Adversefoodreactionsinthebreastfedinfant

Declaration
Adverse food reactions in the
breastfed infant

Note that Joy Anderson has no conflict of interest

to declare

Joy Anderson AM
APD IBCLC
Cert IV Breastfeeding Education
(Counselling and Community)

Overview
Main causes of unsettled infant
Various types of food sensitivity in Infants
Food-chemical intolerance
Tests used for food allergy and food intolerance
Recommendations and management for the food-sensitive
infant
Resources

Main causes of unsettled infant

breastfeeding
b
tf di
iissues
Milk supply
low supply
oversupply lactose overload

Attachment issues infant

sucking air
tongue-tie, upper-lip-tie
high palate or other cause

Couple of case studies

2016JoyAnderson,AM,APD,IBCLC
ForindividualuseofiLactation'sBreastfeeding:passionandbiology participantsonly

Adversefoodreactionsinthebreastfedinfant

Main causes of unsettled infant

other
th issues
i
Medical
overt injury or illness
positional turn
subtle injury, often caused by infant
being pulled out by the head

Types of food sensitivities

Presentation in
breastfed infant

food allergy
food intolerance
reactions to windy foods

Symptoms are like those of lactose intolerance (note that lactose is the
D for disaccharide)
Occur in onion and garlic, legumes, wheat, stone fruit, pears, apples,
honey and others

Lactose intolerance

Windy foods
(via breastmilk)

irritable behaviour
reflux
eczema
(particularly on the
face)
colitis/bloody
stools, mucus

irritable behaviour,
including colic,
crying, disturbed
sleep
reflux
eczema/itchy
rashes
nappy rash
constipation
diarrhoea
green stools
mucus in stool

colic and crying

low weight gain
copious, often
green, bowel
motions
wind in bowel
nappy rash

colic and crying

wind in bowel
Gut symptoms only

Gut symptoms only

Secondary to gut
damage from
another cause,
such as gastro,
food allergy or food
intolerance.

Types of food sensitivities

Stands for Fermentable Oligosaccharides, Disaccharides,

Monosaccharides and Polyols
Range of various small, poorly-absorbed carbohydrates that are
fermented in the bowel = dietary fibre or prebiotics

Food-chemical
intolerance

[ acute reactions:
rash around mouth,
hives/swelling,
vomiting, breathing
difficulties,
anaphylaxis (very
rare via breastmilk)]

Food sensitivity (via breastmilk)

FODMAPs (in Irritable Bowel Syndrome)

Food allergy

Family history

Food allergy

Food-chemical
intolerance

Lactose
intolerance

Windy foods
(via breastmilk)

Allergic/atopic
(asthma, eczema,
hay fever, food or
other allergies), or
none

Includes irritable
bowel (IBS), rashes,
reflux, headaches,
mouth ulcers, fuzzy
thinking, ADHD, low
mood, constipation,
diarrhoea

Possibly allergies or
food-chemical
intolerance or no
history

No particular history

Adult lactose
intolerance not
related.

Lack of absorption means that they cannot affect a breastfed baby

Breastmilk naturally contains lactose and human milk oligosaccharides

2016JoyAnderson,AM,APD,IBCLC
ForindividualuseofiLactation'sBreastfeeding:passionandbiology participantsonly

Adversefoodreactionsinthebreastfedinfant

Types of food sensitivities

Timing of
reactions

Types of food sensitivities

Food allergy

Food-chemical
intolerance

Lactose
intolerance

Windy foods
(via breastmilk)

If direct contact,
minutes to 12 hours;
via breastmilk, hours
to days;
Reproducible

Hours to several
days;
Variable

Ongoing if
underlying cause
not addressed

Usually hours

Mechanism

Types of food sensitivities

Food triggers

Food-chemical
intolerance

Lactose
intolerance

Windy foods
(via breastmilk)

Specific food
proteins (egg, milk,
peanut, wheat,
soy, tree nuts,
sesame, fish,
shellfish are most
common)

Selected additives
(preservatives, antioxidants, colours,
flavours)

Whatever is
causing gut
damage

Legumes, such as
beans, lentils,
chickpeas, etc and
some vegetables,
such as cabbage,
broccoli, cauliflower
and Brussels sprouts

First 5 most
common in infants

Food-chemical
intolerance

Lactose
intolerance

Windy foods
(via breastmilk)

Immune (IgE
antibody or cellmediated)

Non-immune, druglike effects (irritation

of nerve endings)

Loss of lactase
enzyme due to gut
damage from
underlying cause

Unknown in infants
via breastmilk

Types of food sensitivities

Food allergy

Natural food
chemicals
((salicylates,
li l t
amines,
i
glutamates)

