In this podcast episode, a pediatric gastroenterologist, Pediatric GI expert Dr. Victoria Martin joins me to demystify milk intolerance in babies—what FPIAP and cow’s milk protein intolerance really mean, why these diagnoses are tricky, and how families can find practical, evidence-based solutions.shares her expertise on milk intolerances in infants.
Dr. Martin emphasizes the importance of supporting breastfeeding mothers, addressing misconceptions about milk allergies, and the potential benefits of early allergen exposure. Additionally, Dr. Martin and the host discuss the role of lactose intolerance, and nutritional considerations for infants.
Dr. Victoria (Tori) Martin is an Assistant Professor of Pediatrics at Harvard Medical School, Co-Director of the Pediatric Gastroenterology Section of the Food Allergy Center at Massachusetts General Hospital for Children, and Associate Program Director of the MGHfC Pediatric GI Fellowship. Her research focuses on early-life GI health, food antigens, and the infant microbiome.
Key takeaways
- “Lactose intolerance” is not a typical infant diagnosis; infant concerns are usually protein related.
- Microscopic stool blood alone has limits—treat the baby, not just the test.
- For breastfed infants with visible blood and discomfort, consider short, targeted milk-protein elimination, then a re-challenge in ~1 month to confirm diagnosis and avoid unnecessary long-term restriction.
- Hypoallergenic formulas are an option; prioritize growth, feeding comfort, and family well-being.
- Early, safe introduction of other allergens (e.g., peanut, egg) should still proceed on schedule unless otherwise directed by your clinician.
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Episode Transcript
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Unknown (00:00):
Hello listeners. This is Dr Jessica Hochman. I'm
(00:02):
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sponsor an episode, and I'll letyou know for a good match and
get back to you. Hieveryone, and welcome back to
(00:31):
your child is normal. I'm yourhost. Dr Jessica Hochman, so
today we're tackling a situationthat actually comes up all the
time in pediatrics, milkintolerance in babies. My guest
is Dr Victoria Martin, and she'san Assistant Professor of
Pediatrics at Harvard MedicalSchool and the Associate Program
Director of the pediatric gifellowship at Massachusetts
General Hospital for Children.
(00:53):
In this conversation, we diginto food protein induced,
allergic proctor colitis andcow's milk protein intolerance,
a condition that I realize maynot sound familiar, but it is
surprisingly common in one largeBoston Area study, for example,
about 17% of otherwise healthyinfants were given this
diagnosis when blood or mucuswas found in a stool. We'll talk
about why these diagnoses aretricky and how we can best
(01:15):
support babies and familiesthrough them. So whether you're
a pediatrician or a parent, thisepisode will offer clear,
compassionate and practicalguidance. Dr Martin, I'm so
grateful that you came here onthe podcast and to everyone
listening. Thank you so much forspending part of your day here
on your child is normal. I wantto take a moment to tell you
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Dr Martin, thank you so much forbeing here on the podcast. I'm
(02:18):
really looking forward to thisconversation. Thanks so much for
having me. I have to tell you Iheard you on another podcast
vowel sounds, and oftentimes Ilisten to podcasts that
reinforce what I'm thinking, oryou might learn some new ideas,
but your podcast actuallychanged the way I practice
medicine today, and I'm soappreciative of the work that
you're doing. Oh, thank you somuch. I love hearing that people
(02:41):
are finding it helpful. Sofirst, tell everybody a little
bit about yourself. What kind ofresearch do you do, and what
kind of a doctor are you sure?
Yeah, so I'm a pediatricgastroenterologist out of Mass
General Hospital for Children inBoston, and I became really
interested in understanding theearliest places in our body,
that food and antigen, which arethings that can cause allergy
(03:05):
and microbe like the bacteria,all live and interact very early
on in the infant GI tract, andhow that might set us up for
various types of health anddisease as we get older. And so
that's predominantly what I'vebeen studying. What a relevant
topic I do. Think there's a lotthat we want to know and
understand about the gutmicrobiome, and we also know
(03:28):
that we're seeing an increase inGI issues like intolerances to
various foods. We're seeing alot of eczema on the rise, and
we're trying to figure out howit all ties in. And I think
there's a lot of help that weneed in that area of research. I
agree. Thanks. So what I'mlooking forward to talking with
you about today is, as a generalpediatrician, I find that a lot
of parents have questions whenit comes to milk and how the
(03:51):
body tolerates milk in general.
So first, I wanted to talk toyou about a very common scenario
that comes up with babies in mypractice, and that is finding
out that babies may haveintolerances to milk. So can you
tell me a little bit about this?
How common is a milk intoleranceto a baby? And what does that
(04:11):
mean? Exactly, what symptomsshould parents be noticing in
their babies? Yeah, it's such agreat question. So one of the
things that's tricky in thatoftentimes, when we hear these
symptoms, a baby is drinkingeither breast milk or maybe an
infant formula product, and wemake assumptions if they don't
seem to be tolerating that well,the milk proteins, or some part
(04:32):
of the milk is the problem, butwe don't really know that.
Oftentimes, there are so manyother ingredients in both of
those things that it can be alittle hard to know. I would say
babies that come into the officeand are really fussy, really
miserably uncomfortable, usuallyaround a month or so of age when
this starts, and have blood thatparents can see in the diaper
(04:56):
and maybe really mucus.
Stringy stool. Those areprobably the easiest to say.
This seems like this thingcalled we call it allergic
practically this, or foodprotein induced allergic
practically this. Those areprobably the easiest to feel
confident that we know what'sgoing on, although we can talk
(05:18):
more later about the fact thatwe actually don't understand how
it works. I think the kids thatare harder are the kids that
come in with some less obvioussymptoms. They're a little
fussy, maybe they're spitty orrefluxy. They're really kind of
uncomfortable with feeds. Theydon't sleep well at night, and
very often, we suspect a milkprotein may be causing part of
(05:41):
the problem or something in itsdiet, but we don't really know
that, and it can be quite hardto be sure. So to answer your
question about how commonlywe're seeing this in a large
population that we studied inthe greater Boston area, this
was being diagnosed in 17% ofhealthy children. That's a lot,
and that was when we requiredthat they had some amount of
(06:05):
blood or mucus in their stool.
So that didn't include thatsecond category of kids who
might get this diagnosis. But itmight be less clear. I think
this topic is so it's sointeresting to me, and I'm so
glad that you are trying to getto the bottom of it. No, no pun
intended. Sorry, bad joke. But Iwould say, as a pediatrician,
what I see all the time isparents come in with a fussy
(06:25):
infant, which invariably kidsthat are a month two months old,
they're fussy. They're notsleeping well. Everybody's
tired, and they notice that thestools are on the mucousy side.
There might not be visibleblood, and maybe babies are
spitting up a little bit, whichalso was normal, and then we end
up looking for solutions to helpthe family. So we will check
their stool, and very commonlyI'll notice microscopic amounts
(06:47):
of blood in the stool. Test soit's not visible to my eye or to
their eye, but we test it, wefind microscopic amounts of
blood. And then this is where Istruggle as a pediatrician,
because then we makerecommendations to families that
seem really hard. We're tellingbreastfed moms to take milk out
of their diet, to take nuts outof their diet, to take soy out
of their diet, which is reallyhard for a new mom, or we're
(07:08):
telling them to make formulachanges. And I always question
how much we're really helpingfamilies. You know, we check
back in a week or two weekslater, and sometimes the
fussiness is still there, and soI guess I hope that I'm making
recommendations that are makingthe baby feel better, but I'm
also not certain that we are.
(07:29):
Yeah, I'm so glad you bring thisup. I think this is one of the
hardest parts about managementhere. I think something
important to know is that inother types of diseases, when we
recommend a treatment. Even inpediatrics, someone's done a
study where they took a bunch ofkids with a problem and they
randomized them into kids whoget this, let's say, a medicine,
(07:50):
and kids who don't, and then youreally prove quite rigorously
that the medicine or thetreatment helps. So I think it's
important for everyone to knowthat that's never been done for
this. And so what we're going onis things that collectively,
people feel like might behelping. But the problem is
that, as you mentioned, so manybabies are fussy at this age,
and so often in one month or twomonths, they get less fussy. And
(08:14):
so if we make changes, we oftenattribute those to the changes
we made, both because we wantthat to be true and because that
seems to make sense, but it alsocould be that they would have
gotten better if we just gavethem some more time or some
other types of support. And so Ithink you're right to be
skeptical about how often we'redoing the right thing. I try
really hard to think about thesekids in two really distinct
(08:35):
categories, kids who come to me,who are breastfed, my job as the
pediatrician, I think, is thatif their family is motivated to
continue breastfeeding, I wantto do everything in my power to
make that happen. And so ifgiving mom or the family dietary
restrictions that are going tobe challenging is going to get
in the way of that, I almostnever think that that's the
(08:57):
right thing to do. Formula is alittle different because you're
already on infant formula. I'mnot sure. There's a tremendous
amount of evidence to say that ahypoallergenic formula, meaning
one that the milk protein isbroken down in versus not, are
much worse or less good from agrowth nutrition outcome
standpoint, than a cow with milkbased formula. And so negatives
(09:20):
I notice are the cost. Sometimesit's hard to find and they don't
smell as good. Otherwise thedifference in that
recommendation, I agree, yes,yes, there are some differences
across ingredients that parentsare starting to ask me about.
Those formulas tend to have cornsyrup in them, for example,
maltodextrin, non lactosesugars. We can talk a little bit
about sugars and lactose alittle later on, but and
(09:42):
recognize some of thoseconcerns, but I think that when
I have a breastfeeding parent, Ispend a lot more energy trying
to not disrupt that than I dotrying to think about dietary
elimination that may get in theway of a happy, healthy,
thriving breastfeedingrelationship. Otherwise. Yeah.
Yeah. So I guess I have twoquestions that I want to ask you
(10:03):
about. First is, if we find thatthere's microscopic blood in the
stool, a lot of parents worrythat must mean that there's some
inflammation going on the bodythat can't be good. Is there any
knowledge that we have thathaving a little bit of
microscopic blood can be harmfulto the baby? In other words, if
we let it keep going withmicroscopic blood. Is that a bad
thing? Do we know if that's abad thing? Yeah, thanks so much
(10:26):
for asking this question. Ourstudy where we followed 1000
kids in the greater Boston area.
We're following them for 18years, but they're around 10
now. We took all babies borninto a healthy practice. This is
called the G map study, and thenwe followed the ones that
developed allergic colitis andthe ones that didn't. And
because this question has comeup so much, I went back, and we
(10:46):
decided to pull out of ourfreezer the stool samples we had
collected from babies that hadno symptoms. So never had
parents had any concerns, butfrom that time, like from around
one month of age, and when wetested their stool for blood,
and this is after having been inthe freezer for a while. So this
is probably quite anunderestimate. The rates of
(11:06):
blood in their stools was atleast 10%
so 10% of babies had microscopicblood in the stool, if we
checked when there were noconcerns and there was no reason
to check in a research setting,these results haven't been
published yet, but they'recoming soon. So I can't tell you
where to look yet, but it'scoming soon. It totally makes
sense to me, because we're notchecking every baby, of course,
(11:29):
microscopic bud in the stool, sothere must be babies that have
it that we're not finding outabout, and they're doing right.
