Will Whole Milk Constipate a Baby More Than 2 Percent Milk

Iran J Pediatr. 2012 December; 22(4): 468–474.

The Role of Cow'southward Milk Allergy in Pediatric Chronic Constipation: A Randomized Clinical Trial

Seyed-Mohsen Dehghani, Physician,^{one, 2, *} Bita Ahmadpour, Medico,^two Mahmood Haghighat, MD,² Sara Kashef, Medico,³ Mohammad-Hadi Imanieh, MD,¹ and Mohammad Soleimani, Doctor²

Seyed-Mohsen Dehghani

ⁱTransplant Enquiry Center, Shiraz University of Medical Sciences, Shiraz, Iran

²Gastroenterohepatology Research Center, Shiraz Academy of Medical Sciences, Shiraz, Iran

Bita Ahmadpour

²Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Islamic republic of iran

Mahmood Haghighat

^twoGastroenterohepatology Enquiry Center, Shiraz University of Medical Sciences, Shiraz, Iran

Sara Kashef

³Allergy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

Mohammad-Hadi Imanieh

^oneTransplant Research Heart, Shiraz University of Medical Sciences, Shiraz, Iran

Mohammad Soleimani

²Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

Received 2011 Oct 7; Revised 2012 Feb 18; Accepted 2012 Mar 25.

Abstract

Objective

Cow's milk allergy has different presentations in children and can cause functional bowel symptoms such equally chronic constipation. The aims of this study were to investigate the role of cow's milk allergy as a cause of chronic constipation and effect of cow'south milk costless diet (CMFD) on its treatment in children.

Methods

We performed a randomized clinical study comparison CMFD with cow'due south milk diet (CMD) in 2 groups each consisting of 70 patients (age range, 1-xiii years) with chronic functional constipation (defined equally Rome III criteria). All subjects had been referred to a pediatric gastroenterology clinic and had previously been treated with laxatives for at least iii months without success; also all 140 patients performed pare prick test. The instance group received CMFD for 4 weeks. After that they received CMD for 2 extra weeks. The control group received CMD for whole 6 weeks. A response was defined as decreased in signs and symptoms that not fulfilled Rome Iii criteria after iv weeks of CMFD and came back to Rome III criteria subsequently ii weeks of CMD claiming.

Findings

After 4 weeks 56 (80%) patients of the instance grouping responded in comparison to 33 (47.ane%) patients in the control grouping (P=0.0001). In the instance grouping after 2 weeks claiming 24 out of 56 (42.8%) responders developed constipation according to Rome III criteria. With other words, the frequency of cow's milk allergy amid constipated patients was 80%. Only 1 patient had positive pare prick examination.

Conclusion

In children, chronic constipation can be a manifestation of cow'south milk allergy. At nowadays, although several aspects must exist further investigated, a therapeutic endeavor with elimination diet is appropriate in all children with constipation unresponsive to correct laxative treatment.

Keywords: Cow's Milk, Milk Allergy, Allergy, Chronic Constipation, Children

Introduction

As a gastrointestinal (GI) disease chronic constipation is very mutual in the general population with a prevalence of nearly twenty%[one]. It is likewise very common in children with a frequency between 3% and xvi%[ii]. In dealing with this disease, it is important to be sure that it is not secondary to other weather, similar thyroid disease or built bibelot of GI tract. Life style modification can exist the offset management in chronic functional constipation. And so, if no response is achieved, a therapeutic trial with fiber and/or elementary laxatives is suggested. In spite of these modalities many patients do non answer. It has been reported that at the stop of a five-year follow-upward study, no improvement was seen in 35-45% of the patients[iii].

In children with chronic constipation not responding to laxative handling the symptom may be due to other causes, one of them beingness cow'south milk allergy[four–6].

Association between cow's milk allergy and chronic constipation has been reported by Buisseret in 1978[seven]. In an open only non placebo-controlled study by Iacono et al, was shown that 21 of 27 patients with refractory constipation responded to a cow's milk complimentary diet (CMFD)[5].

Many reports showed the relationship between chronic constipation and cow's milk allergy, but some were against[6, 8–15]. Loening-Baucke reported no improvement of the symptom in children with chronic constipation who had a history of moo-cow'southward milk allergy and accept been on CMFD[3]. Yimyaem et al reviewed the results of 10 cow's milk allergy patients studied from 1997 to 2001 and did non find whatever relation with constipation[16].

In order to clarify these apparently alien results we decided to check the effect of CMFD on our patients with chronic constipation.