Food allergy

Management

Food allergy

Food-chemical
intolerance

Lactose
intolerance

Windy foods
(via breastmilk)

Complete
avoidance of
problem food
proteins

Maintain problem
chemicals/foods
below threshold

Fix the underlying

cause, not avoid
lactose

Avoid/reduce
problem foods in
mothers diet

Some whole foods

(milk, soy, wheat)

2016JoyAnderson,AM,APD,IBCLC
ForindividualuseofiLactation'sBreastfeeding:passionandbiology participantsonly

Adversefoodreactionsinthebreastfedinfant

Food chemicals in food intolerance

Natural food chemical groups

Some food chemicals act like drugs in

the body

Salicylates

Depends on genetic make-up,

enzyme systems
Mechanisms non-immune, no IgE
antibodies

img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/h
ealth_tools/baby_skin_care_slideshow/phototake_photo_of_infant_eczema.jpg

Affect a variety of body systems

Lactose intolerance and windy foods affect only the gut
Natural and artificial food chemicals and some whole foods

Other food chemicals

Glutamates (eg. MSG)

concentrated in/under skin of fruit

and vegetables

higher in fruit when under-ripe

widespread in plant foods, higher

when concentrated

Amines

derived from protein breakdown or

fermentation

higher in fruit when fully ripe,

matured or aged foods

high in chocolate, tasty cheeses

develop on storage and during

cooking

also derived from protein breakdown

known for enhancing the flavour of

foods

Many foods are high in all three

groups, eg. mushrooms, tomatoes,
grapes wine,
grapes,
wine yeast extracts,
extracts stocks
stocks,
sauces

Food intolerance: Concept of threshold

Additives
preservatives
anti-oxidants
colours
flavours
flavour enhancers

Some whole foods

cows milk
soy
wheat
Graphic based on information from RPAH Allergy Unit, Sydney

2016JoyAnderson,AM,APD,IBCLC
ForindividualuseofiLactation'sBreastfeeding:passionandbiology participantsonly

Adversefoodreactionsinthebreastfedinfant

Total body load

Food intolerance: Concept of threshold

The threshold can be affected by:

smells
airborne allergens
weather; high and low temperatures
infections, other illness
www.tvlesson.com/lessonimages/12334.jpg
medications
skin
ki contact
t t with
ith chemicals,
h
i l carpets,
t grass, skin/bath
ki /b th products
d t
hormones
any sort of stress

People with allergies often have intolerances as well

Graphic based on information from RPAH Allergy Unit, Sydney

Tests

Tests

Allergy:

Non-conventional tests:

skin-prick test
blood test for IgE antibodies
(RAST)
elimination and challenge

some are popular with alternative therapists

none are reliable or evidence-based
www.dkimages.com/discover/previews/994/50188000.jpg

Food-chemical intolerance:
only elimination/reduction diet and challenge

2016JoyAnderson,AM,APD,IBCLC
ForindividualuseofiLactation'sBreastfeeding:passionandbiology participantsonly

see ASCIAs website at allergy.org.au/healthprofessionals/papers/unorthodox-techniques-fordiagnosis-and-treatment

Adversefoodreactionsinthebreastfedinfant

Back to the symptomatic infant

Lactose intolerance

Any of the food chemicals can pass into breastmilk

Look for underlying cause and address that lactose intolerance in a

infant is a symptom, not a diagnosis

Both allergy and intolerance can flare eczema,

in particular when milk is the problem food

Keep breastfeeding, possibly use lactase-treated EBM if necessary

Children usually grow out of most food allergies by school age. However,
note allergic march(eg progress to asthma)

If formula-fed, there is no need for lactose-free formula unless the infant

is severely malnourished

People do not grow out of intolerances but they change in severity at

different life stages, and symptoms change

Avoiding lactose in the breastfeeding mothers diet will make no

difference

Hard to distinguish allergy from intolerance in breastfed infant

Tests such as breath hydrogen and reducing substances in stools are

invalid used with breastfed infants under 3 months and possibly older

Recommendations

Recommendations

Infant with high-risk for allergy but no symptoms:

Infant with symptoms of food allergy:

breastfeeding, mother not avoiding allergens

breastfeeding, mother avoids allergen/s (protein)

if infant needs formula, the latest evidence is that

hypoallergenic
yp
g
formulas are not useful to prevent
p
allergy

formula-fed infants under 6 months with milk allergy

should be fed extensively-hydrolysed
y y
y
formula or, if still
reacting, elemental formula
formula-fed infants over 6 months can have soy formula
if tolerated