And so just like I mentionedabout how there's never been
like a randomized, controlledtrial for the dietary
intervention, there's also neverbeen a validation study to say
that checking stool guacs, whichare those tests for microscopic
blood, are actually helpful inidentifying kids who have
(11:52):
colitis or a milk proteinallergy or problem. You know, I
think that from a logicalperspective, if kids are having
a lot of symptoms, and we'reseeing blood and mucus in their
stool, that's really obvious.
Then you start to imagine, oreven better, if the child has
had a sigmoidoscopy, which weused to do more often years ago,
where you actually could look ina with a camera and take a
(12:13):
biopsy. I think if they reallyhave an inflamed GI tract,
that's important to know, andsomething we probably shouldn't
leave alone. But I'm not surethat microscopic blood testing
tells us that. And so we'reimagining that that may be true,
but I think that the times arechanging a little bit, and how
much we feel confident aboutthat assumption, and just to
(12:34):
help clarify what we're talkingabout when we talk about
allergic procto colitis, or I'mgoing to say AP for short, just
to make it easier on people thatwant to understand the
terminology. Are we talkingabout a milk protein allergy?
Are we talking about a milksugar allergy, like lactose? Are
we talking about generalizedinflammation from milk what is
(12:55):
the body responding tonegatively? We don't know. We
know what it's not. So it's notlactose, in the sense that
sugars don't cause allergies,proteins cause allergies. And so
we know that lactoseintolerance, while that happens
a lot in older kids, like afterkids are three, and then
(13:18):
certainly many grown ups. Itdoesn't happen in little
infants. It almost neverhappened. It would be an
exceptionally, exceptionallyrare genetic disorder, and
that's because lactose is thesugar in breast milk. So we've
all evolved for millennia toinitially be fed milk from our
moms, and that milk doesn't havecow's milk protein in it a lot,
(13:41):
although there are some if thatmom is drinking cow's milk or
eating cow's milk product, butit does have lactose from the
body, and so it would really beevolutionarily unwise for us to
have a lot of people that can'ttolerate lactose, because that's
the first sugar that you getexposed to as an infinite breast
milk. I think that's suchhelpful terminology to explain
(14:03):
the difference in because a lotof people call it a lactose
intolerance, but that's really,as you pointed out, something
that we never see in babiesbecause we need it for survival.
Wouldn't make sense if we werehaving frequent issues with the
sugar in breast milk. So, yeah,interesting distinction. I think
it's made extra complicated byall the marketing that young
parents are exposed to, muchworse than pre social media era,
(14:28):
I have to say. And some of thatmarketing comes from companies
trying to sell products, info,formula, probiotics. We'll get
to lots of those topics, butmany of them talk about things
being lactose, low lactose orlactose reduced, not because we
think medically, or any of themedical staff think that that's
an important feature, butbecause it's such a confused
(14:51):
term, that they decided thatremoving lactose from some
products might help parents feelmore comfortable with the
product.
Yeah, or I also find thatthere's some parents that have
lactose intolerance themselves,so they think, oh, maybe this is
genetic. Maybe my baby also hasthis issue, but it doesn't come
up in babies. It comes up as youget older. I find minimum like
(15:12):
the teenage years is really whenlactose intolerance presents.
Yes, we see it occasionally inschool aged children, but much
more commonly as they get older.
That's right. Okay, so whenwe're talking about infants and
babies, and we're finding thatthey're having some sort of
intolerance, or their GI tractisn't agreeing with milk it is
likely the milk protein, yeah, Imean, certainly for allergies
(15:34):
that are life threatening, it'salways the protein. I think
what's tricky is that thisentire entity we don't really
understand, and that's why ourresearch team has been working
really hard to try to digdeeper, because it's really
common, and yet we really don'tunderstand how it works. So we
think it's probably proteinmediated because other
(15:56):
subsequent food allergies arethe life threatening kind, and
also because we've learned thatthese kids seem to be more
allergic in general, often thekind of kid that might go on to
have asthma or eczema or otherfood allergies later. And so the
idea is that probably it's asimilar mechanism to some of
those other diseases, but thosemechanisms aren't totally
(16:19):
perfectly understood yet. Okay,so in my mind, you've helped me
separating the two groups, thegroup that has the microscopic
blood fussy infant between oneand two months, I'm going to try
my best to reassure familiesthat this is likely something
they're going to outgrow. We'llkeep an eye on it, but if the
child's doing okay, the bestthing might be just to hold off
and not make any changes,especially in a breastfed
(16:42):
mother. But as a pediatrician,what would your advice be to
advise a family where the childis fussy is showing visible
blood in the stool? What shouldwe be advising at that point?
Yeah, that family. So then werecommend milk protein
elimination from the mother'sdiet, because the milk proteins
get transmitted into the breastmilk, and that means that the
(17:02):
mom would read labels and avoidanything that has any type of
milk protein in it. And usuallyit takes somewhere between three
to seven days for those milkproteins to get totally cleared
from the breast milk. It'sprobably within a couple of
days, but we say a couple longerthan that to be sure, and then
it might take a week or two oreven three for the baby's GI
tract, if that's the proteinthey were reacting to, to
(17:24):
actually heal and for thesymptoms in the baby to get
better. So I try not to makemore than one change per month.
So if I make an elimination frommilk, I try really hard to wait
a full month before we decide itdidn't really help, or it made a
really big difference. The nextfood to consider eliminating,
(17:44):
most people think is soy,because soy proteins and milk
proteins look kind of similar toour immune system, and there's a
lot of kids who would beallergic to both, but I don't
recommend starting with both,because, again, in the spirit of
wanting to keep things assupportive as possible. For
breastfeeding moms, I want tomake that diet as easy as
possible. The trick is, let'ssay you do that and everybody
(18:09):
thinks that the baby is muchbetter. One of the mistakes I
think we make is that we thensay, okay, let's do this for a
really long time, becauseeverybody's finally feeling
better, but all of theinternational guidelines tell us
that one month after that, afteryou've had that baby who's
feeling much better, you shouldput the milk protein back into
(18:29):
the mom's diet, or the formula,if this is a formula fed infant,
and prove that the Symptoms allcome back. That's called a
challenge. Surprisingly, I thinkmaybe even less than half of
kids, when you do that, willactually have a real reaction
that second time around. And soit's really important that for
(18:51):
that other half who don't thatwe can make everybody's lives
easier. Mom can go back toeating ice cream, and baby can
go back to being happy but nothaving to be on a restricted
diet. And so we really want torestrict the formal diagnosis to
kids who react to thatchallenge, and then those kids
are meant to avoid that allergenfor a bit longer. It's a little
debated, but maybe three, six oreven nine months. And then is
(19:14):
there a certain point in timewhen you notice that most kids
outgrow this allergic protocolitis or AP. So nobody's done
this in a systematic way, right?
So we've never had a study wherethey said, Okay, we're giving
you it now. Now we're giving itto you, and we're gonna see that
earliest moment that you'reready. So we've been walking
back when we've been introducingand I would say there was one
(19:37):
paper pretty recently that foundthat even as early as three
months after the diagnosis wasmade, children were already
ready to tolerate the allergenor the antigen again, so already
ready to tolerate the milk thatit seemed they weren't
tolerating three months before,I find this information so
helpful, because, as you pointedout, it's a difficult challenge
(19:58):
for mothers.
Have to take out dairy fromtheir diet. I have so many moms
that they're struggling as itis, having a newborn, and then
when our advice is to take outtheir favorite dessert or take
out their daily cappuccino thatthey look forward to, it's hard,
and it makes what's already hardeven harder. And so I'm so
(20:19):
grateful that you've taught meto try to reintroduce milk a
month later, because I thinkthat's doable. I feel like for
somebody mentally to know, okay,in a month I can retry this, and
there's a better than halfchance that it's gonna be okay
when we reintroduce it. Becausebefore I heard this advice from
you, I was waiting, honestly,until about six months to tell
moms to reintroduce the milk.
Yeah, many people were waitingnine or 12 months, which is what
(20:42):
the guidelines say, if you didthe challenge, and they reacted
to the challenge. And I thinkthat if is the part that many of
us kind of missed or have had ahard time implementing, but is
super, super important, and I'vebeen doing this now for some
time in my clinic, these babiescome to see me very often, and
I'm often surprised by the kidthat I was sure so clearly
(21:04):
responded to milk eliminationjust a month ago. Don't seem to
care when we put it back in. AndI don't think that means we were
wrong the first time. I thinkit's really possible that
there's a rebalancing of the GItract, of the microbes that live
there, of the health of thebarrier, such that one month
later, they're better. And so Idon't think if the challenge is
(21:30):
negative, so to speak, that wewere wrong, I think more often,
and maybe it just means thatit's over already. Just to be
clear, what would the symptomsbe that we should be concerned
about when the milk is reintroreintroduced, because babies, in
general, have some time thatthey're fussy. So what would a
failed challenge actually looklike? Yeah, I think it would
mean certainly if there's, youknow, a diaper full of blood and
(21:51):
mucus, those are helpful andobvious, but also pretty rare. I
think a baby that goes frombeing content to miserable,
really difficult to settle,difficult to put down with
sleeping through the night andisn't sleeping at all, is
vomiting a lot, is taking lessvolumes of their breast milk or
formula, or isn't gaining weightas well. Those would all be
(22:12):
symptoms that would at leastmake me think about it. But
you're right. Sometimes kids arealso teething or also having a
sleep regression, and so I trynot to rely on any one symptom
to make this decision, but moreof a global assessment of how
we're doing. What I also reallyappreciate about your
recommendation is that I findonce we notice microscopic blood
in the stool, a lot of theadvice has been so restrictive
(22:36):
for moms to take out so manyproteins out of their diet that
they end up giving up onbreastfeeding altogether because
it's just so challenging. Sothis is really refreshing advice
to me, because I think whateverwe can do to support moms more
to be successful breastfeeders,I think is a great path forward.
Yeah, and I think that, youknow, we're still working really
hard to understand themechanism, but we have lots of
(22:58):
promising data suggesting thatsome of this really has to do
with the microbes that live inbaby's gi tracts, and we know
that the healthiest way to setup a healthy microbiome in a
baby's GI tract is breast milk.
So it hurts my heart a lot whenI meet patients who come to me
and have already given up onbreastfeeding because the diet
(23:18):
they were put on was too hardand now we're on formula. That's
the right choice for somepeople, probably for quite a
small minority, but I never wantthat to be the goal standard.
