all cases of eczema in younger children.
While most allergic responses are instantaneous, some reactions take time- ranging from hours to days- to become obvious. Delayed reactions are difficult to recognise and it is best to consult an allergy specialist.
Severe forms of allergy lead to anaphylaxis which occurs within a few minutes of exposure to the triggering allergen. The immune system produces antibodies (IgE) to attack and neutralise the ‘alien’ substances. This is often a serious medical emergency that calls for immediate attention of doctors.
The Australasian Society of Clinical Immunology and Allergy (ASCIA) website lists the common symptoms of an anaphylactic reaction.
Steps to take to prevent anaphylaxis
After getting your baby or child treated in the emergency room for an anaphylactic reaction, there are some things you can do to prevent such attacks in the future.
The first step is to consult an allergy specialist to find out what caused the severe allergic reaction.
The doctor may order a blood test or a skin prick test (SPT) to identify the allergy trigger. The blood test is done to find out how much of IgE antibodies are present and what allergens have triggered them. Called the RAST or RadioAllergoSorbent test, the doctor can understand which specific allergen is responsible for your baby’s severe allergic reaction. The doctor then prescribes a treatment course that is best suited for your baby.
The second step is to eliminate the particular allergen if it relates to food. The doctor can help you understand how to substitute with other non-allergenic foods so as to not affect the child’s nutrition intake.
The ACSIA provides more information on what the allergens are and how to avoid them.
Understanding allergy to cow’s milk
About 2% of children and infants in Australia experience allergy to cow’s milk. Called cow’s milk allergy or CMA, the responses occur even when a small amount of milk is ingested.
Many milk products for toddlers and formula for infants contain cow’s milk, including a2 Platinum®.
Babies who are breastfed can also experience allergic responses when the mother consumes cow’s milk which passes into the breast milk. An Accredited Practising Dietitian (APD) or a General Physician can guide how to deal with such an allergy.
Most infants outgrow cow’s milk allergy at age 4 or so, but sometimes the allergy carries on to adulthood.
An allergy doctor makes use of the RAST test or a skin prick test (SPT) to know if the baby is still allergic to cow’s milk. The doctor can use a combination of these tests along with a “food challenge” involving ingesting small amounts of cow’s milk. The milk challenge is done to confirm the findings of the RAST or SPT test. Besides, these tests sometimes show a false negative. Only an experienced and qualified allergy specialist should advise and carry out milk challenges in clinical settings.
The ASCIA website provides detailed information on this aspect under the cow’s milk allergy section.
If your baby is on a formula that contains cow’s milk, it is best to speak to your doctor to know how to replace the formula with one that does not contain the allergen. Alternative formulae are available but should be prescribed by a qualified healthcare provider. Hydrolysed or partially hydrolysed formulae also contain cow’s milk proteins in easily digestible form, but can still trigger allergy reactions in the baby. It is best to avoid these if your baby has cow’s milk allergy. Many foods contain cow’s milk including cakes, cookies, biscuits and so on. The food labels specify if the product is dairy-free or not.
Dealing with intolerances
Certain substances or chemicals naturally occurring or added to foods or in the environment can trigger intolerance. These reactions are usually milder than allergies and do not involve the immune system. Even when symptoms are severe, they are usually not fatal and do not progress to anaphylactic reactions as is common in allergies.
Intolerances are experienced by those highly sensitive to certain substances. Babies who are sensitive to milk or other foods can experience colic, excessive crying, skin rash or diarrhoea. Ingesting different foods that contain the same substance that a person is sensitive to can lead to intolerance. For instance, histamines and salicylates are present in many foods and eating these foods over a period of time can cause increased levels of these in the system. Even if small amounts of these foods are eaten at a time, over a long period of time, a build-up of such triggers can occur.
Responses to foods that cause intolerance vary in each individual. The threshold or tolerance level also varies in each individual to these intolerance-causing substances. Crossing the threshold levels lead to the manifestation of intolerance symptoms.
Responses can be immediate or may take hours to days to become obvious. With the delayed onset of responses, it can be difficult to identify the root cause. It is common to think that the last food or meal eaten was responsible for the intolerance. But in reality, the intolerance is due to repeated exposure to a substance over a period of time.
Bloating, headaches, diarrhoea, vomiting, hives, and tiredness are some of the common symptoms of food intolerance.
Unlike food allergy, food intolerance cannot be diagnosed with the use of blood tests such as RAST or SPT.
But an allergy specialist can help rule out allergies. Once allergies have been ruled out, a specialist dietitian can help identify intolerances with the help of elimination diets.
Babies who are breastfed can also experience intolerance to certain substances that get passed on to mother’s milk. If the mother’s diet contained cruciferous vegetables such as cabbage, broccoli or turnips, these can pass on to the breast milk and cause bloating and colic in babies. Consulting a General Physician or an Accredited Practising Dietitian (APD) is the best course of action to understand what is causing intolerance in babies.
How to deal with diarrhoea
The World Health Organisation defines diarrhoea as the passing of three or more stools that are liquid or loose per day. Passing loose stools more often than is normal for a person is also considered as diarrhoea. Frequent passage of formed stools is not categorised as diarrhoea. Babies who are breastfed tend to pass pale coloured stools many times in a day and this is a normal occurrence. This is not taken to be diarrhoea.
Diarrhoea occurs usually as the result of an infection that affects the gastrointestinal system or the digestive system. The infection causing agent is usually a virus or a bacteria.
Ingesting contaminated water or food or transmission from other people who are infected are the common causes of contracting these infections. Lack of proper hygiene including frequent washing of hands with soap can also result in transmission of infective agents to the baby. To avoid passing on contaminants to the baby, frequent hand-washing with soap after changing nappies or before and after feeding is a must.