2016JoyAnderson,AM,APD,IBCLC
ForindividualuseofiLactation'sBreastfeeding:passionandbiology participantsonly

Adversefoodreactionsinthebreastfedinfant

Recommendations
Allergy testing can be done in infants (refer to allergist) but can
be unreliable, not all IgE-mediated (test negative)
Breastfeeding mother can do a trial elimination diet and check
for symptom relief in the infant
In some cases,
cases a simple blanding
blanding-down
down of the mother
motherss diet
can reduce symptoms in the infant (if cause is food chemicals)

Management
A dietitian with an interest in food sensitivity can
individualise the elimination diet with the mother
ensure nutritional adequacy
p
provide support
pp

In some, only one type of food, eg. dairy, has to be avoided

Management

Summary

It is common for the mother and other family members to

notice reduction in their own symptoms

There are a number of reasons infants might be unsettled and have

symptoms that look like a reaction to food

In some cases, weaning the infant onto extensivelyhydrolysed or elemental formula and leaving
investigations until starting solids
For some, temporary weaning, maternal elimination diet
and subsequent challenge with breastmilk

Food chemicals, substances from windy foods and allergens from

mothers diet do transfer to breastmilk and can affect a sensitive infant
A breastfeeding mother can alter her diet to avoid the food/s to which
her infant is sensitive
The elimination diet and investigations need to be individualised for
each mother-infant pair
A dietitian with an interest in food sensitivity in infants is the best person
to assist a mother with this

2016JoyAnderson,AM,APD,IBCLC
ForindividualuseofiLactation'sBreastfeeding:passionandbiology participantsonly

Adversefoodreactionsinthebreastfedinfant

Finding a dietitian
In Australia, Dietitians Association of Australia (DAA) website:
daa.asn.au Find an Accredited Practising Dietitian

Resources
Joys publications on food intolerances:

Search according to Area of Practice: Allergy and food sensitivity or

Breastfeeding (or Infant Feeding)

Anderson J 2010 Unplanned reactions. Child magazines, June 2010 (link to pdf on Joys
website: dieteticsandlactation.com.au)

Select one Area of Practice and check individual listings of dietitians for the
other. Starting with Breastfeeding will give you smaller numbers

Refine search by State for local dietitian. Note that some do phone, Skype
and/or email consultations

Anderson J 2012 Crying baby, sleepless nights. Could it be something mother is eating?
Essence 48(5): 810 (September issue) [ABA members magazine]

Anderson J 2012 Food allergy and intolerance. In Brodribb W (ed) Breastfeeding

M
Management
t in
i Australia
A t li 4th edn.
d Australian
A t li
Breastfeeding
B
tf di
A
Association,
i ti
East
E t Malvern,
M l
Vic
Vi pp
424430

Anderson J 2013 Food-chemical intolerance in the breastfed infant. Breastfeed Rev 21(1): 17
20

Anderson J 2014 Breastfeeding and food sensitivities. Australian Breastfeeding Association

website: breastfeeding.asn.au/bfinfo/breastfeeding-and-food-sensitivities

Upcoming book (in press)

Food Intolerance Network website: fedup.com.au Support

Note that these may not all deal with mothers/infants

Separately lists those offering Skype (and/or phone and/or email)

consultations and some will consult with international clients

Resources

Resources

Food-chemical intolerance:
Joan Breakeys e-books (see foodintolerancepro.com):
Are You Food Sensitive? Second edition
Fussy Baby: Practical Advice on Introduction of Solids, Eating Development
and Food Sensitivity
g Troublesome Foods
Tolerating
Also website articles and blog
Sue Dengates Fed Up and The Failsafe Cookbook, and Food Intolerance
Network website (fedup.com.au)

2016JoyAnderson,AM,APD,IBCLC
ForindividualuseofiLactation'sBreastfeeding:passionandbiology participantsonly

Allergy and food-chemical intolerance: Royal Prince Alfred Hospital

Allergy Unit, Sydney www.sswahs.nsw.gov.au/rpa/allergy and
allergy.net.au; RPAH Elimination Diet Handbook
Allergy: Australasian Society for Clinical Immunology and Allergy
allergy.org.au
Lactose intolerance/overload: breastfeeding.asn.au and use search
term lactose (Joys articles will be first two listed)

Adversefoodreactionsinthebreastfedinfant

Case studies
Catherine and Luke
Melanie and Jacob

2016JoyAnderson,AM,APD,IBCLC
ForindividualuseofiLactation'sBreastfeeding:passionandbiology participantsonly