Subjects and Methods

In this randomized clinical trial all consecutive patients less than 14 years of age with chronic constipation referred to Pediatric Gastroentero-logy Clinic affiliated with Shiraz University of Medical Sciences between Apr 2009 and Apr 2010 were evaluated. We used Rome Three criteria for definition of functional constipation[17], i.eastward. two or more of the following in a child with a developmental historic period of at least iv years with insufficient criteria for diagnosis of inflammatory bowel syndrome:

1. Two or fewer defecations in the toilet per week.

2. At to the lowest degree i episode of fecal incontinence per week.

3. History of retentive posturing or excessive volitional stool retentivity.

4. History of painful or hard bowel movements.

5. Presence of a big fecal mass in the rectum.

6. History of large diameter stools that may obstruct the toilet.

Criteria fulfilled at least in one case per week for at least two months before diagnosis, and one month of at to the lowest degree two of the following in infants up to 4 years of age:

1. Two or fewer defecations per week.

2. At least 1 episode/week of incontinence later the conquering of toileting skills.

3. History of excessive stool retention.

4. History of painful or hard bowel movements.

5. Presence of a large fecal mass in the rectum.

6. History of large diameter stools which may obstruct the toilet[17].

The exclusion criteria were anatomical causes of constipation (eg, Hirschsprung'south disease, spinal illness), constipation due to other disorders (eg, hypothyroidism, psychomotor retardation), prior anal surgery, and use of medications that tin crusade constipation.

140 children were enrolled: 73 boys and 67 girls (52.1% and 47.ix%, respectively), age range, i-thirteen years; (mean, 4.half dozen±2.7 years). They all fed cow's milk, dairy products, or commercial formulas derived from moo-cow'southward milk. Previous handling with different laxatives such as lactulose, Mg(OH)₂, methane series, and PEG for at to the lowest degree three months had been unsuccessful in all patients. When the patient was first seen, complete concrete exam including rectal examination was washed and a detailed chart was compiled containing the results of the physical test and medical history information such as breast feeding during the offset months of life, credence of formula at weaning, and especially the presence or absence of Rome III criteria. Next day the patient received Peel Prick Exam.

Diagnosis of cow's milk allergy induced constipation was based on increased frequency of defecation or decreased number of signs and symptoms later on iv weeks CMFD and coming back to Rome Three criteria after 2 weeks of challenge with CMD in comparing to the control group. We define CMFD every bit a nutrition complimentary of whatsoever dairy products made of cow'due south milk.

At the commencement visit, the parents were asked to record the kid's signs and symptoms, and all medications were discontinued. Then the patient was assigned to receive PEG solution 0.5 gram/Kg/twenty-four hour period and CMFD or PEG solution with the same dose and CMD for the next iv weeks. PEG was prescribed past pediatric gastroenterologist to all patients. The order of dietary treatment was randomly assigned by a estimator generated method with the private patient as the unit of measurement of randomization and according to this randomization the patients were recommended to receive CMFD or CMD by a pediatric allergist. At the end of the treatment, the protocols were evaluated again past pediatric gastroenterologist who was blinded to the blazon of diet. At baseline and at the end of the first written report periods, the children were examined by a researcher. During the study period, the parents recorded the number of bowel movements, equally well as the advent of the stools and the child's difficulty in passing them. To ensure that the children did non receive any other kind of milk or milk-containing foods during the written report, the parents were given a list of the most common milk-containing foods to be avoided. During the study period, they were asked to tape the amount and type of food their child had eaten each day. At the finish of the report, we analyzed these diaries to evaluate adherence to the diet and the quantity of milk consumed. The parents were able to contact u.s. whenever necessary, and phone contacts helped to ensure adherence to the diet. Afterward the outset study period, the children who were on the CMFD were given the CMD for another two weeks. During the two calendar week challenge flow, the parents recorded any clinical symptoms, and the patients were reexamined in the infirmary for any adverse reaction, and at the end of the challenge menstruum they were evaluated for presence of constipation again. Informed consent was obtained from the parents of all the patients involved in the study. The report was approved by Institutional Review Lath of Shiraz University of Medical Sciences. Frequency analysis was performed with Fisher'southward exact examination. The Pearson Chi-Square and McNemar tests were used to compare the Rome criteria, and Student's t-exam for parametric analysis. All P-values were ii-tailed, and P-values less than 0.05 were considered to bespeak statistical significance.

