Elimination diets

If you have a reflux baby and you’ve decided to go down the route of investigating possible food intolerances through an elimination diet you will need all the support you can get. It is a long, hard road and friends and family just do not understand how hard it is nor how strict you have to be. It’s not like going on a diet to lose weight, where you can have the odd piece of chocolate and get back on the wagon tomorrow. If you’re doing this for your baby then the tiniest slip-up can leave you with 24 hours of no sleep and tinnitus from the screaming.

Essentially, you have to remove all the likely offending foods from baby’s diet until you get to ‘baseline’ or a symptom-free baby. Most commonly, all traces of dairy and soy are eliminated from the diet for between two and three weeks. This means watching their nappies carefully until most or all of the mucous is gone. Stools have a lag effect because mucous is a symptom of gut damage and this takes time to heal. After this time the baby should become markedly more settled and the persistence of mucous in stools should start easing. Once your baby has been at baseline for two weeks you can start to very gradually reintroduce foods until you’ve identified the culprits. If baby reacts to something, remove the food from your diet again and wait several days before trying a different food. If symptoms do not settle within a reasonable timeframe you could then embark on a full elimination diet removing all allergy causing foods and/or food chemicals.

There are many different elimination diets out there. When I first set down this path I followed the Dr Sears Elimination Diet, which basically consists of eating nothing but pears, potatoes, sweet potatoes and rice for two weeks. I followed it pretty religiously, except that I also ate zucchini. I noticed after two weeks that Ada’s symptoms had improved dramatically. She was so peaceful! The only problem was that I was literally starving to death and if I had to eat another lamb chop I was going to hurt somebody. So I chucked in the towel and went back to eating everything except dairy. This was a huge mistake because I very quickly undid all of my hard work and went back to having a super cranky baby all over again!

The second elimination diet I tried was the Royal Prince Alfred Hospital Failsafe Diet. This one was developed by allergists at a leading hospital in Sydney, Australia and is accompanied by a handbook and a cookbook. It is also the one that accredited practising dieticians and nutritionists (in Australia) are familiar with, so you’re more likely to get support from health professionals to follow it.

I followed this one strictly for two weeks, and while we didn’t get the same reduction in symptoms as with the Dr Sears diet I was a much happier mama for having a little variety in my diet. Because it was more sustainable I was able to stick it out for 10 months, during which time I gradually reintroduced foods into my diet until we had narrowed A’s intolerances down to dairy, soy, wheat and egg. As you can imagine I wasn’t left with a huge range of food choices and I ended up eating a lot of meat, fruit and vegetables! I also lost 24 kilos but that most certainly was not my motivation.

During this time we also commenced solids with A, which is a separate story (coming soon!)

As an aside, ‘all traces of dairy’ literally means just that – check packets for the words ‘contains milk‘, do not eat things which have been baked with milk, do not eat things that might even contain the barest smidgen of cow’s milk protein. So many people fail with the elimination diet because they didn’t realise they couldn’t just cut out their usual cappuccino and yoghurt and everything would be fine.

I would love to hear from anyone who’s been through an elimination diet for their baby. Please post your experience below and your best tips for any mamas considering attempting it!

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Does my baby have food intolerances?

If your baby has reflux or is having difficulty sleeping it is worth asking some questions about possible food intolerances. In many cases, reflux can be a major symptom of the food intolerance/s and once you identify and eliminate the offending food you can usually eliminate or significantly reduce the reflux.

First of all it’s important to note that infant reflux generally stems from one or all of the following triggers:

  1. Anatomical/structural – baby has a weak or immature oesophageal sphincter that simply allows food and stomach acid to spill up into the oesophagus (and often beyond!)
  2. Aerophagia – baby has a poor latch and can’t form a complete seal on the breast or bottle, either due to a tongue-tie, lip-tie or both. This means that baby is sucking in air along with milk, creating significant gastric discomfort and often reflux.
  3. Food intolerances/allergies – adults suffer from reflux symptoms as a result of food intolerances, so why not babies? When a food intolerance is present the proteins in the offending food damage the inside lining of the intestinal tract and the body reacts accordingly. In reflux babies Milk Soy Protein Intolerance (MSPI)is the most likely cause. It is thought that about half of reflux babies have a cow’s milk protein intolerance, and about half of these again also have a soy protein intolerance.