And I had one patient with ababy who was quite sick, so
really, clearly had colitis.
Actually had a colonoscopy,because there was so much blood,
we were trying to figure outwhere it was coming from, and it
(23:39):
was this allergic disease, buther mom was really motivated to
breastfeed, and so we had done areally complex diet. Mom was
great about doing it. Baby stillwasn't getting better. And so
mom took a break and just pumpedfor one month while we did an
elemental hypoallergenicformula. And one month later,
when we gave that breast milkback, it was completely healed,
(24:01):
and that baby did awesome forthe rest of infancy. And so even
in that super severe case, webriefly interrupted
breastfeeding, but we didn'tdisrupt the relationship, and
that baby got six more months ofbreast milk after that. And so I
think even in the most severecases, there's a lot of
opportunity to continuebreastfeeding if moms want that,
and babies want that too, andI'm assuming from what you're
(24:22):
saying, if the baby was able tohandle breast milk a month
later, were they also able tohandle the stored breast milk?
In other words, I think a lot ofmoms think that stored breast
milk that's been put in thefreezer, all that hard work,
then has to be thrown away. Butcan they use it? Is it usable?
Yes, as a mom who reallystruggled with every single
ounce that made it to myfreezer, those stories also hurt
(24:44):
my heart. That milk is almostalways usable, and so it's one
of the first questions on myintake. When I meet parents of
new babies like this, is to savethat milk, label it well, so
label what you remember yourdiet was or wasn't at the time
that you pumped.
It, but it's actually reallyawesome for introduction or for
a challenge, for example, if youwanted to expose the baby to
(25:07):
breast milk that had milk in it,but you didn't want the effects
of that to last a week or two,you could use frozen milk for a
challenge, for example, and thenonly open up mom's diet to new
foods if that went well. Andsimilarly, even if kids react a
lot in a month, sometimes threemonths from now, that milk is
perfect for them, so it is veryrare. In fact, I don't think
(25:29):
I've ever told a mom that hermilk should be donated or given
away. We've almost always foundgood ways to use it. Ultimately,
wonderful. Now, what if there'sa situation where a family feels
hesitant to do a challenge in amonth. Is there any harm in
waiting three, six months beforethey reintroduce milk into the
diet? What is the benefit ofdoing a challenge a month later?
(25:51):
I think the first benefit ofdoing the challenge is that it
makes moms do the diet for lesslong as they can, right? So I
think that's the number onethat, like you said, it's an
achievable goal, something wecan do, but not necessarily,
really prolonged. We know thatearly introduction and exposure
to allergen to babies directlyonce they get a bit older, 4567,
(26:15):
months, helps prevent foodallergies. So there was that big
study called the LEAP study,about 10 years ago now, that
really changed everybody'sunderstanding of how food
allergies happen, and made usrealize that introducing peanut
in the case of that study, in asafe way for babies, starting at
four months, for babies who areat risk, prevented peanut
(26:36):
allergy develop in a lot ofthose kids, we don't have the
same information to say thatthat's true in breast milk,
another word moms who eatpeanuts versus don't eat peanut
and have peanut in their breastmilk, it doesn't have the same
protective effect, although youcan imagine those are a little
harder to control, because momswho are avoiding peanut might be
avoiding peanut because they'reallergic and then that has
(26:58):
genetic complexity as well. Sothe short answer is, I don't
think there's a big risk towaiting two months or three
months for a challenge in a onemonth old. Let's say if that
feels more comfortable to afamily, as long as it's not
leading to ending abreastfeeding relationship. But
I do think that once kids areold enough to tolerate foods
(27:19):
like starting to think aboutsolids, it's a good time to
start talking about thoseallergens. And that could start
with other allergens like peanutand egg, but then maybe should
also include something likeyogurt that has milk protein.
Yeah, I think this is a greatpoint to make, that the earlier
our immune system is exposed toa variety of foods, things in
the environment, the moretolerant we become. And so I
(27:41):
think it's an easy temptationfor us to just want to avoid all
of the foods that maypotentially be bothering our
children, but it actuallybehooves the child to be exposed
early and often if they tolerateit, because we can avoid
allergies potentially in thefuture. Yes, and there's been
this term for a long time, theallergic or the atopic March,
(28:02):
and we've known for a while thatdiseases like eczema of the skin
that show up very early might beone of the first signs of an
allergic kid, and then canprogress later by a couple of
different mechanisms tosubsequent allergies like food
allergy and asthma. We havegrowing data, and there's a fair
number of papers after ourssaying that we think this
(28:26):
allergic procto colitis mightactually be the first step on
that atopic or allergic march.
And so I think it's anespecially important population
for us to be thoughtful about,because the elite study where
they introduced peanut early onwas in kids who had moderate to
severe eczema and a few othercriteria for enrollment, because
that was their risk factor. ButI suspect that these babies that
(28:49):
have this allergic proctocolitis early in life are
similarly at risk, and yet,before we were having them,
avoid a lot of things for a longtime. And I also think we sort
of maybe inadvertently,historically made parents worry
about foods, and so they wereprobably later to introduce
other foods. And this baby thatthey had eliminated milk from,
(29:11):
and I think probably the reverseis true, that these kids, we
should be paying extra attentionto making sure they get peanut
for example, even if we haven'tdone the challenge for milk yet,
or even if we don't feel readyto proceed on the milk or soy
train, I would say peanut or eggor these other known allergens
should probably be happeningearly, like kids with moderate
to severe eczema. I think thisis a great point to make,
(29:33):
because I think if a parent seesa child react in their infant's
early life to milk, we can makethe assumption that, oh, this is
best to avoid for a long periodof time, but the opposite is
actually true. We want to thinkabout reintroducing it as soon
as possible to potentially avoidlifelong allergies. And I know
we don't have something like theLEAP trial for milk, but I have
read studies where kids that dohave milk allergies if we expose
(29:57):
them.
Or to milk in different forms.
You know, in baked forms, theyactually can outgrow the milk
allergy sooner than if theyweren't exposed. Yeah. I mean,
we certainly don't recommendexposure in someone who's had
anaphylaxis, right? So if you'vebeen diagnosed with a milk
allergy and you went to theemergency room and got an
EpiPen, then we don't doexposure until your blood tests
(30:17):
and skin tests might tell youthat you're ready, but there's
conflicting data about how earlythe exposure to cows milk
protein and in what form may ormay not help prevent IGE
mediated milk allergy later.
It's interesting, right? Becausewe're the only mammal that
consumes milk from another one,right? And so there are a lot of
(30:41):
really interesting evolutionarydiscussions around whether we
should be drinking any cow'smilk or anybody else's milk, but
human milk. I think that thatcan be a nutritional decision
and a family decision and acultural decision, but it makes
sense that we may have a littlebit of a harder time getting
used to or tolerating cow's milksometimes, and so I don't think
(31:02):
it's the only show in town,particularly as kids get older,
if it's something that folksaren't tolerating. Well, in your
opinion, is it your sense thatthe allergic proctor colitis is
increasing overall, or do youthink we're just diagnosing it
more? Yeah, this is really hard.
I would say both. I think thatwe're paying attention to it
more. I think people are lookingat it more. I think people are
(31:23):
testing more stools than theyused to, and parents are asking
more questions about that. Andso I think we're probably
noticing it or diagnosing itmore, and I think it's also
happening more, and that wouldbe consistent with every other
allergic disease on the map.
Right in parts of the worldwhere we have rising rates of
(31:44):
allergy, we have high risingrates of lots of allergic
conditions, IGE mediated foodallergy in particular. So just
to make sure I understand yourthoughts on this, if a family
comes in with a child who isslightly on the fussier side,
has some microscopic milk in thestool, your advice would be to
make changes as slowly aspossible. Is that what I'm
understanding? Yes, yes. I thinkmy advice is to make changes
(32:09):
slowly and to have our opinionof those changes and how they're
working be based on how the babyseems, and not focused on
whether or not there's amicroscopic test showing blood
in the stool. I really wouldfollow lots of mucus, lots of
diarrhea, obvious blood weight,faltering, feeding challenges,
symptoms like that. But in achild who's sort of a little bit
(32:29):
fussy but generally thriving anddoing well, I often think we can
do nothing and watch and seewhat happens. And I think that
if those kids aren't going totolerate milk protein, they'll
let you know they will getworse, they will get more
uncomfortable. And I'm notsaying that we want that, but I
think making sure we know thatwe're dealing with something
pathologic that needs to beaddressed is important too. Now,
(32:51):
you mentioned that we're theonly species that consumes
another animal's milk, so Inotice a lot of growing interest
in my families, in being vegan.
From your perspective, is thereany harm in babies avoiding milk
altogether? Babies under 12months need certain nutritional
factors. Those can come frommilk, which, of course, then
wouldn't necessarily have cow'smilk if mom was vegan. So that
(33:13):
would be totally fine. There area few formulas that aren't cow
milk based, that are availablein the United States and meet
all the nutritional criteria.
And so I would say those aresafe. The FDA reviewed all of
those to make sure that theyhave the micronutrients that
kids need once we get into likeover one then kids don't need
(33:36):
milk at all of any kind, butmany rely on it for really
important nutritional aspects oftheir diet, fat content, protein
content, calcium, vitamin D. Andso I would say that anybody
who's going to be on arestricted diet for any reason,
allergies, preference, culture,it makes good sense to see their
pediatrician and maybe anutritionist to make sure that
(33:59):
they're ticking those boxes andthat they don't need a
multivitamin to get enoughcalcium or making sure that
they're getting vitamin Dsometimes in kids who are
slightly pickier ways to makesure they're getting protein and
fat in the right proportions,which some kids rely on cow's
milk for. So yeah, there's noreason we have to have cow's
milk in our life, but we do haveto meet our nutritional needs,
(34:20):
and so sometimes we need helpmaking sure our kids are doing
that. As you mentioned, thereare some nutritional benefits
from milk, but all of thosenutritional benefits we can get
from other foods, right? Likevitamin D, there's not a ton
from milk, it's mostly sun. Ilive in Southern California, so
it's easy for me to say, but Iknow it's added into milk.
There's protein. We can getprotein from other sources.
There's vitamin A, we can getthat from fruits and vegetables.
(34:42):
There's calcium, which we canalso get from beans and
broccoli, and there's other milkvariants out there. But the
thing that I get concerned aboutis I don't want to induce a
lactose intolerance in a child,and let me know if this is an
incorrect assumption. But.
I worry that a kid could grow upto be in their elementary school
(35:04):
years, go to a birthday party,try a pizza for the first time,
and have a difficult timedigesting it, and then they're
that kid that can't eat like allthe other kids, and so I don't
want to impose an issue on a kidthat we might be able to
prevent. Yeah, I don't know ifthere's literature about the
long periods of avoidance andinduction of lactose intolerance
(35:24):
in particular. So that's a coolquestion. I haven't thought
about that exact question, but Ithink that in general, my advice
for most things is moderation.
