DD is now almost 4 months and ebf. She has been a frequent spitter (constantly changing wet bibs) and has all the symptoms of reflux (coughing with stridor - the stridor has since settled, gurgly/wet voice, wet burps, hiccups and lots of silent reflux, unsettled often during feeds...popping on and off, coughing lots and making throat clearing noises). She is also a frequent feeder and seems to pass gas and have fairly explosive, wet bowel movements. I think I had an oversupply problem in the early days, which resolved with attention to feeding longer on one side before switching (3 hours) and has since balanced out....however the reflux symptoms didn't really change. She seems to be a relatively happy baby, but seems to be in pain somtimes - arching her back, frowning, fussing (I think her temperment is easygoing in general) and is following her growth curve. She has never slept well....not at all on her back, and only on her side in bed with me. We tried elevating the head of her bed, swaddling, etc...but nothing helped her sleep in the recommended position for SIDS prevention. So, alas, I gave in a few weeks ago and started putting her down on her tummy for naps (supervised) so she could get used to the position. And no surprises: she actually started napping for longer than 10 minutes! Anywhere from 25 min - 2 hours (though usually they are shorter) and she was coughing less in her sleep. Once she seemed used to the tummy sleeping, I started doing this at night in the crib (firm mattress) right next to my bed. She had previously been only sleeping with me (snuggled up and suckling all night)....however, my back/body is in pain from the sleep position and I really wanted her to sleep in a crib so I could have a little bit of time to myself in the evenings and was less nervous about her being alone in an adult bed. We get anywhere from 30 min to 4 hours in her crib at night before she wakes...and then finishes the night in bed with me.
So - that's some of the history...
For her reflux - since the spitting seemed to make her a bit irritable (plus the cough/stridor concerned me) I thought it was worth doing a dairy elimination diet. I lasted 3 weeks total. Initially I thought it "might" have helped a little bit (she had an eczema rash which cleared soon after....but then she got a cold and the hand/foot/mouth disease and her reflux got worse. Once she was over the viruses than I gave it another week of no dairy in my diet (I was strict other than consuming some products that had a cross-contamination risk,eg dark chocolate). When I reintroduced the dairy, I honestly couldn't tell if she was worse or better. Initially she seemed worse, but then she improved. It was sometime after this that I noticed her spit up had a brown tinge on a couple occasions - but that stopped. Then a week or so later, I noticed a bowel movement that had a bright red streak. Then a few days later another one was full of small brown spots (she had had some explosive ones the day before, followed by a very long sleep at night). The day before was also the day I introduced a dissolvable children's vitamin D tab (put on my breast) that has a lactose base (SISU brand). Upon closer examination the dark spots definitely looked to be spots of blood (not bright) and they were mixed with her usual high amount of mucous. A couple other times I've noticed dark spots. The colour is otherwise the typical mustard. I haven't given her that vitamin D supplement since. It's the only thing I have every introduced into her gut besides my milk. I didn't even try gripe water for that reason....
Re. her reflux and the blood, I have twice taken her to our family physician (who has an interest in pediatrics) - (in BC, Canada, pediatricians are referred services, not primary care providers). She was not concerned about the blood or mucous in the stool. She thinks it's just an anal fissure. She also doubted dairy allergy, saying it is extremely unlikely in breastfed babies and didn't think another elimination diet was worth it, and figured it was just coincidence that it happened after the vitamin D tab. She didn't think medication was needed for the reflux. Her only concern seemed to be that my baby followed her growth curve and had her vaccinations...and that we should follow up in 4-6 weeks to ensure she is still growing well. I have no concerns with growth/development and am perfectly capable of assessing that myself - so I'm tempted to skip the next checkups because I feel it will just be the same thing again....check growth, listen to chest and rush me out the door.
What do you think? Dairy allergy? Reflux that should be treated? Or just normal physiological reflux and nothing to worry about? It's going to get worse when solids are introduced....so I'm almost tempted to delay that just so her spit-up remains lower acidity and has a lower chance of causing esophageal irritation. I certainly can eliminate dairy again...but it is definitely a big challenge as my other daughter and husband both eat significant amounts, e.g. cheese, yoghurt, etc. and there is always the risk of accidental ingestion/cross-contamination. If I don't have to, then I won't.
I'm not sure what to do as I'm not convinced my doctor has really taken a careful enough history to make a judgement. We are in a rural area, so referrals to allergists or pediatric GI's are pretty much not an option (reserved for very severe cases). Our one and only pediatrician has the worst bedside manner with parents I've ever experienced and has questionable clinical judgement - many of our town's residents refuse to see him. My baby looks healthy (although a tiny bit pale, which maybe could be her normal colour?) Thanks so much for any insights you can offer!
I needed to add that today I rubbed a bit of yoghurt on the back of my baby's forearm...and she got a few red bumps there. Is this a definitive allergy sign? Or...again...maybe just another coincidence (as my doctor seems to think...).
It would certainly be easy enough to try the yogurt on the forearm again. If you have the "courage," you could rough a little spot of skin up ever so slightly with an emery board to increase the exposure to her system. Do another little patch without yogurt in it then.