NB: There are other triggers (e.g. dysphagia, delayed gastric emptying, pyloric stenosis, eosinophilic oesophagitis) but these are less common and I don’t have any direct experience with them. In addition, while some babies simply have ‘anatomical reflux’, others (such as A) have all three of the aforementioned triggers!

For this post I’ll be focusing just on food intolerances.

Many health professionals claim that it’s highly unusual for babies to react to food proteins through breastmilk and that the baby is more likely to be suffering from colic (which is code for ‘I don’t know why this baby is so unhappy’). However, studies are increasingly finding links between the food ingested by mama and the gut reaction of the baby.

Symptoms of food intolerance in babies

  • spitting up or vomiting
  • persistent mucous in stools with or without stringy bits (the mucous will ‘bridge’ the folds of the nappy)
  • diarrhoea, loose and watery stools, frequent stools
  • ‘burny poos’ – persistent acidic stools
  • profuse painful wind, and lower abdominal pain
  • strange, persistent rashes or unexplained eczema
  • persistent nappy rash and burnt bottom
  • crying
  • fussing
  • grizzling and generally unhappy
  • squirming constantly
  • refusing to feed or constantly seeming hungry
  • upset digestion
  • ‘failure to thrive’, slow weight gain and underweight
  • insomnia and inability to settle
  • red cheeks and ears which can come and go and feel hot to the touch
  • sandpaper-like roughness on the upper arms

Note that many of the above are also symptoms of reflux, teething and various other bubba ‘grievances’. Most food intolerance reactions occur in the lower gut, specifically stools, abdominal pain and wind. If you suspect your baby is reacting to a food it is critical that you see a knowledgeable health professional to discuss. 

What might your health professional suggest?

Obviously babies can’t tell us if they feel yucky after eating a certain food and it’s even more challenging when you’re breastfeeding because the reactions can be so delayed. Therefore if you’re going to go down the elimination diet route on behalf of your baby you’ll have to become a little bit forensic (more information about elimination diets here).

Whilst allergies can be diagnosed through either a skin prick test or a blood test, intolerances are much trickier. In adults intolerances are usually diagnosed by undergoing an elimination diet wherein the most likely offending foods are removed from the diet for a period of two to three weeks and then reintroduced gradually to determine which are the trigger foods.

If you’re bottle-feeding your health professional may suggest that you try a hypoallergenic formula, and failing that may suggest an amino acid formula where the proteins are fully broken down.

Your health professional may also suggest that baby’s symptoms are being caused by other factors, such as an overactive or forceful letdown (if you’re breastfeeding) or temporary lactose intolerance after illness.

The 5-Second Newborn Check All Parents Should Do: A Follow-Up

I was going to post a similar write up about MTHFR and the link to tongue-ties and other midline defects but the Paleo Hygienist has done so very eloquently here! Really interesting stuff.

The Paleo Hygienist

I had debated whether or not I wanted to share my experience of dealing with a tongue and lip-tied baby and the breastfeeding issues my daughter and I dealt with, but I am so glad I did!  I want to thank all of you that have commented, emailed me and shared my blog post with others.  I have received such positive responses and some great information from so many of you!

After receiving some information and links from others out there that have also had experience with tongue/lip-ties or have researched this topic, I wanted to post a follow-up to pass along that information.  I still don’t have any solid answers as to what exactly causes tongue and lip-ties, I’m not sure anyone really knows the exact cause, but I want to share the information I have received so those of you interested in researching more on this issue can have some avenues…

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Let’s talk about sex, baby

I promised my physiotherapist I would write this post because it’s an issue for so many post-partum women but they’re just too embarrassed to talk about it or ask for help. Nevertheless it’s a problem that’s easily solved.

So what’s the issue? Seriously painful intercourse. If you feel uncomfortable even just thinking about getting intimate with your partner because of the anticipation of pain, and it’s been more than 6 weeks since having your baby then you should bring it up with a trusted health professional. It is not normal to feel pain with intercourse more than 6 weeks post-partum and if you ignore it then it can start to have serious ramifications.

The most likely cause of your pain is a build up of scar tissue in your vagina and then a subsequent fear association. Here’s the most common scenario: you have sex for the first time after giving birth and it hurts, a lot, so next time you start to get intimate your body remembers the pain and starts to clench your muscles in anticipation. This is the start of a vicious cycle because of course it’s going to hurt if you’re clenched up like a clam!