So at least in my house, my kidshave cows milk. Sometimes,
sometimes they'll ask for aglass of milk. We certainly have
a lot of Italian blood, sothere's a lot of cheese and
everything. And I think that'sprobably some amount of exposure
(35:47):
over time may help kids be ableto tolerate that, like you said
at a birthday party or somethinglike that. But to your point,
there are certainly kids who canlive long, happy, healthy lives
without cow's milk, or evenwithout a replacement, as long
as they meet their other needs.
And so I try to support familiesin that if that's what their
preference is, yeah. I also haveto say I do have plenty of vegan
(36:10):
families that are in mypractice, and their kids are
definitely thriving withouthaving any cow's milk. So I see
it working in all ways, and aslong as you're paying attention
to getting a nice variety ofnutrition in the diet, yeah, and
I think in the US, I see a lotof kids who are relying too
heavily on cow's milk, andthat's getting in the way of
their ability to learn to enjoya whole range of really
(36:31):
important other food. So I thinkvariety and exposure and
building flexibility. You know,we have some oat milk, we have
some almond milk, and I lovethat our kid can take and
appreciate all of them, and I dothink that allows them to be at
someone else's house who hassome other kind of milk and not
have that be derailing for themsocially or otherwise. So I
think that that's really wise.
It is true that there are somekids out there that love their
(36:52):
milk, and I do think if you fillup too much on milk, it can curb
your appetite for showing aninterest in other healthy foods
for the diet. So that's a goodpoint to make. Yeah. So now to
circle back, we had touched onlactose intolerance earlier,
which is different from the milkprotein intolerance. This is the
intolerance of the actual sugarin milk. Can we talk more about
(37:13):
that? When does that usuallyshow up? And how do you advise
parents who have kids that areintolerant of the milk sugar,
the lactose. Yeah, so lactose isthe sugar in milk and in usually
broken down by specific bacteriathat are in the GI tract. And
when that's not workingcorrectly, then you can become
(37:34):
lactose intolerant, meaning thatsome amount of that sugar then
really bothers you thatpresents, usually with really
loose diarrheal stools aftereating lactose bloating or
discomfort. So usually,classically, kids will tell me
that they really like ice cream,but they've noticed that when
they have that bowl of icecream, they have to run to the
bathroom afterwards, and theirstomach feels pretty
(37:56):
uncomfortable, and often they'llhave an explosive diarrheal
stool after that, you can testfor lactose intolerance by doing
a breath test. So this is kindof a cool test you can do in the
office, usually a GI office,where you breathe into a bag,
and we can measure the hydrogencoming out of your exhaled
breath, whether you have enoughlactase, the enzyme to break
down lactose, and whether that'sbeing broken down correctly. Is
(38:16):
that a pretty accurate test? Andis it pretty easy to come in?
It's pretty accurate and it'seasy to come by. It's not in
every lab or in every primarycare office, but most sort of
hospital based groups, and Isuspect many outpatient groups
have it too. Actually, duringcovid, they developed the
ability to send it to people'shomes as like a kit, and so
(38:37):
parents can even have it sent totheir home if their insurance
covers that, which is prettyneat. So this often present in
teenage years, like youmentioned, or sometimes, I mean,
very often presents in olderadults. But we're focusing on
kids here today, some kids findthat they have a particular
amount of lactose they cantolerate. So, you know, some
people can tell me that they canhave like, a quarter inch of
(38:59):
cream cheese on their bagel, butnot like a full inch of cream
cheese on their bagel beforethey have symptoms, and some
people really just can'ttolerate any at all. Yeah, I
definitely find that some peoplecan have some yogurt or some
aged cheeses, but if you givethem a full glass of milk,
forget about it. They're reallyuncomfortable, exactly. Yeah,
this can also be a temporaryphenomenon. It's worth noting
(39:21):
when kids have a viral illnessor an infectious illness. So if
you have that terrible stomachbug that goes through your
school and then you notice thata week or two later, your kid's
having a really hard time,sometimes that's what's called
transient lactose intolerance.
It's a post viral process orpost infectious process, and
that just means that thosebacteria that are supposed to be
(39:41):
doing that job got wiped out bythat other illness, and they
need a little chance to recover.
And so sometimes avoidinglactose for a week or two or
three in that post infectiousperiod, and then slowly
reintroducing it can help.
That's a really helpfulreminder, because that's
definitely something that I seea lot with families. And so
great to know that that's notgoing to be.
Forever? Yeah, usually not. Soin general, as you go through
(40:04):
your research as a GI doctorwho's focusing on milk protein
intolerance, is there somethingthat you wish pediatricians or
parents had a betterunderstanding about cow's milk
in general, I think the biggestthing that I wish is that we all
do everything in our power tohelp new families survive what
(40:25):
is a really hard time, which ishaving a new baby in the house.
And I think I didn't fullyappreciate it, to be honest,
despite impeccable pediatricstraining, until I had my own
little ones, some of which weremore difficult than others in
those early phases. And so Ithink first and foremost,
though, of course, it's what weall mean to do, making sure that
(40:45):
we're really understanding whatparents are worried about. And I
think milk protein might bescapegoated more often than is
fair. And I think that in aneffort to do everything we can
to be helpful, sometimes we dotoo much, changing, changing
formula, changing diet, givingmore things to do when really, I
think sometimes we needreassurance that babies are
super fussy, sometimes,sometimes for a while, and that
(41:08):
can be okay. And so I thinktalking to your pediatrician,
trusting your pediatrician,sometimes seeing them, often, if
that's what you need to feellike you're on the right track
over ending a breastfeedingrelationship, or feeling really
alienated or really strugglingwith feeding, would be my
biggest wishes. Thank you somuch for that. I think that is a
(41:30):
reoccurring issue that comes up,not just with milk protein, but
I also find with things like thetongue tie procedure or putting
a child on reflux medications, Ifeel like a lot of times with
fussy babies, we want to dosomething. We want to fix it. We
want to fix the problem fast.
And oftentimes, I find the mosthelpful solution is just being a
(41:51):
support system for the family,really reassuring them that
their kid is healthy and normaland that it's going to get
better over time. We just needto get through it, day by day,
nap by nap, and sometimes doingless ends up being better for
the child and the family. Yeah,and, you know, one of the things
I hear a lot in my office that Itry to reframe for families is
(42:11):
that sometimes I hear parentstell me, I'm here to see you
become my pediatrician blew meoff or didn't share my concerns.
Pediatricians are incrediblehuman beings who are also being
asked to do a lot more than ishumanly possible in the 15 to 20
minutes that we're allowed tospend with our patients
sometimes, right? And so one ofthe things that I think is
(42:32):
really helpful to arm parentswith is this question, can you
help me understand why you'rereassured, or why you're not
worried, because we have thiswhole list in our brain from all
the textbooks we memorized wayback when and everything we've
learned since that allow us tofeel confident that this isn't
something that is gonna makeyour kid allergic forever. This
(42:53):
isn't something big or bad orscary, and yet, I'm not sure we
always articulate all of thosethings. And so I think sometimes
one advice, a piece I would giveis to when you're feeling like
your pediatrician is telling youthat you probably don't need to
change anything. That doesn'tmean they don't hear you and
they don't see you. It meansthat they've laid all the
(43:14):
options and think that thesafest, best option is to what
we call watchfully wait. And ifthat feels unsatisfying, I think
asking questions about why thatis or why they feel that way
sometimes can be clarifying forparents, to know that it's not
just that we don't believe youthat your baby is fussy, it's
that we want to do no harm,which is what we're supposed to
(43:34):
do absolutely. And that's not tosay that sometimes intervening
isn't the better option for thechild and for the family, but I
do think the beauty of having apediatrician is that you can see
them next week, you can followup into skin and not acting
right away. Doesn't mean we'renot going to do something at
some point, but we have theluxury of having a relationship
(43:55):
and checking in on you later,and that's a very, very
important tool that I wouldn'tforget about, for pediatricians
and for families, yeah, and Ithink sometimes maybe people
feel like we're kicking the candown the road. And I think
rather, we're using time andobservation. And that's why in
medicine, it's called watchfulwaiting, right? Because we know
that many things get better ontheir own with time, with far
(44:15):
less risk than whatever we mighthave intervened with. And so
waiting and seeing where we area week from now and two weeks
from now can often be reallyilluminating, and sometimes kids
are much worse, and then we knowthat it's time to act. And
that's really helpfulinformation. And there's nothing
to say that waiting a week ortwo with a diagnosis like this,
reflux, milk protein, allergy,allergic colitis, puts kids in
(44:39):
any worse a position, and inmany ways, that might allow the
problem to go away on its own.
Thank you. So okay, as we finishup, I just thought I would fire
off if you're okay with this, ifyou milk myths that I'd like you
to either tell me true false, ormaybe it depends. Is that okay
with you? Yep.
(45:00):
All right, so the first one, ifa baby is fussy, it's probably a
milk allergy, true, false, or itdepends. I would say either
false or it depends. I think itdefinitely depends, and more
often than not, it's probablynot okay. Lactose Intolerance is
that common in toddlers? Nofalse goat milk? Is that a safe
alternative to cow's milk forinfants, I would say false, or
(45:23):
it depends. So neither goat'smilk nor cow's milk are safe for
infant if they're not in aninfant formula preparation. But
if we're talking about aninfant's formula, there is one
now, FDA approved goat's milkbased infant formula on the
market, and I would say thatthat is safe. Is that? Kabrita?
Yes. All right, here's a bigone. Kids need milk to grow
(45:44):
properly, true, false, false,false. We chatted about this a
lot, but I think there are lotsof other ways to get whatever
you might get from milk, but ifyou need help with that, a
nutritionist or yourpediatrician can help. Just
thought, yeah, why not reinforcethat one more time? All right,
if a kid avoids milk, they willmost likely become calcium
(46:04):
deficient, a false or itdepends, it depends on what else
they're eating, right? So Iactually have the calcium
requirement chart posted insidemy pantry closet, because I find
it really helpful to remindourselves. I think we sort of
rely on calcium being in milkfor a lot of kids in the US in
particular. And though knowingwhat those amounts are and what
(46:25):
other foods you can find them into make sure you get your
appropriate amount of calcium isimportant. It is a significant
amount, so you do have to putsome thought into making sure
you're getting that calcium fromother places, in my experience.
But it can be done, for sure. Itcan be done. My kids are doing
it. I have to say, I rarely seea kid that's calcium deficient.
Maybe I just don't know aboutit. But really, yeah, I think
(46:46):
that we probably worry about itmore than it turns into to a
real bone health problem. Ithink it's one of those things,
though, that you're building upover time, and you might not see
those deficiency problems untillater in life. And we'd love to
set people not up for that, forthat bone fracture or other
thing that gives us that cluelater, absolutely Well, Dr
Martin, I've so enjoyed talkingto you this information I think
(47:08):
will be so helpful for many ofmy listeners, and honestly and
for myself as I continue being apediatrician and guiding
families that I meet. So thankyou so much. Thank you so much.
