You may have heard or seen parents’ concern about their children’s bowel changes, especially as babies. The truth is that constipation and food allergies almost 30% of the paediatric population. 35 to 52% of these children suffer from symptoms for years and almost a third have constipation in adulthood. Usually the main complaint of those who have a milk allergy is diarrhea, so how to identify whether or not cow’s milk is the cause of constipation?
First we need to understand how constipation occurs. According to the paediatric criteria of Rome IV, constipation is defined by the presence of two or more of the following symptoms for at least one month and may not be related to other medical conditions:
- less than three evacuations per week;
- at least one episode of fecal incontinence per week after the acquisition of sanitary skills;
- retaining posture or excessive retention of volitionic feces;
- painful or hard bowel movements;
- presence of a large fecal mass in the rehest or history of obstruction of the toilet by large stools.
That’s why environmental, behavioral, immunological and genetic factors are the ones that most contribute to to the frame and generate barrier function (skin, intestine) and affect the immune pathways. Knowing this, the most vulnerable audience is the children with neurological or motor complications, atopy and food allergies, who have suffered from sexual abuse, violence or psychological stress.
It is noteworthy that the microbiota plays a central role in the development of food allergy. Recent studies suggest that eating bacteria protect against food allergy. In contrast, dysbiosis impairs this regulatory response and promotes allergic disease, as both metabolites generated by coerian bacteria, as well as diet derivatives, regulate the immune tolerance of the mucosa, and promote the integrity of the epithelial barrier.
Cow’s Milk x Constipation
Cow’s milk is the most common food allergen gastrointestinal motility of children, mainly through non-IgE-mediated reactions. The development of this allergy may be associated with duration of breastfeeding and early exposure to cow’s milk in infants and children.
Common Symptoms in Constipation
Typically, children with cow’s milk-related constipation have other clinical manifestations (such as eczema and allergic rhinitis), or symptoms in the gastrointestinal tract (such as regurgitation). The symptoms may occur jointly, starting with regurgitation or childhood diarrhoea and progressing to constipation and dermatitis or respiratory manifestations years later. Similarly, constipation may also be the only manifestation reported by these individuals.
In general, the most common symptoms are regurgitation, vomiting, refusal or food aversion, poor growth, cramps, abdominal pain, diarrhea, and constipation. As many of these symptoms are also present in reflux disease and gastrointestinal disorders, the distinction between allergic and non-allergic cases often becomes difficult. However, it is essential to make early diagnosis, since the symptoms are susceptible to dietary modification.
Diagnosis of constipation associated with food allergies
A formal diagnosis of constipation by food allergy is made by eliminating cow’s milk for 2-4 weeks. If symptoms disappear during the elimination diet and reappear with reintroduction, a causal link can then be established. This method is effective because constipation is often not ige-mediated, and so tests for food-specific IgE become inconclusive. Thus, exclusion can be made for therapeutic purposes and then gradually reintroduced as tolerated.
Thus, lack of diagnosis can compromise the nutrition and growth of these children, and can reduce the quality of life of both the patient and the family, and late diagnosis is more common in allergies not mediated by IgE.
Treatments
The guidelines recommend education, behavior modifications, adequate physical activity, a normal intake by age of fiber and water, progressing if necessary to pharmacological treatments. The elimination diet is typically used as a treatment supplement to conventional therapies, although only the diet can already lead to relief of symptoms.
It is noteworthy that in the case of infants it is recommended to continue breastfeeding, but the mother should avoid all dairy products, this change requires close monitoring to protect the nutritional safety of both mother and baby. When human milk is not available or insufficient, hypoallergenic formulas are recommended to be, they may vary in terms of protein source and content, method and degree of hydrolysis, and additional components, which affect tolerance and efficacy. Other alternatives to herbal milk are not complete in nutritional aspect, and are contraindicated as cow’s milk substitutes in infants.
Most children respond well only with the elimination of milk from the diet. In this way, elimination of multiple foods is only necessary depending on the severity or persistence of symptoms. In this case, each food should be removed separately and requires close medical and dietary support to optimize adherence and nutrition.
Clinical practice
Constipation is the most common gastrointestinal disorder in children and many of them have chronic symptoms that require prolonged treatment. Knowing the challenges of ading, high cost for further investigations, and repeated consultations generate high impacts on the family routine. The most effective diagnosis is the elimination of dairy products for 4 weeks, so if symptoms disappear during this phase and reappear with reintroduction, a link can then be established between constipation and milk consumption. This approach avoids unnecessary invasive testing or prolonged treatment with medicines that require grip and continuity. Nutritional assessment should be recommended to avoid macro and micronutrient deficiencies during diet.
Bibliographic references
Study suggestion:
Understand more about cow’s milk protein allergy – Science Play
Watch the video on Science Play with Karina Al Assal:
Gut and Brain Axis, Strategies in Practice
Article: Connor F, Salvatore S, D’Auria E, Baldassarre ME, Acunzo M, Di Bella G, Farella I, Sestito S, Pensabene L. Cows’ Milk Allergy-Associated Constipation: When to Look for It? The Narrative Review. Nutrients. 2022; 14(6):1317. https://doi.org/10.3390/nu14061317