Many doctors will tell women either to: a) just be patient, try to relax and not put pressure on yourself, b) use more lubricant, and/or c) prescribe a topical oestrogen ointment to help the body lubricate the area naturally. While these measures are certainly helpful they don’t actually solve the underlying cause of the problem, which is the scar tissue caused by the trauma of pushing a giant baby out through your vagina.

What can you do? Try and get yourself seen by a specialist ‘continence physio’. Many state and territory health departments (in Australia) have a number of public continence physios so you don’t have to pay out of pocket. You might be thinking, ‘oh, but I don’t have a continence problem!’ That’s great! But these physiotherapists are specialists in the gynaecological realm – they are intimately (so to speak) acquainted with your pink bits and how they function best. A continence physio will show you how to massage your internal scar tissue in such a way that it eventually disappears! Only then will you be able to remove the fear association and actually start to enjoy intercourse again.

Please note that breastfeeding may complicate this scenario because your body does not produce as much oestrogen, which is needed to lubricate your vagina. As such it is worth talking to your health professional about options such as the topical oestrogen ointment in addition to seeking treatment for the scar tissue.

Tongue-ties and lip-ties – how do they impact on breastfeeding and baby’s digestion?

So this topic is pretty much the number one reason I’m writing this blog. I’m not a health professional but I’m a mama who knew absolutely nothing about tongue or lip-ties until my second baby came along.  As I detailed in The Story of N, my first breastfeeding experience was heartbreaking for me and could have been saved if more health professionals them knew about tongue and lip-ties. The second time round it was A’s epic reflux that put me on the path to learning about this most fascinating topic.

So what exactly is a tongue-tie?

Ankyloglossia is the scientific term for a tongue-tie, which is where the lingual frenulum (a membrane or piece of skin connecting the underside of the tongue to the floor of the mouth) is unusually short, thick or tight. As a result, the mobility of the tongue may be severely restricted. The International Affiliation of Tongue-tie Professionals explains that a lingual frenulum is the ’embryologic remnant of the tissue in the midline of the under surface of the tongue and the floor of the mouth’. In most babies this remnant of tissue fully regresses by birth. In the cases where it doesn’t some researchers define this as a midline defect (more on this and MTHFR here).

And a lip-tie?

An upper lip-tie, or maxillary lip-tie, is where a labial frenulum (a membrane connecting the lip to the gums) is very short or thick and pins the upper lip too tightly to the upper gum. As a result, baby cannot flange his/her upper lip out when latching on to the breast making it harder to maintain a good seal.

Okay, so how is this connected to breastfeeding and reflux?

This eye-opening article by Dr Lawrence Kotlow, a dental surgeon, should be read by everyone with a reflux baby. I’m not saying that every baby’s reflux is necessarily caused by a tongue-tie or a lip-tie but there is a disturbingly common correlation.

Dr Kotlow makes the following arguments:

  • When the infant attempts to latch using just the lips to try to maintain a gentle grip on the breast, breastfeeding can be problematic for both the infant and the mother. Problems for the infant may include failure to thrive, prolonged and frequent breastfeeding with poor milk transfer, inability to maintain an effective latch, colic, and reflux. Mothers often develop plugged ducts, pain during feeding, flattened, compressed and injured nipples, and mastitis.
  • Consequences of an incorrect latch may include the following: poor suck, poor seal around the breast, loud clicking noises due to tongue recoil, extended feeding times, poor infant weight gain, and infant fussiness and irritability during and after breastfeeding.

  • Normal movement of the tongue (rippling from the front of the tongue to the back) is difficult or impossible if the tongue is tethered to the floor of the mouth.

The issue, I think, is two-fold: firstly, since baby can’t form an adequate seal s/he will suck in air whilst feeding resulting in aerophagia. Dr Kotlow notes that ‘if an excessive amount of air reaches the stomach (pathologic aerophagia), abdominal  distension, belching, and flatulence often develop. This may trigger recurrent crying in affected infants.’ Secondly, the tongue plays a critical role in digestion – it’s the first muscle involved in peristalsis, which is the rippling, wave-like motion that helps to move food through the digestive system.

See this great website by Carmen Fernando, a speech-language pathologist based in Sydney, Australia for a more detailed explanation of the impact of tongue-tie on breastfeeding.