It was such a pleasure. I lovebeing here. Thank
you so much for listening toyour child as normal. I'm so
grateful you're here and part ofthis community. If you're
enjoying this podcast, it wouldmean the world if you shared an
(47:29):
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don't forget to follow me onInstagram at ask Dr Jessica for
more parenting tips and updates.
See you next Monday. You.
Hello listeners. This is Dr Jessica Hochman. I'm
(00:02):
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If you have a product, serviceor a message that you think our
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sponsor an episode, and I'll letyou know for a good match and
get back to you. Hieveryone, and welcome back to
(00:31):
your child is normal. I'm yourhost. Dr Jessica Hochman, so
today we're tackling a situationthat actually comes up all the
time in pediatrics, milkintolerance in babies. My guest
is Dr Victoria Martin, and she'san Assistant Professor of
Pediatrics at Harvard MedicalSchool and the Associate Program
Director of the pediatric gifellowship at Massachusetts
General Hospital for Children.
(00:53):
In this conversation, we diginto food protein induced,
allergic proctor colitis andcow's milk protein intolerance,
a condition that I realize maynot sound familiar, but it is
surprisingly common in one largeBoston Area study, for example,
about 17% of otherwise healthyinfants were given this
diagnosis when blood or mucuswas found in a stool. We'll talk
about why these diagnoses aretricky and how we can best
(01:15):
support babies and familiesthrough them. So whether you're
a pediatrician or a parent, thisepisode will offer clear,
compassionate and practicalguidance. Dr Martin, I'm so
grateful that you came here onthe podcast and to everyone
listening. Thank you so much forspending part of your day here
on your child is normal. I wantto take a moment to tell you
about tiny health. Tiny healthis the first and only at home
(01:36):
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everyone's microbiome is unique,so without testing, it's nearly
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that's where tiny health comesin their Easy at Home test gives
you a clear snapshot of yourchild's gut microbiome, and
(01:57):
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The results help you knowexactly what supports may be
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Dr Jessica, D, R, J, E, S, S, I,C, A for an exclusive discount.
Dr Martin, thank you so much forbeing here on the podcast. I'm
(02:18):
really looking forward to thisconversation. Thanks so much for
having me. I have to tell you Iheard you on another podcast
vowel sounds, and oftentimes Ilisten to podcasts that
reinforce what I'm thinking, oryou might learn some new ideas,
but your podcast actuallychanged the way I practice
medicine today, and I'm soappreciative of the work that
you're doing. Oh, thank you somuch. I love hearing that people
(02:41):
are finding it helpful. Sofirst, tell everybody a little
bit about yourself. What kind ofresearch do you do, and what
kind of a doctor are you sure?
Yeah, so I'm a pediatricgastroenterologist out of Mass
General Hospital for Children inBoston, and I became really
interested in understanding theearliest places in our body,
that food and antigen, which arethings that can cause allergy
(03:05):
and microbe like the bacteria,all live and interact very early
on in the infant GI tract, andhow that might set us up for
various types of health anddisease as we get older. And so
that's predominantly what I'vebeen studying. What a relevant
topic I do. Think there's a lotthat we want to know and
understand about the gutmicrobiome, and we also know
(03:28):
that we're seeing an increase inGI issues like intolerances to
various foods. We're seeing alot of eczema on the rise, and
we're trying to figure out howit all ties in. And I think
there's a lot of help that weneed in that area of research. I
agree. Thanks. So what I'mlooking forward to talking with
you about today is, as a generalpediatrician, I find that a lot
of parents have questions whenit comes to milk and how the
(03:51):
body tolerates milk in general.
So first, I wanted to talk toyou about a very common scenario
that comes up with babies in mypractice, and that is finding
out that babies may haveintolerances to milk. So can you
tell me a little bit about this?
How common is a milk intoleranceto a baby? And what does that
(04:11):
mean? Exactly, what symptomsshould parents be noticing in
their babies? Yeah, it's such agreat question. So one of the
things that's tricky in thatoftentimes, when we hear these
symptoms, a baby is drinkingeither breast milk or maybe an
infant formula product, and wemake assumptions if they don't
seem to be tolerating that well,the milk proteins, or some part
(04:32):
of the milk is the problem, butwe don't really know that.
Oftentimes, there are so manyother ingredients in both of
those things that it can be alittle hard to know. I would say
babies that come into the officeand are really fussy, really
miserably uncomfortable, usuallyaround a month or so of age when
this starts, and have blood thatparents can see in the diaper
(04:56):
and maybe really mucus.
Stringy stool. Those areprobably the easiest to say.
This seems like this thingcalled we call it allergic
practically this, or foodprotein induced allergic
practically this. Those areprobably the easiest to feel
confident that we know what'sgoing on, although we can talk
(05:18):
more later about the fact thatwe actually don't understand how
it works. I think the kids thatare harder are the kids that
come in with some less obvioussymptoms. They're a little
fussy, maybe they're spitty orrefluxy. They're really kind of
uncomfortable with feeds. Theydon't sleep well at night, and
very often, we suspect a milkprotein may be causing part of
(05:41):
the problem or something in itsdiet, but we don't really know
that, and it can be quite hardto be sure. So to answer your
question about how commonlywe're seeing this in a large
population that we studied inthe greater Boston area, this
was being diagnosed in 17% ofhealthy children. That's a lot,
and that was when we requiredthat they had some amount of
(06:05):
blood or mucus in their stool.
So that didn't include thatsecond category of kids who
might get this diagnosis. But itmight be less clear. I think
this topic is so it's sointeresting to me, and I'm so
glad that you are trying to getto the bottom of it. No, no pun
intended. Sorry, bad joke. But Iwould say, as a pediatrician,
what I see all the time isparents come in with a fussy
(06:25):
infant, which invariably kidsthat are a month two months old,
they're fussy. They're notsleeping well. Everybody's
tired, and they notice that thestools are on the mucousy side.
There might not be visibleblood, and maybe babies are
spitting up a little bit, whichalso was normal, and then we end
up looking for solutions to helpthe family. So we will check
their stool, and very commonlyI'll notice microscopic amounts
(06:47):
of blood in the stool. Test soit's not visible to my eye or to
their eye, but we test it, wefind microscopic amounts of
blood. And then this is where Istruggle as a pediatrician,
because then we makerecommendations to families that
seem really hard. We're tellingbreastfed moms to take milk out
of their diet, to take nuts outof their diet, to take soy out
of their diet, which is reallyhard for a new mom, or we're
(07:08):
telling them to make formulachanges. And I always question
how much we're really helpingfamilies. You know, we check
back in a week or two weekslater, and sometimes the
fussiness is still there, and soI guess I hope that I'm making
recommendations that are makingthe baby feel better, but I'm
also not certain that we are.
(07:29):
Yeah, I'm so glad you bring thisup. I think this is one of the
hardest parts about managementhere. I think something
important to know is that inother types of diseases, when we
recommend a treatment. Even inpediatrics, someone's done a
study where they took a bunch ofkids with a problem and they
randomized them into kids whoget this, let's say, a medicine,
(07:50):
and kids who don't, and then youreally prove quite rigorously
that the medicine or thetreatment helps. So I think it's
important for everyone to knowthat that's never been done for
this. And so what we're going onis things that collectively,
people feel like might behelping. But the problem is
that, as you mentioned, so manybabies are fussy at this age,
and so often in one month or twomonths, they get less fussy. And
(08:14):
so if we make changes, we oftenattribute those to the changes
we made, both because we wantthat to be true and because that
seems to make sense, but it alsocould be that they would have
gotten better if we just gavethem some more time or some
other types of support. And so Ithink you're right to be
skeptical about how often we'redoing the right thing. I try
really hard to think about thesekids in two really distinct
(08:35):
categories, kids who come to me,who are breastfed, my job as the
pediatrician, I think, is thatif their family is motivated to
continue breastfeeding, I wantto do everything in my power to
make that happen. And so ifgiving mom or the family dietary
restrictions that are going tobe challenging is going to get
in the way of that, I almostnever think that that's the
(08:57):
right thing to do. Formula is alittle different because you're
already on infant formula. I'mnot sure. There's a tremendous
amount of evidence to say that ahypoallergenic formula, meaning
one that the milk protein isbroken down in versus not, are
much worse or less good from agrowth nutrition outcome
standpoint, than a cow with milkbased formula. And so negatives
(09:20):
I notice are the cost. Sometimesit's hard to find and they don't
smell as good. Otherwise thedifference in that
recommendation, I agree, yes,yes, there are some differences
across ingredients that parentsare starting to ask me about.
Those formulas tend to have cornsyrup in them, for example,
maltodextrin, non lactosesugars. We can talk a little bit
about sugars and lactose alittle later on, but and
(09:42):
recognize some of thoseconcerns, but I think that when
I have a breastfeeding parent, Ispend a lot more energy trying
to not disrupt that than I dotrying to think about dietary
elimination that may get in theway of a happy, healthy,
thriving breastfeedingrelationship. Otherwise. Yeah.
Yeah. So I guess I have twoquestions that I want to ask you
(10:03):
about. First is, if we find thatthere's microscopic blood in the
stool, a lot of parents worrythat must mean that there's some
inflammation going on the bodythat can't be good. Is there any
knowledge that we have thathaving a little bit of
microscopic blood can be harmfulto the baby? In other words, if
we let it keep going withmicroscopic blood. Is that a bad
thing? Do we know if that's abad thing? Yeah, thanks so much
(10:26):
for asking this question. Ourstudy where we followed 1000
kids in the greater Boston area.
We're following them for 18years, but they're around 10
now. We took all babies borninto a healthy practice. This is
called the G map study, and thenwe followed the ones that
developed allergic colitis andthe ones that didn't. And
because this question has comeup so much, I went back, and we
(10:46):
decided to pull out of ourfreezer the stool samples we had
collected from babies that hadno symptoms. So never had
parents had any concerns, butfrom that time, like from around
one month of age, and when wetested their stool for blood,
and this is after having been inthe freezer for a while. So this
is probably quite anunderestimate. The rates of
(11:06):
blood in their stools was atleast 10%
so 10% of babies had microscopicblood in the stool, if we
checked when there were noconcerns and there was no reason
to check in a research setting,these results haven't been
published yet, but they'recoming soon. So I can't tell you
where to look yet, but it'scoming soon. It totally makes
sense to me, because we're notchecking every baby, of course,
(11:29):
microscopic bud in the stool, sothere must be babies that have
it that we're not finding outabout, and they're doing right.