Findings

Two groups were matched for age, sexual activity, duration of illness, frequency of breast feeding at birth and signs and symptoms of constipation at the time of entry to study. The base-line characteristics of the 140 patients are shown in Tables 1 and ​ 2. Eighty-four (60%) children had abdominal hurting and only 7 (5%) patients had anal fissures. After iv weeks 56 (80%) patients of the case group responded in comparison to 33 (47.one%) patients in control group (P=0.0001). The comparing of Rome criteria in the case group before trial and 4 weeks after CMFD are shown in Table 3. Table 4 shows the comparing of these criteria between example and control group. All patients in case group underwent a challenge with CMD for ii weeks. The comparison of Rome criteria in case group earlier trial and at the end of trial are shown in Table 5. None of the patients who received CMD had an acute reaction. Subsequently this period 24 out of 56 (42.viii%) responders adult constipation co-ordinate to Rome Iii criteria. With other words, the frequency of cow's milk allergy among constipated patients was 80% but the frequency of cow'due south milk allergy induced constipation based on our definition (increased frequency of defecation or decreased number of signs and symptoms after four weeks CMFD and coming back to Rome 3 criteria after 2 weeks of claiming with CMD) was 34.3%.

Table 1

Clinical characteristics of children with chronic constipation before trial

Parameter	Patients on Cow'southward Milk Costless Nutrition (n = 70)	Patients on Moo-cow'due south Milk Diet (n = 70)	P-value
Age [mean (SD)](months)	54.7 (32.2)	55.v (34.one)	0.887
Sex (Male/Female)	39/31	34/36	0.501
Breast feeding at nativity (%)	23 (32.ix)	17 (24.3)	0.348
Duration of illness [mean (SD)](months)	26.3 (22.7)	26.ane (19.3)	0.955
Abdominal pain	xl	44	0.606
Anal crevice	v	2	0.447

Table 2

Comparison of Rome criteria in children with chronic constipation before trial

Parameter	Patients on Cow'southward Milk Gratuitous Nutrition (n = 70)	Patients on Cow's Milk Diet (north = 70)	P-value
≤ two defecations per calendar week	56	63	0.2
≥ 1episode/week of incontinence after the acquisition of toileting skills	28	25	0.7
History of retentive posturing or excessive volitional stool retention	61	58	0.6
History of painful or hard bowel movements	69	66	0.iv
Presence of a large fecal mass in the rectum	40	63	0.0001
History of large bore stools	69	66	0.four

Table three

Comparison of Rome criteria in children with chronic constipation before trial and 4 weeks subsequently cow's milk free diet

Parameter	Patients on Cow's Milk Free Diet before Trial (n = seventy)	Patient on Cow's Milk Free Diet after iv Weeks (n = 70)	P-value
≤ 2 defecations per week	56	3	0.000
≥ one episode/week of incontinence later the conquering of toileting skills	28	two	0.000
History of retentive posturing or excessive volitional stool retention	61	7	0.000
History of painful or difficult bowel movements	69	9	0.000
Presence of a large fecal mass in the rectum	40	2	0.000
History of large bore stools	69	9	0.000

Table iv

Comparison of Rome criteria in children with chronic constipation on cow'due south milk free diet and cow'south milk nutrition after 4 weeks

Parameter	Patients on Cow's Milk Free Diet (due north = lxx)	Patients on Cow's Milk Diet (due north = 70)	P-value
≤ two defecations per calendar week	iii	xx	0.0003
≥ 1 episode/week of incontinence subsequently the acquisition of toileting skills	ii	15	0.002
History of retentive posturing or excessive volitional stool retentivity	7	19	0.02
History of painful or hard bowel movements	9	32	0.0001
Presence of a large fecal mass in the rectum	2	20	0.0001
History of large bore stools	9	32	0.0001

Table 5

Comparison of Rome criteria in children with chronic constipation on moo-cow'south milk free diet before trial and ii weeks subsequently cow'south milk diet claiming

Parameter	Patients on Moo-cow's Milk Free Nutrition before Trial (north = 70)	Patient on Cow's Milk Free Diet 2 Weeks after Cow's Milk Diet Challenge (northward = 70)	P-value
≤ 2 defecations per calendar week	56	eleven	<0.001
≥ 1 episode/week of incontinence after the acquisition of toileting skills	28	vii	<0.001
History of retentive posturing or excessive volitional stool retention	61	10	<0.001
History of painful or hard bowel movements	69	xx	<0.001
Presence of a large fecal mass in the rectum	twoscore	vii	<0.001
History of large diameter stools	69	twenty	<0.001

At beginning of the report in that location was a tendency towards a high frequency of negative skin prick test amid the patients with functional constipation, and in only 1 child with cow's milk allergy induced constipation it was positive.