No amount of ‘expert’ lactation consultants or breastfeeding books could help with our issues until I found someone who specialised in identifying and treating tongue and lip-ties. This is why I strongly recommend that any mamas having difficulty with breastfeeding and/or reflux research tongue-ties and lip-ties and get their babies checked out!

There is a wonderful Facebook group with heaps of information and knowledgeable parents and practitioners. It’s a closed group so you do have to request to join.

Infant (Acid) Reflux

Let’s begin by saying I had never heard of infant reflux before A came along. I’d heard about adults having it and it sounded horrendous. I suffered from pretty epic heartburn whilst pregnant both times, but absolutely nothing prepared me for the total, life-changing horror of having a baby with infant reflux (AKA acid reflux, gastro-oesophageal reflux, gastric reflux).

When the symptoms first started showing I immediately jumped on Dr Google. After feeds A would start screaming, usually within 5 minutes, arch her back, flail her arms around, hiccup and go really stiff like a board yet super squirmy like a cat that doesn’t want to be petted. She was a constant bundle of misery and wouldn’t sleep for more than 10 minutes at a time. I searched for ‘baby screams after feeding’ and instantly hit on a million articles about infant reflux. I also came across a few articles about colic.

I took A straight to our family doctor who has additional specialist qualifications in childhood health, although he’s not a paediatrician. He examined her and said to me, ‘all babies cry. They’re all unsettled during the first six weeks. I wouldn’t recommend any medication – they have terrible side-effects, and besides, all babies have reflux because their oesophageal sphincters are immature. She looks fine to me. I’m sure she’ll settle down – it’s probably just colic and she’ll grow out of it.’ Well… more on our story can be found at The Story of A but suffice it to say that she most certainly did have problematic reflux and I wish I’d been able to attend that first appointment armed with more of the knowledge and confidence that I have now!

So what is infant reflux?

Infant reflux is where the contents of the baby’s stomach (food and digestive acids) are brought up into the oesophagus and regurgitated. The baby may then vomit out or ‘spit up’ the stomach contents (which in the case of very young babies is usually the milk they just drank). The acid can burn and may cause the baby great discomfort and/or pain. Adults often refer to reflux symptoms as indigestion.

In many cases reflux is simply an unfortunate side effect of an immature lower oesophageal sphincter. As the baby or child matures so does the ring of muscle at the top of the stomach, which controls the flow of food from the oesophagus into the stomach and is supposed to prevent stomach acid and digested food from going back up again.

Picture from the very helpful ‘What is Gastric Reflux?’ page on http://www.cryingoverspiltmilk.co.nz

Bryan Vartabedian’s book Colic Solved was the first thing I read that gave me a comprehensive understanding of infant reflux. The author is a paediatric gastroenterologist and the book is a thoroughly researched account of some of the real causes of ‘colic’ and ways of dealing with it. He notes that ‘many if not most cases of colic are actually caused by acid reflux’. In Chapter Three he details the ‘Seven Signs of Reflux in Your Baby’ including:

  • Spitting up and vomiting (as well as ‘wet burps’)
  • Constant hiccups
  • Feeding disturbances
  • Chronic irritability
  • Discomfort when lying on the back
  • Sleep disturbance
  • Chronic cough and/or congestion

Dr Vartabedian also discusses gas as an ‘unexpected consequence of feeding problems’, because babies with reflux typically swallow a lot of air while they’re feeding.

The chapter that really opened my eyes was Chapter Five, ‘Milk Protein Allergy’ AKA cow’s milk protein allergy/intolerance or CMPI. As discussed in The Story of A an osteopath initially suggested to me that dairy might be the source of Ada’s woes, but it was in Colic Solved that I learned about the symptoms of CMPI and realised that it was indeed a problem.

However, as informative and practical as Dr Vartabedian’s book is, it doesn’t mention tongue or lip ties as a cause of reflux at all. Instead it urges parents of reflux babies to treat with medications, and describes seeking alternative treatments such as aromatherapy and chiropractic as ‘just a couple of the extreme measures that parents will resort to when faced with the feeling that there’s nothing that can help their baby.’ As someone who sought and found great help from osteopathy for A’s reflux, not to mention having bodywork recommended by Dr Nigro after getting A’s tongue tie and lip tie revised, I found the absence of thorough discussion on these topics and treatments disappointing.

More on tongue tie and lip tie and their connection with reflux coming soon…