And so just like I mentionedabout how there's never been
like a randomized, controlledtrial for the dietary
intervention, there's also neverbeen a validation study to say
that checking stool guacs, whichare those tests for microscopic
blood, are actually helpful inidentifying kids who have
(11:52):
colitis or a milk proteinallergy or problem. You know, I
think that from a logicalperspective, if kids are having
a lot of symptoms, and we'reseeing blood and mucus in their
stool, that's really obvious.
Then you start to imagine, oreven better, if the child has
had a sigmoidoscopy, which weused to do more often years ago,
where you actually could look ina with a camera and take a
(12:13):
biopsy. I think if they reallyhave an inflamed GI tract,
that's important to know, andsomething we probably shouldn't
leave alone. But I'm not surethat microscopic blood testing
tells us that. And so we'reimagining that that may be true,
but I think that the times arechanging a little bit, and how
much we feel confident aboutthat assumption, and just to
(12:34):
help clarify what we're talkingabout when we talk about
allergic procto colitis, or I'mgoing to say AP for short, just
to make it easier on people thatwant to understand the
terminology. Are we talkingabout a milk protein allergy?
Are we talking about a milksugar allergy, like lactose? Are
we talking about generalizedinflammation from milk what is
(12:55):
the body responding tonegatively? We don't know. We
know what it's not. So it's notlactose, in the sense that
sugars don't cause allergies,proteins cause allergies. And so
we know that lactoseintolerance, while that happens
a lot in older kids, like afterkids are three, and then
(13:18):
certainly many grown ups. Itdoesn't happen in little
infants. It almost neverhappened. It would be an
exceptionally, exceptionallyrare genetic disorder, and
that's because lactose is thesugar in breast milk. So we've
all evolved for millennia toinitially be fed milk from our
moms, and that milk doesn't havecow's milk protein in it a lot,
(13:41):
although there are some if thatmom is drinking cow's milk or
eating cow's milk product, butit does have lactose from the
body, and so it would really beevolutionarily unwise for us to
have a lot of people that can'ttolerate lactose, because that's
the first sugar that you getexposed to as an infinite breast
milk. I think that's suchhelpful terminology to explain
(14:03):
the difference in because a lotof people call it a lactose
intolerance, but that's really,as you pointed out, something
that we never see in babiesbecause we need it for survival.
Wouldn't make sense if we werehaving frequent issues with the
sugar in breast milk. So, yeah,interesting distinction. I think
it's made extra complicated byall the marketing that young
parents are exposed to, muchworse than pre social media era,
(14:28):
I have to say. And some of thatmarketing comes from companies
trying to sell products, info,formula, probiotics. We'll get
to lots of those topics, butmany of them talk about things
being lactose, low lactose orlactose reduced, not because we
think medically, or any of themedical staff think that that's
an important feature, butbecause it's such a confused
(14:51):
term, that they decided thatremoving lactose from some
products might help parents feelmore comfortable with the
product.
Yeah, or I also find thatthere's some parents that have
lactose intolerance themselves,so they think, oh, maybe this is
genetic. Maybe my baby also hasthis issue, but it doesn't come
up in babies. It comes up as youget older. I find minimum like
(15:12):
the teenage years is really whenlactose intolerance presents.
Yes, we see it occasionally inschool aged children, but much
more commonly as they get older.
That's right. Okay, so whenwe're talking about infants and
babies, and we're finding thatthey're having some sort of
intolerance, or their GI tractisn't agreeing with milk it is
likely the milk protein, yeah, Imean, certainly for allergies
(15:34):
that are life threatening, it'salways the protein. I think
what's tricky is that thisentire entity we don't really
understand, and that's why ourresearch team has been working
really hard to try to digdeeper, because it's really
common, and yet we really don'tunderstand how it works. So we
think it's probably proteinmediated because other
(15:56):
subsequent food allergies arethe life threatening kind, and
also because we've learned thatthese kids seem to be more
allergic in general, often thekind of kid that might go on to
have asthma or eczema or otherfood allergies later. And so the
idea is that probably it's asimilar mechanism to some of
those other diseases, but thosemechanisms aren't totally
(16:19):
perfectly understood yet. Okay,so in my mind, you've helped me
separating the two groups, thegroup that has the microscopic
blood fussy infant between oneand two months, I'm going to try
my best to reassure familiesthat this is likely something
they're going to outgrow. We'llkeep an eye on it, but if the
child's doing okay, the bestthing might be just to hold off
and not make any changes,especially in a breastfed
(16:42):
mother. But as a pediatrician,what would your advice be to
advise a family where the childis fussy is showing visible
blood in the stool? What shouldwe be advising at that point?
Yeah, that family. So then werecommend milk protein
elimination from the mother'sdiet, because the milk proteins
get transmitted into the breastmilk, and that means that the
(17:02):
mom would read labels and avoidanything that has any type of
milk protein in it. And usuallyit takes somewhere between three
to seven days for those milkproteins to get totally cleared
from the breast milk. It'sprobably within a couple of
days, but we say a couple longerthan that to be sure, and then
it might take a week or two oreven three for the baby's GI
tract, if that's the proteinthey were reacting to, to
(17:24):
actually heal and for thesymptoms in the baby to get
better. So I try not to makemore than one change per month.
So if I make an elimination frommilk, I try really hard to wait
a full month before we decide itdidn't really help, or it made a
really big difference. The nextfood to consider eliminating,
(17:44):
most people think is soy,because soy proteins and milk
proteins look kind of similar toour immune system, and there's a
lot of kids who would beallergic to both, but I don't
recommend starting with both,because, again, in the spirit of
wanting to keep things assupportive as possible. For
breastfeeding moms, I want tomake that diet as easy as
possible. The trick is, let'ssay you do that and everybody
(18:09):
thinks that the baby is muchbetter. One of the mistakes I
think we make is that we thensay, okay, let's do this for a
really long time, becauseeverybody's finally feeling
better, but all of theinternational guidelines tell us
that one month after that, afteryou've had that baby who's
feeling much better, you shouldput the milk protein back into
(18:29):
the mom's diet, or the formula,if this is a formula fed infant,
and prove that the Symptoms allcome back. That's called a
challenge. Surprisingly, I thinkmaybe even less than half of
kids, when you do that, willactually have a real reaction
that second time around. And soit's really important that for
(18:51):
that other half who don't thatwe can make everybody's lives
easier. Mom can go back toeating ice cream, and baby can
go back to being happy but nothaving to be on a restricted
diet. And so we really want torestrict the formal diagnosis to
kids who react to thatchallenge, and then those kids
are meant to avoid that allergenfor a bit longer. It's a little
debated, but maybe three, six oreven nine months. And then is
(19:14):
there a certain point in timewhen you notice that most kids
outgrow this allergic protocolitis or AP. So nobody's done
this in a systematic way, right?
So we've never had a study wherethey said, Okay, we're giving
you it now. Now we're giving itto you, and we're gonna see that
earliest moment that you'reready. So we've been walking
back when we've been introducingand I would say there was one
(19:37):
paper pretty recently that foundthat even as early as three
months after the diagnosis wasmade, children were already
ready to tolerate the allergenor the antigen again, so already
ready to tolerate the milk thatit seemed they weren't
tolerating three months before,I find this information so
helpful, because, as you pointedout, it's a difficult challenge
(19:58):
for mothers.
Have to take out dairy fromtheir diet. I have so many moms
that they're struggling as itis, having a newborn, and then
when our advice is to take outtheir favorite dessert or take
out their daily cappuccino thatthey look forward to, it's hard,
and it makes what's already hardeven harder. And so I'm so
(20:19):
grateful that you've taught meto try to reintroduce milk a
month later, because I thinkthat's doable. I feel like for
somebody mentally to know, okay,in a month I can retry this, and
there's a better than halfchance that it's gonna be okay
when we reintroduce it. Becausebefore I heard this advice from
you, I was waiting, honestly,until about six months to tell
moms to reintroduce the milk.
Yeah, many people were waitingnine or 12 months, which is what
(20:42):
the guidelines say, if you didthe challenge, and they reacted
to the challenge. And I thinkthat if is the part that many of
us kind of missed or have had ahard time implementing, but is
super, super important, and I'vebeen doing this now for some
time in my clinic, these babiescome to see me very often, and
I'm often surprised by the kidthat I was sure so clearly
(21:04):
responded to milk eliminationjust a month ago. Don't seem to
care when we put it back in. AndI don't think that means we were
wrong the first time. I thinkit's really possible that
there's a rebalancing of the GItract, of the microbes that live
there, of the health of thebarrier, such that one month
later, they're better. And so Idon't think if the challenge is
(21:30):
negative, so to speak, that wewere wrong, I think more often,
and maybe it just means thatit's over already. Just to be
clear, what would the symptomsbe that we should be concerned
about when the milk is reintroreintroduced, because babies, in
general, have some time thatthey're fussy. So what would a
failed challenge actually looklike? Yeah, I think it would
mean certainly if there's, youknow, a diaper full of blood and
(21:51):
mucus, those are helpful andobvious, but also pretty rare. I
think a baby that goes frombeing content to miserable,
really difficult to settle,difficult to put down with
sleeping through the night andisn't sleeping at all, is
vomiting a lot, is taking lessvolumes of their breast milk or
formula, or isn't gaining weightas well. Those would all be
(22:12):
symptoms that would at leastmake me think about it. But
you're right. Sometimes kids arealso teething or also having a
sleep regression, and so I trynot to rely on any one symptom
to make this decision, but moreof a global assessment of how
we're doing. What I also reallyappreciate about your
recommendation is that I findonce we notice microscopic blood
in the stool, a lot of theadvice has been so restrictive
(22:36):
for moms to take out so manyproteins out of their diet that
they end up giving up onbreastfeeding altogether because
it's just so challenging. Sothis is really refreshing advice
to me, because I think whateverwe can do to support moms more
to be successful breastfeeders,I think is a great path forward.
Yeah, and I think that, youknow, we're still working really
hard to understand themechanism, but we have lots of
(22:58):
promising data suggesting thatsome of this really has to do
with the microbes that live inbaby's gi tracts, and we know
that the healthiest way to setup a healthy microbiome in a
baby's GI tract is breast milk.
So it hurts my heart a lot whenI meet patients who come to me
and have already given up onbreastfeeding because the diet
(23:18):
they were put on was too hardand now we're on formula. That's
the right choice for somepeople, probably for quite a
small minority, but I never wantthat to be the goal standard.
And I had one patient with ababy who was quite sick, so
really, clearly had colitis.
Actually had a colonoscopy,because there was so much blood,
we were trying to figure outwhere it was coming from, and it
(23:39):
was this allergic disease, buther mom was really motivated to
breastfeed, and so we had done areally complex diet. Mom was
great about doing it. Baby stillwasn't getting better. And so
mom took a break and just pumpedfor one month while we did an
elemental hypoallergenicformula. And one month later,
when we gave that breast milkback, it was completely healed,
(24:01):
and that baby did awesome forthe rest of infancy. And so even
in that super severe case, webriefly interrupted
breastfeeding, but we didn'tdisrupt the relationship, and
that baby got six more months ofbreast milk after that. And so I
think even in the most severecases, there's a lot of
opportunity to continuebreastfeeding if moms want that,
and babies want that too, andI'm assuming from what you're
(24:22):
saying, if the baby was able tohandle breast milk a month
later, were they also able tohandle the stored breast milk?