Untreated, prolonged diarrhoea that is a result of an infection can be dangerous to babies or toddlers. Diarrhoea can result in dehydration because the body loses large amounts of water and essential electrolytes including potassium, sodium and chloride. Viral or bacterial gut infection also normally cause vomiting which may result in the body losing additional electrolytes and water. Immediate and continuous replacement of lost electrolytes and water is critical to avoiding dehydration. Doctors and the WHO recommend oral rehydration solution or ORS to prevent dehydration. ORS in the form of icicles is ideal for small children or toddlers. Doctors recommend keeping ORS icicles or solutions handy in the fridge if you have toddlers.
Dehydration is not immediately obvious and it takes time to develop typical symptoms of restlessness, tiredness, thirst and irritable or cranky behaviour. Reduced urine output, dryness of skin, sunken eyes, drowsiness and avoidance of food are other signs of serious dehydration.
Babies and toddlers are highly vulnerable to dehydration which can rapidly set in. If the baby or toddler has diarrhoea, it is advised to immediately contact the doctor to know how to prevent dehydration.
A gut infection that stems from a bacteria or virus can spread easily and affect others in the family or in immediate contact. Here are some ways to prevent the spreading of the infection if your baby or toddler has been affected.
- Do not let your toddler or child come in contact with other children till he or she recovers fully
- The child or toddler should not share drink or food with other children
- Hand washing and overall hygiene are important. After changing nappies, before feeding and cleaning soiled clothes, wash your hands well with soap.
- Always follow good hand-washing practices before preparing a feed for your baby or cooking for your toddler
- Educate yourself and others regarding how diarrhoea spreads
All about colic
In Australia, about one in five babies experience colic. Called infantile colic or simply colic, this condition can be marked by excessive crying in babies that can often be more than three hours in a day. Parents find it difficult to settle and manage the colicky baby.
Usually, colic develops at around two weeks after a full term birth and is known to resolve by three or four months. The crying episodes start sometime in the evening or late afternoon and the usual techniques of cuddling or rocking are not effective.
If you suspect your baby has colic, consult an experienced health care provider to understand if there are any medical reasons behind the colic.
What causes colic?
The exact reason for colic is not known. Some of the factors attributed to colic include spasms in the muscles of the still-developing digestive system, gas, hypersensitivity to surroundings. Other factors that may play a role in colic include hormones or a sensitive nervous system. Some theories also speculate that babies experience colic as a result of trying to adjust to the many changes after coming out of the womb.
Sensitivity or intolerance to certain substances in the breast milk caused by the mother’s diet is believed to cause colic. Medications that the mother is on, if any, may also pass on to the breast milk and cause discomfort to the baby.
Sometimes other medical conditions can cause the excessive crying. These can include acid reflux, indigestion, infection, a heart condition, pressure in the brain or other serious health conditions. Consulting a doctor is the best way to rule out these conditions.
What are the symptoms of colic?
Crying excessively is the most obvious symptom of colic. Other than this, the following symptoms are also seen:
- Grimacing or frowning
- Face turning red
- Drawing up of legs.
- Noises in the stomach
- Passing stools or wind after the crying episode
If the doctor finds a medical reason for the baby’s colic, a treatment course as needed will be prescribed. If no medical causes are found, no medications are prescribed. The following advice is usually given to parents to deal with a colicky baby.
- Although it is challenging to deal with a colicky baby, parents need to remain calm.
- Cuddling and other techniques to calm the baby might help
- It may also help to allow the baby to suck at the breast which has a calming effect.
- Sucking at a bottle or a dummy may also help calm the baby down when the baby has had the recommended amount of milk in the day.
- Holding the baby or rocking gently can also help
- Speaking in a soft tone to the baby can help settle the baby
- Soft music, warm bath or massage with a baby oil are other techniques that can be tried.
What is reflux?
When the substances in the stomach spill over into the oesophagus or the mouth, it is called reflux or gastroesophageal reflux (GOR). Reflux or regurgitation is a common occurrence in at least two-thirds of infants less than four months of age. After four months and up to eight months of age, the reflux decreases and is found in one-third of infants. Usually, the problem resolves completely by the time the baby reaches 12 or 14 months.
What is the cause of reflux?
The gastrointestinal system is in a developing stage in infants. They have an oesophagus that is shorter than children who are older. This may cause the reflux and is more likely when babies swallow too quickly. The food pipe elongates over a period of time and this is when symptoms begin to resolve. The sphincter is a muscle that prevents stomach contents from entering the food tract. This also matures over time preventing reflux. It may also occur because infants are on their back until they learn to sit and this could lead to spilling of stomach contents on to the food tract. As they learn to sit or stand, gravity itself would assist in keeping the stomach contents in their place.
Infants with reflux may also have these symptoms:
- Arching of back
- Stomach pain
- Inflammation or swelling of food tract or Oesophagitis
- Crying or irritability
- Aspiration which results in frequent chest infections
- Failure to thrive
- Refusing to feed
How is reflux diagnosed?
If you notice symptoms of reflux in your baby, consult a doctor immediately to get an accurate diagnosis and begin a treatment. Some possible remedial actions include
- giving smaller feeds of formula or breast milk to aid in the prevention of spillage.
- using thicker formula may help those infants who have reflux related to the volume of feed.
Holding the baby in an upright position for at least half an hour after feeding will help reduce reflux.
Gastroesophageal reflux disease
Gastroesophageal reflux disease (GORD) is a condition that has more severe symptoms than reflux. When reflux becomes chronic or does not resolve, a diagnosis of GORD may be made. Consult a medical professional to address the problem immediately.