Discussion

Cow'southward milk allergy has many signs and symptoms. Some studies showed that chronic diarrhea is the mostly encountered GI symptom of cow's milk allergy in children[6], constipation being another but non too frequent symptom. It is not notwithstanding confirmed that allergy to moo-cow'southward milk could crusade refractory chronic constipation.

Several clinical studies take been done in pediatric cow's milk allergy with inconsistent results. Recently information technology is agreed that constipation seems to exist the outcome of hypersensitivity to cow's milk proteins[4–12, 18]. In a recent written report the role of allergy in the etiology of constipation in children was investigated. Nighty-9 out of 136 (72.8%) constipated children less than 3 years of age had allergy to cow'due south milk protein every bit a cause of constipation and subsequently introduction of the elimination diet clinical comeback was observed in all children. The authors concluded that cow's milk allergy is the most common cause of constipation in the outset 3 years of life[19].

Syrigou EI et al in Greece showed that constipation was improved in 28/32 constipated children with positive atopy patch test (APT) after withdrawing the APT-positive foods for an 8-week menses[twenty]. We plant a relation between the intake of cow's milk products and constipation in about 1 third (34.3%) of the patients. In a study in Spain 35 of the 69 constipated children (51%) improved during the first CMFD period, viii of these did non develop constipation when CM was reintroduced, and other 27 children (39%) developed constipation during the CM challenge and improved during the second CMFD phase, which is consistent with our report[21].

Only i patient had positive skin prick test. Positive skin prick test response indicates the possible association between the food tested and the patient'southward reaction to that specific food. Although positive skin prick test response only "suggests" the presence of symptomatic allergy, the negative peel prick examination response is an excellent means of excluding IgE-mediated food allergy. In this regard Irastorza I et al did non find an IgE-mediated immunologic mechanism in children with chronic constipation[21], but for approval this, further study is needed. The present study showed that excluding moo-cow's milk products from children'due south diet with chronic constipation is associated with improvement of the signs and symptoms in lxxx% of patients. This percentage of responding to emptying diet was the same as in other studies[4–6, 18]. In ane study, of 27 children with chronic functional constipation who did non respond to two months of laxative therapy, 21 (77.7%) were responsive to elimination of cow'south milk and dairy products for a 1 month catamenia[22], this is comparable with our results.

Nosotros institute that CMD has a meaningful effect on making signs and symptoms of constipation, and other factors may have effect on these signs and symptoms like other proteins in other diets, and compliance of patients and their parents during the written report. It is not completely agreed that 2 weeks of claiming exam is enough for coming back of all signs and symptoms of CMD dependent constipation, and if it was longer, further signs and symptoms might recur.

Furthermore, clinical examination of the children in our study showed a depression frequency (5%) of severe anal fissures. Because in some studies[4, 7, xi], these lesions reappeared after the reintroduction of moo-cow's milk and before the onset of constipation, it is hypothesized that these are one of the mechanisms causing constipation. Merely in our study, we found no crusade and effect relationship betwixt anal fissure and constipation.

This study has some limitations. Our pediatric gastroenterology department is a referral center, the pediatricians who referred patients, may have preselected the patients. Besides, we could not totally rule out psychological factors, which are oftentimes suggested equally the crusade of chronic constipation. In most previous studies, similar ours, all the patients had been previously treated unsuccessfully with laxatives; and so, the high frequency of cow'southward milk allergy in constipated children in these studies may have been due in part to their inclusion criteria.

Conclusion

Chronic constipation can be a manifestation of moo-cow's milk allergy in children. At nowadays, although many questions exist that take no answer, but a therapeutic trial with elimination diet is advisable in all children with constipation unresponsive to correct laxative treatment.

Acquittance

Local Research Ethics Committee of Shiraz University of Medical Sciences has approved this research.