In other words, I think a lot ofmoms think that stored breast
milk that's been put in thefreezer, all that hard work,
then has to be thrown away. Butcan they use it? Is it usable?
Yes, as a mom who reallystruggled with every single
ounce that made it to myfreezer, those stories also hurt
(24:44):
my heart. That milk is almostalways usable, and so it's one
of the first questions on myintake. When I meet parents of
new babies like this, is to savethat milk, label it well, so
label what you remember yourdiet was or wasn't at the time
that you pumped.
It, but it's actually reallyawesome for introduction or for
a challenge, for example, if youwanted to expose the baby to
(25:07):
breast milk that had milk in it,but you didn't want the effects
of that to last a week or two,you could use frozen milk for a
challenge, for example, and thenonly open up mom's diet to new
foods if that went well. Andsimilarly, even if kids react a
lot in a month, sometimes threemonths from now, that milk is
perfect for them, so it is veryrare. In fact, I don't think
(25:29):
I've ever told a mom that hermilk should be donated or given
away. We've almost always foundgood ways to use it. Ultimately,
wonderful. Now, what if there'sa situation where a family feels
hesitant to do a challenge in amonth. Is there any harm in
waiting three, six months beforethey reintroduce milk into the
diet? What is the benefit ofdoing a challenge a month later?
(25:51):
I think the first benefit ofdoing the challenge is that it
makes moms do the diet for lesslong as they can, right? So I
think that's the number onethat, like you said, it's an
achievable goal, something wecan do, but not necessarily,
really prolonged. We know thatearly introduction and exposure
to allergen to babies directlyonce they get a bit older, 4567,
(26:15):
months, helps prevent foodallergies. So there was that big
study called the LEAP study,about 10 years ago now, that
really changed everybody'sunderstanding of how food
allergies happen, and made usrealize that introducing peanut
in the case of that study, in asafe way for babies, starting at
four months, for babies who areat risk, prevented peanut
(26:36):
allergy develop in a lot ofthose kids, we don't have the
same information to say thatthat's true in breast milk,
another word moms who eatpeanuts versus don't eat peanut
and have peanut in their breastmilk, it doesn't have the same
protective effect, although youcan imagine those are a little
harder to control, because momswho are avoiding peanut might be
avoiding peanut because they'reallergic and then that has
(26:58):
genetic complexity as well. Sothe short answer is, I don't
think there's a big risk towaiting two months or three
months for a challenge in a onemonth old. Let's say if that
feels more comfortable to afamily, as long as it's not
leading to ending abreastfeeding relationship. But
I do think that once kids areold enough to tolerate foods
(27:19):
like starting to think aboutsolids, it's a good time to
start talking about thoseallergens. And that could start
with other allergens like peanutand egg, but then maybe should
also include something likeyogurt that has milk protein.
Yeah, I think this is a greatpoint to make, that the earlier
our immune system is exposed toa variety of foods, things in
the environment, the moretolerant we become. And so I
(27:41):
think it's an easy temptationfor us to just want to avoid all
of the foods that maypotentially be bothering our
children, but it actuallybehooves the child to be exposed
early and often if they tolerateit, because we can avoid
allergies potentially in thefuture. Yes, and there's been
this term for a long time, theallergic or the atopic March,
(28:02):
and we've known for a while thatdiseases like eczema of the skin
that show up very early might beone of the first signs of an
allergic kid, and then canprogress later by a couple of
different mechanisms tosubsequent allergies like food
allergy and asthma. We havegrowing data, and there's a fair
number of papers after ourssaying that we think this
(28:26):
allergic procto colitis mightactually be the first step on
that atopic or allergic march.
And so I think it's anespecially important population
for us to be thoughtful about,because the elite study where
they introduced peanut early onwas in kids who had moderate to
severe eczema and a few othercriteria for enrollment, because
that was their risk factor. ButI suspect that these babies that
(28:49):
have this allergic proctocolitis early in life are
similarly at risk, and yet,before we were having them,
avoid a lot of things for a longtime. And I also think we sort
of maybe inadvertently,historically made parents worry
about foods, and so they wereprobably later to introduce
other foods. And this baby thatthey had eliminated milk from,
(29:11):
and I think probably the reverseis true, that these kids, we
should be paying extra attentionto making sure they get peanut
for example, even if we haven'tdone the challenge for milk yet,
or even if we don't feel readyto proceed on the milk or soy
train, I would say peanut or eggor these other known allergens
should probably be happeningearly, like kids with moderate
to severe eczema. I think thisis a great point to make,
(29:33):
because I think if a parent seesa child react in their infant's
early life to milk, we can makethe assumption that, oh, this is
best to avoid for a long periodof time, but the opposite is
actually true. We want to thinkabout reintroducing it as soon
as possible to potentially avoidlifelong allergies. And I know
we don't have something like theLEAP trial for milk, but I have
read studies where kids that dohave milk allergies if we expose
(29:57):
them.
Or to milk in different forms.
You know, in baked forms, theyactually can outgrow the milk
allergy sooner than if theyweren't exposed. Yeah. I mean,
we certainly don't recommendexposure in someone who's had
anaphylaxis, right? So if you'vebeen diagnosed with a milk
allergy and you went to theemergency room and got an
EpiPen, then we don't doexposure until your blood tests
(30:17):
and skin tests might tell youthat you're ready, but there's
conflicting data about how earlythe exposure to cows milk
protein and in what form may ormay not help prevent IGE
mediated milk allergy later.
It's interesting, right? Becausewe're the only mammal that
consumes milk from another one,right? And so there are a lot of
(30:41):
really interesting evolutionarydiscussions around whether we
should be drinking any cow'smilk or anybody else's milk, but
human milk. I think that thatcan be a nutritional decision
and a family decision and acultural decision, but it makes
sense that we may have a littlebit of a harder time getting
used to or tolerating cow's milksometimes, and so I don't think
(31:02):
it's the only show in town,particularly as kids get older,
if it's something that folksaren't tolerating. Well, in your
opinion, is it your sense thatthe allergic proctor colitis is
increasing overall, or do youthink we're just diagnosing it
more? Yeah, this is really hard.
I would say both. I think thatwe're paying attention to it
more. I think people are lookingat it more. I think people are
(31:23):
testing more stools than theyused to, and parents are asking
more questions about that. Andso I think we're probably
noticing it or diagnosing itmore, and I think it's also
happening more, and that wouldbe consistent with every other
allergic disease on the map.
Right in parts of the worldwhere we have rising rates of
(31:44):
allergy, we have high risingrates of lots of allergic
conditions, IGE mediated foodallergy in particular. So just
to make sure I understand yourthoughts on this, if a family
comes in with a child who isslightly on the fussier side,
has some microscopic milk in thestool, your advice would be to
make changes as slowly aspossible. Is that what I'm
understanding? Yes, yes. I thinkmy advice is to make changes
(32:09):
slowly and to have our opinionof those changes and how they're
working be based on how the babyseems, and not focused on
whether or not there's amicroscopic test showing blood
in the stool. I really wouldfollow lots of mucus, lots of
diarrhea, obvious blood weight,faltering, feeding challenges,
symptoms like that. But in achild who's sort of a little bit
(32:29):
fussy but generally thriving anddoing well, I often think we can
do nothing and watch and seewhat happens. And I think that
if those kids aren't going totolerate milk protein, they'll
let you know they will getworse, they will get more
uncomfortable. And I'm notsaying that we want that, but I
think making sure we know thatwe're dealing with something
pathologic that needs to beaddressed is important too. Now,
(32:51):
you mentioned that we're theonly species that consumes
another animal's milk, so Inotice a lot of growing interest
in my families, in being vegan.
From your perspective, is thereany harm in babies avoiding milk
altogether? Babies under 12months need certain nutritional
factors. Those can come frommilk, which, of course, then
wouldn't necessarily have cow'smilk if mom was vegan. So that
(33:13):
would be totally fine. There area few formulas that aren't cow
milk based, that are availablein the United States and meet
all the nutritional criteria.
And so I would say those aresafe. The FDA reviewed all of
those to make sure that theyhave the micronutrients that
kids need once we get into likeover one then kids don't need
(33:36):
milk at all of any kind, butmany rely on it for really
important nutritional aspects oftheir diet, fat content, protein
content, calcium, vitamin D. Andso I would say that anybody
who's going to be on arestricted diet for any reason,
allergies, preference, culture,it makes good sense to see their
pediatrician and maybe anutritionist to make sure that
(33:59):
they're ticking those boxes andthat they don't need a
multivitamin to get enoughcalcium or making sure that
they're getting vitamin Dsometimes in kids who are
slightly pickier ways to makesure they're getting protein and
fat in the right proportions,which some kids rely on cow's
milk for. So yeah, there's noreason we have to have cow's
milk in our life, but we do haveto meet our nutritional needs,
(34:20):
and so sometimes we need helpmaking sure our kids are doing
that. As you mentioned, thereare some nutritional benefits
from milk, but all of thosenutritional benefits we can get
from other foods, right? Likevitamin D, there's not a ton
from milk, it's mostly sun. Ilive in Southern California, so
it's easy for me to say, but Iknow it's added into milk.
There's protein. We can getprotein from other sources.
There's vitamin A, we can getthat from fruits and vegetables.
(34:42):
There's calcium, which we canalso get from beans and
broccoli, and there's other milkvariants out there. But the
thing that I get concerned aboutis I don't want to induce a
lactose intolerance in a child,and let me know if this is an
incorrect assumption. But.
I worry that a kid could grow upto be in their elementary school
(35:04):
years, go to a birthday party,try a pizza for the first time,
and have a difficult timedigesting it, and then they're
that kid that can't eat like allthe other kids, and so I don't
want to impose an issue on a kidthat we might be able to
prevent. Yeah, I don't know ifthere's literature about the
long periods of avoidance andinduction of lactose intolerance
(35:24):
in particular. So that's a coolquestion. I haven't thought
about that exact question, but Ithink that in general, my advice
for most things is moderation.
So at least in my house, my kidshave cows milk. Sometimes,
sometimes they'll ask for aglass of milk. We certainly have
a lot of Italian blood, sothere's a lot of cheese and
everything. And I think that'sprobably some amount of exposure
(35:47):
over time may help kids be ableto tolerate that, like you said
at a birthday party or somethinglike that. But to your point,
there are certainly kids who canlive long, happy, healthy lives
without cow's milk, or evenwithout a replacement, as long
as they meet their other needs.
