Reflux and Cow Milk Allergy: Is there a link?

Reflux seems to be the hot ticket diagnosis for newborns and many are prescribed pharmaceuticals to manage symptoms or are instructed to initiate a dairy elimination diet. GER, or gastroesophageal reflux, is present in virtually every infant however. It is a normal physiologic event. Respectfully, it can also be quite dangerous, even fatal, but discerning between a scenario that is truly pathological is important as interventions imposed on an otherwise normal physiologic process can undermine breastfeeding and lead to early weaning, imposing risks of its own.

Reflux is considered physiologic when the infant thrives well and experiences no complications. Regurgitation of at least one episode per day occurs in half of all newborns through three months of age infants, increasing to more than two-thirds of all infants by four months of age, finally decreasing to 5% of children between the ages of ten and twelve months. Symptoms can be normal through two years of age.

Pathologic GER is reflux associated with other manifestations, such as, failure to thrive or weight loss, feeding or sleeping problems, chronic respiratory disorders, esophagitis, hematemesis, stricture, sideropenic anemia, apnea, apparent life-threatening episodes or sudden infant death syndrome, and Sandifer's syndrome. Recurring respiratory symptoms is an atypical presentation without the regurgitation and vomiting, but reflux just the same.

Food allergy is actually a secondary GER, and is considered GERD or GER disease. This diagnosis is difficult to make. Infections, metabolic and neurologic disorders are also causes for secondary GER.

Cow milk intolerance defines any reproducible clinical adverse reaction to cow milk, and is suggested with increased total or specific blood immunoglobulin (Ig) E or positive skin-prick test, but no reliable routine test is available for definitive diagnosis. Cow milk allergy is reported in 0.3% to 7.5% of infants, most before the fourth month of life. In breastfed infants, allergy occurs in approximately 0.5% of babies.

Approximately 30% to 70% of infants with cow milk allergy manifest dermatological symptoms, and 20% to 30% manifest respiratory symptoms. Meaning, more than half with cow milk allergy demonstrate symptoms involving more than one major system. Clinical response to an elimination diet and a challenge is the diagnostic principle for food allergy. Diagnosis of specifically cow milk protein enteropathy ideally necessitates the proof of small bowel damage with patchy partial villous atropy and increased intraepithelial lymphocytes.

Natural tolerance in infants who are affected by cow's milk is frequently achieved within the first years of life. A quarter find remission by two years of age, half by three, and 78% by 6 years of age. GER and cow milk allergy are generally self-limiting symptoms, possibly interrelated, with only a small proportion of infants who will continue to have the disease-related symptoms after early infancy.

Soy-protein-based formula is NOT recommended in the initial treatment of cow milk allergy (CMA), although most infants with IgE-mediated CMA may do well on soy formula, particularly after the age of 6 months. Soy is not effective in preventing allergy and the atopic manifestations are comparable in the cow milk verses soy groups.

Breastfed infants have less and shorter reflux episodes three and four hours after feeding, which is believed to be contributed to more quiet sleep, improved clearance rate, and enhanced gastric emptying, and may be related to differences in macronutrient content such as lipids and other components such as growth factors. When a CMA-related GERD is suspected, a dietetic trial with complete avoidance of CMP (with calcium supplementation when required) in the maternal diet is suggested for 3 to 4 weeks. When helpful, CMP should be reintroduced in the maternal diet to prove any casual relationship.

However, prior to recommending an elimination diet in our practice, the Nurse Midwives investigate thoroughly the breastfeeding relationship for oversupply. This alone can cause colitis and is easily rectified. Probiotics are vital, as Lactobacillus is quite beneficial for atopic dermatitis and of course, gut health. Finally, although it is politically incorrect for a midwife to suggest ditching store bought milk for raw milk, I don't believe humans were created to drink orange juice without consuming the orange, nor do I believe we were created to consume cow's milk without all the components removed through pasteurization, or frankly with all the preservatives, antibiotics, fortifiers and hormones. Can we diagnosis a cow milk allergy if real cow milk isn't even being consumed?

Salvatore, S. & Vandenplas. Y. (2002). Gastroesophageal reflux and cow milk allergy: is there a link? Pediatrics, 110(5), 972-983.