Typically, I wouldn't expect a lactose ingredient to cause problems, except that it can be contaminated with milk proteins. Certainly those with moderate to severe milk allergies need to avoid lactose ingredients and any other milk derivatives. It's hard to know whether she reacted to the D product or whether it was a coincidence but you were right to simplify the picture by just removing it for now.
Unfortunately, doctors get milk allergies confused with lactose intolerance. Mother's milk is full of lactose and babies are designed to digest lactose. The true problem in babies who react to animal milk is the foreign milk proteins. Yes, these are shown to pass on in mother's milk. Your milk eliminations were unsuccessful meaning that either she's not allergic/intolerant to milk, or that there are other equally irritating foods in our diet. Do you experience any GI or allergy problems yourself?
You sound like the perfect pediatrician for your daughter. If you are concerned that she's experiencing too much discomfort, or suffering health impairments, a more intensive elimination diet would be worth trying --- going down to a very simple, hypoallergenic diet to see whether she improves or not in a few to several days, then adding foods back in one at a time.
You can take probiotics yourself to increase the amount passed on to your daughter through your milk. Fish oil would be good too and you can certainly supplement vitamin D yourself and pass more to your little girl. These efforts might ease her symptoms some.
Linda F. Palmer, DC
"The Baby Bond"
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Thank you so much for your thoughtful reply. It's actually good timing as I had a pediatrician appointment in another town an hour away today, and she was quite helpful. I also have a script for Zantac, which she encouraged me to think about/research...and in her experience, short term use hasn't resulted in any problems such as infections, etc. After this evening I might use it (more later..)
I showed the ped some recent photos of dd2's stool that showed the copious amounts and the mucous and dark spots (mixed in with mucous) and she agreed that probably was a sign of some sort of gut irritation and has given me some home swabs to get stool samples to test for occult blood. She didn't like the report of blood in the spit up a few times (and once a neon yellow streak)...and wanted a call if it occurred again. She also has ordered a stool sample to check the sugar content of the stool (query lactose intolerance...but to my understanding, this would be a secondary intolerance due to lactose overload, possibly from gut irritation?). Basically the point of the lactose testing would be just to know...but not much that could be done about it since she would advise to continue breastfeeding, and that foremilk/hindmilk imbalance is probably not an issue now. We have a follow up appointment booked in a month. In the meantime, I had eliminated dairy for the past month...however, unbeknownst to me I had been consuming it about once per week in pesto....and I also had a couple accidental ingestions of products containing butter. And in retrospect, I think the same thing happened with my original dairy elimination diet - a few oopses! So it doesn't seem I've actually given the dairy elimination a fair enough chance. The second time I cut it out, I actually noticed much less reflux within 2-3 days...however she also had a cold virus and was having a BM 2-3x/day, instead of her usual one every other day, or 1 per day...so maybe it was the increase transit time that helped decrease the reflux?
Anyway, I was advised to resume dairy for now until the test results come back (so I don't get a false negative) and then re-evaluate at that time whether to cut it out of my diet again. So today I splurged and had spinach quiche with feta, and a creamy fruity bar from my favourite bakery...and this evening the back arching and fussing during and after feeding was worse. But again....she also has another cold! So many confounding variables affecting the science of my little experiments! I had also tried to cut back on soy, thinking it could be a problem also.
I am taking a liquid Calcium/Magnesium supplement with vitamin D added. I also consume fish oil daily along with my dairy-free prenatal multi. I'll add a probiotic - I guess I've been missing it since I stopped my plain organic yoghurt. As far as I know I don't have any food allergies (just reactions to bug bites - big whelts) but there's a family history of other allergies and GI issues (my dad had surgery to remove a diverticulum in throat and a brother has IBS). I thought I had escaped that, but now it seems my gut doesn't agree with wheat (or possibly gluten)...and I wonder if I should get the blood test for celiac (I also have that "chicken skin" on upper arms and legs which I understand can be assiciated with celiac). So perhaps I have a leaky gut??
Thanks again for your help! It's definitely been a learning journey.
I just thought I'd add an update: I travelled to visit family for 1.5 weeks....and during that time the reflux, fussiness and the watery stools improved a LOT. Following the pediatrician appointment I resumed eating my typical diet (incl. dairy) for experimental purposes. So...during this trip, I consumed lots of dairy; however I realized I wasn't consuming much in the way of soy. When I returned home again, the reflux worsened and the stools got looser (orange/yellow watery diarrhea, along with some obvious bits of white curd mixed in). We were eating a fair bit of soy (tofu, soymilk). I've also noticed some bright yellow streaks in her spit-up again (neon yellow with greenish tinge)
Is it possible that dairy is not an issue....but soy is? I've been trying very hard to eliminate both soy and dairy, but keep having slip-ups (dh cooks and uses ingredients without checking labels...or I eat something but then realize it had soy, e.g. raisins - with soybean or canola oil, etc. I'm going to try to persist with strict soy elimination. My multivitamin and fish oil contains tocopherols (Vitamin E) - so I wonder if I need to cut those out too?