And so I try to support familiesin that if that's what their
preference is, yeah. I also haveto say I do have plenty of vegan
(36:10):
families that are in mypractice, and their kids are
definitely thriving withouthaving any cow's milk. So I see
it working in all ways, and aslong as you're paying attention
to getting a nice variety ofnutrition in the diet, yeah, and
I think in the US, I see a lotof kids who are relying too
heavily on cow's milk, andthat's getting in the way of
their ability to learn to enjoya whole range of really
(36:31):
important other food. So I thinkvariety and exposure and
building flexibility. You know,we have some oat milk, we have
some almond milk, and I lovethat our kid can take and
appreciate all of them, and I dothink that allows them to be at
someone else's house who hassome other kind of milk and not
have that be derailing for themsocially or otherwise. So I
think that that's really wise.
It is true that there are somekids out there that love their
(36:52):
milk, and I do think if you fillup too much on milk, it can curb
your appetite for showing aninterest in other healthy foods
for the diet. So that's a goodpoint to make. Yeah. So now to
circle back, we had touched onlactose intolerance earlier,
which is different from the milkprotein intolerance. This is the
intolerance of the actual sugarin milk. Can we talk more about
(37:13):
that? When does that usuallyshow up? And how do you advise
parents who have kids that areintolerant of the milk sugar,
the lactose. Yeah, so lactose isthe sugar in milk and in usually
broken down by specific bacteriathat are in the GI tract. And
when that's not workingcorrectly, then you can become
(37:34):
lactose intolerant, meaning thatsome amount of that sugar then
really bothers you thatpresents, usually with really
loose diarrheal stools aftereating lactose bloating or
discomfort. So usually,classically, kids will tell me
that they really like ice cream,but they've noticed that when
they have that bowl of icecream, they have to run to the
bathroom afterwards, and theirstomach feels pretty
(37:56):
uncomfortable, and often they'llhave an explosive diarrheal
stool after that, you can testfor lactose intolerance by doing
a breath test. So this is kindof a cool test you can do in the
office, usually a GI office,where you breathe into a bag,
and we can measure the hydrogencoming out of your exhaled
breath, whether you have enoughlactase, the enzyme to break
down lactose, and whether that'sbeing broken down correctly. Is
(38:16):
that a pretty accurate test? Andis it pretty easy to come in?
It's pretty accurate and it'seasy to come by. It's not in
every lab or in every primarycare office, but most sort of
hospital based groups, and Isuspect many outpatient groups
have it too. Actually, duringcovid, they developed the
ability to send it to people'shomes as like a kit, and so
(38:37):
parents can even have it sent totheir home if their insurance
covers that, which is prettyneat. So this often present in
teenage years, like youmentioned, or sometimes, I mean,
very often presents in olderadults. But we're focusing on
kids here today, some kids findthat they have a particular
amount of lactose they cantolerate. So, you know, some
people can tell me that they canhave like, a quarter inch of
(38:59):
cream cheese on their bagel, butnot like a full inch of cream
cheese on their bagel beforethey have symptoms, and some
people really just can'ttolerate any at all. Yeah, I
definitely find that some peoplecan have some yogurt or some
aged cheeses, but if you givethem a full glass of milk,
forget about it. They're reallyuncomfortable, exactly. Yeah,
this can also be a temporaryphenomenon. It's worth noting
(39:21):
when kids have a viral illnessor an infectious illness. So if
you have that terrible stomachbug that goes through your
school and then you notice thata week or two later, your kid's
having a really hard time,sometimes that's what's called
transient lactose intolerance.
It's a post viral process orpost infectious process, and
that just means that thosebacteria that are supposed to be
(39:41):
doing that job got wiped out bythat other illness, and they
need a little chance to recover.
And so sometimes avoidinglactose for a week or two or
three in that post infectiousperiod, and then slowly
reintroducing it can help.
That's a really helpfulreminder, because that's
definitely something that I seea lot with families. And so
great to know that that's notgoing to be.
Forever? Yeah, usually not. Soin general, as you go through
(40:04):
your research as a GI doctorwho's focusing on milk protein
intolerance, is there somethingthat you wish pediatricians or
parents had a betterunderstanding about cow's milk
in general, I think the biggestthing that I wish is that we all
do everything in our power tohelp new families survive what
(40:25):
is a really hard time, which ishaving a new baby in the house.
And I think I didn't fullyappreciate it, to be honest,
despite impeccable pediatricstraining, until I had my own
little ones, some of which weremore difficult than others in
those early phases. And so Ithink first and foremost,
though, of course, it's what weall mean to do, making sure that
(40:45):
we're really understanding whatparents are worried about. And I
think milk protein might bescapegoated more often than is
fair. And I think that in aneffort to do everything we can
to be helpful, sometimes we dotoo much, changing, changing
formula, changing diet, givingmore things to do when really, I
think sometimes we needreassurance that babies are
super fussy, sometimes,sometimes for a while, and that
(41:08):
can be okay. And so I thinktalking to your pediatrician,
trusting your pediatrician,sometimes seeing them, often, if
that's what you need to feellike you're on the right track
over ending a breastfeedingrelationship, or feeling really
alienated or really strugglingwith feeding, would be my
biggest wishes. Thank you somuch for that. I think that is a
(41:30):
reoccurring issue that comes up,not just with milk protein, but
I also find with things like thetongue tie procedure or putting
a child on reflux medications, Ifeel like a lot of times with
fussy babies, we want to dosomething. We want to fix it. We
want to fix the problem fast.
And oftentimes, I find the mosthelpful solution is just being a
(41:51):
support system for the family,really reassuring them that
their kid is healthy and normaland that it's going to get
better over time. We just needto get through it, day by day,
nap by nap, and sometimes doingless ends up being better for
the child and the family. Yeah,and, you know, one of the things
I hear a lot in my office that Itry to reframe for families is
(42:11):
that sometimes I hear parentstell me, I'm here to see you
become my pediatrician blew meoff or didn't share my concerns.
Pediatricians are incrediblehuman beings who are also being
asked to do a lot more than ishumanly possible in the 15 to 20
minutes that we're allowed tospend with our patients
sometimes, right? And so one ofthe things that I think is
(42:32):
really helpful to arm parentswith is this question, can you
help me understand why you'rereassured, or why you're not
worried, because we have thiswhole list in our brain from all
the textbooks we memorized wayback when and everything we've
learned since that allow us tofeel confident that this isn't
something that is gonna makeyour kid allergic forever. This
(42:53):
isn't something big or bad orscary, and yet, I'm not sure we
always articulate all of thosethings. And so I think sometimes
one advice, a piece I would giveis to when you're feeling like
your pediatrician is telling youthat you probably don't need to
change anything. That doesn'tmean they don't hear you and
they don't see you. It meansthat they've laid all the
(43:14):
options and think that thesafest, best option is to what
we call watchfully wait. And ifthat feels unsatisfying, I think
asking questions about why thatis or why they feel that way
sometimes can be clarifying forparents, to know that it's not
just that we don't believe youthat your baby is fussy, it's
that we want to do no harm,which is what we're supposed to
(43:34):
do absolutely. And that's not tosay that sometimes intervening
isn't the better option for thechild and for the family, but I
do think the beauty of having apediatrician is that you can see
them next week, you can followup into skin and not acting
right away. Doesn't mean we'renot going to do something at
some point, but we have theluxury of having a relationship
(43:55):
and checking in on you later,and that's a very, very
important tool that I wouldn'tforget about, for pediatricians
and for families, yeah, and Ithink sometimes maybe people
feel like we're kicking the candown the road. And I think
rather, we're using time andobservation. And that's why in
medicine, it's called watchfulwaiting, right? Because we know
that many things get better ontheir own with time, with far
(44:15):
less risk than whatever we mighthave intervened with. And so
waiting and seeing where we area week from now and two weeks
from now can often be reallyilluminating, and sometimes kids
are much worse, and then we knowthat it's time to act. And
that's really helpfulinformation. And there's nothing
to say that waiting a week ortwo with a diagnosis like this,
reflux, milk protein, allergy,allergic colitis, puts kids in
(44:39):
any worse a position, and inmany ways, that might allow the
problem to go away on its own.
Thank you. So okay, as we finishup, I just thought I would fire
off if you're okay with this, ifyou milk myths that I'd like you
to either tell me true false, ormaybe it depends. Is that okay
with you? Yep.
(45:00):
All right, so the first one, ifa baby is fussy, it's probably a
milk allergy, true, false, or itdepends. I would say either
false or it depends. I think itdefinitely depends, and more
often than not, it's probablynot okay. Lactose Intolerance is
that common in toddlers? Nofalse goat milk? Is that a safe
alternative to cow's milk forinfants, I would say false, or
(45:23):
it depends. So neither goat'smilk nor cow's milk are safe for
infant if they're not in aninfant formula preparation. But
if we're talking about aninfant's formula, there is one
now, FDA approved goat's milkbased infant formula on the
market, and I would say thatthat is safe. Is that? Kabrita?
Yes. All right, here's a bigone. Kids need milk to grow
(45:44):
properly, true, false, false,false. We chatted about this a
lot, but I think there are lotsof other ways to get whatever
you might get from milk, but ifyou need help with that, a
nutritionist or yourpediatrician can help. Just
thought, yeah, why not reinforcethat one more time? All right,
if a kid avoids milk, they willmost likely become calcium
(46:04):
deficient, a false or itdepends, it depends on what else
they're eating, right? So Iactually have the calcium
requirement chart posted insidemy pantry closet, because I find
it really helpful to remindourselves. I think we sort of
rely on calcium being in milkfor a lot of kids in the US in
particular. And though knowingwhat those amounts are and what
(46:25):
other foods you can find them into make sure you get your
appropriate amount of calcium isimportant. It is a significant
amount, so you do have to putsome thought into making sure
you're getting that calcium fromother places, in my experience.
But it can be done, for sure. Itcan be done. My kids are doing
it. I have to say, I rarely seea kid that's calcium deficient.
Maybe I just don't know aboutit. But really, yeah, I think
(46:46):
that we probably worry about itmore than it turns into to a
real bone health problem. Ithink it's one of those things,
though, that you're building upover time, and you might not see
those deficiency problems untillater in life. And we'd love to
set people not up for that, forthat bone fracture or other
thing that gives us that cluelater, absolutely Well, Dr
Martin, I've so enjoyed talkingto you this information I think
(47:08):
will be so helpful for many ofmy listeners, and honestly and
for myself as I continue being apediatrician and guiding
families that I meet. So thankyou so much. Thank you so much.
It was such a pleasure. I lovebeing here. Thank
you so much for listening toyour child as normal. I'm so
grateful you're here and part ofthis community. If you're
enjoying this podcast, it wouldmean the world if you shared an
(47:29):
episode with a friend subscribedand left a five star review. And
don't forget to follow me onInstagram at ask Dr Jessica for
more parenting tips and updates.
See you next Monday. You.
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