References

one. Locke GR, Three, Pemberton JH, Phillips SF. American Gastroenterology Association medical position statement: guidelines on constipation. Gastroenterology. 2000;119(half dozen):1761–78. [PubMed] [Google Scholar]

2. Loening-Baucke V. Constipation in early childhood: patient characteristics, treatment and long-term follow-up. Gut. 1993;34(10):1400–iv. [PMC free article] [PubMed] [Google Scholar]

3. Loening-Baucke Five. Controversies in the management of chronic constipation. J Pediatr Gastroenterol Nutr. 2001;32(Suppl one):S38–9. [PubMed] [Google Scholar]

4. van Ginkel R, Reitsma JB, Buller HA, et al. Childhood constipation: longitudinal follow-up beyond puberty. Gastroenterology. 2003;125(2):357–63. [PubMed] [Google Scholar]

5. Iacono Thousand, Carroccio A, Cavataio F, et al. Chronic constipation every bit a symptom of cow milk allergy. J Pediatr. 1995;126(1):34–9. [PubMed] [Google Scholar]

6. Iacono G, Cavataio F, Montalto G, et al. Intolerance of cow'south milk and chronic constipation in children. North Engl J Med. 1998;339(16):1100–4. [PubMed] [Google Scholar]

7. Buisseret PD. Common manifestations of moo-cow'due south milk allergy in children. Lancet. 1978;1(8059):504–5. [PubMed] [Google Scholar]

8. Chin KC, Tarlow MJ, Allfree AJ. Allergy to cow'southward milk presenting as a chronic constipation. Br Med J (Clin Res Ed) 1983;287(6405):1593. [PMC free article] [PubMed] [Google Scholar]

ten. Davidson M, Kugler MM, Baue CH. Diagnosis and management in children with severe and protracted constipation and obstipation. J Pediatr. 1963;62:261–75. [PubMed] [Google Scholar]

11. Shah N, Lindley 1000, Milla P. Cow'due south milk and chronic constipation in children. Northward Engl J Med. 1999;340(xi):891–2. [PubMed] [Google Scholar]

12. Daher S, Soleé D, de Morais MB. Cow's milk and chronic constipation in children. N Engl J Med. 1999;340(xi):891. [PubMed] [Google Scholar]

thirteen. Daher South, Tahan Southward, Solé D, et al. Cow's milk protein intolerance and chronic constipation in children. Pediatr Allergy Immunol. 2001;12(6):339–42. [PubMed] [Google Scholar]

14. Vanderhoof JA, Perry D, Hanner TL, et al. Allergic constipation; association with infantile milk allergy. Clin Pediatr. 2001;40(7):399–402. [PubMed] [Google Scholar]

15. Turunen S, Karttunen TJ, Kokkonen J. Lymphoid nodular hyperplasia and moo-cow's milk hypersensitivity in children with chronic constipation. J Pediatr. 2004;145(5):606–11. [PubMed] [Google Scholar]

xvi. Yimyaem P, Chongsrisawat Five, Vivatvakin B, et al. Gastrointestinal manifestations of cow'south milk protein allergy during the first year of life. J Med Assoc Thai. 2003;86(2):116–23. [PubMed] [Google Scholar]

17. Rasquin A, Di Lorenzo C, Forbes D, et al. Babyhood functional gastrointestinal disorders: kid/adolescent. Gastroenterology. 2006;130(5):1527–37. [PMC complimentary commodity] [PubMed] [Google Scholar]

eighteen. Carroccio A, Montalto K, Custro N, et al. Prove of very delayed clinical reactions to moo-cow's milk in cow's milk intolerant patients. Allergy. 2000;55(6):574–9. [PubMed] [Google Scholar]

19. Kamer B, Dólka East, Pyziak K, et al. Food allergy equally a cause of constipation in children in the first iii years of life - ain observations. Med Wieku Rozwoj. 2011;15(2):157–61. [PubMed] [Google Scholar]

20. Syrigou EI, Pitsios C, Panagiotou I, et al. Food allergy-related paediatric constipation: the usefulness of atopy patch examination. Eur J Pediatr. 2011;170(9):1173–8. [PubMed] [Google Scholar]

21. Irastorza I, Ibañez B, Delgado-Sanzonetti L, et al. Cow'south-milk-complimentary diet equally a therapeutic pick in childhood chronic constipation. J Pediatr Gastroenterol Nutr. 2010;51(2):171–half dozen. [PubMed] [Google Scholar]

22. El-Hodhod MA, Younis NT, Zaitoun YA, Daoud SD. Moo-cow's milk allergy related pediatric constipation: advisable fourth dimension of milk tolerance. Pediatr Allergy Immunol. 2010;21(two Pt 2):e407–1. [PubMed] [Google Scholar]

mooreeptich.blogspot.com

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3533146/