Narrator:

Introducing Doctor Vanderhoff, a Paediatric Gastroenterologist, Professor and leader in the field of Paediatric Gastroenterology and Nutrition. He held leadership positions, including Vice President of Global Medical Affairs and chief medical officer for Mead Johnson Nutrition.

Doctor Vanderhoff currently serves as Chief of Paediatric Gastroenterology at the Boys Town National Research Hospital in Omaha, Nebraska, USA. As an attending physician in GI nutrition at Boston Children's Hospital, Senior lecturer in Paediatrics at the Harvard Medical School, and Professor Emeritus of Paediatrics at the University of Nebraska College of Medicine.

Please welcome Doctor Vanderhoff.

Dr Jon Vanderhoff:

Thank you all very much. This is the English version of the last talk. So, I. Anyway. If you're a practicing paediatrician, I think one of the most frustrating things for you, is to have a mother bring in a fussy baby. And I think the last talk that you heard kind of gives you a perspective on how difficult some of these babies can be.

And, and how, you have to sort of establish an approach to, to deal with, with a mother who brings in a baby like this and help them through this, the, this difficult period in their life. So, what I'm going to do is sort of concentrate on, on the second part of that, which is, is the part that involves, trying to make a very quick decision in your mind whether this is a baby with infantile colic and you need reassurance or whether there's something else going on and you need to do something about it.

And if it's anything for you, like it is in the United States nowadays, you don't have much time to make this decision because, the patients come in very fast. And so, we'll talk a little bit about that. First thing I have to do is mentioned some disclosures. And I always like to tell people that, if they have a company and they would like to get their name on this list, the price is really quite low. Yeah. And I'd be happy to give talks for you. So, this is sort of a summary of the first, first presentation is that, you know, there are some babies that cry and that's normal. And actually, all babies cry. That's normal. And then there are some babies who cry too much, and that's colic. And then we have another set of babies that cry too much because there's something else wrong with them. And you, as the, the paediatrician, have to have to look at that baby and ask a few questions and try to figure out very quickly if this is one of those babies in the third category, or if you need to simply, you know, move on to the explanation and help the mother through the problem. And unfortunately, what I think we often have in paediatrics is what I call kind of a knee jerk response to these kids and the first knee jerk response is, to start them on acid suppression like a PPI or an H2 receptor antagonist.

And, and so, at least in the United States, it's been very, it's very common for paediatricians to do this. And the reason, why they do this as they think that a lot of times these babies spit up a little bit and they think they have gastroesophageal reflux, and they think that the acid from the, from the stomach and the oesophagus is causing the baby pain and discomfort. And they think that because, either they're old like me and they reflux and or hurts, or they're females and they've been pregnant. And they know that when they were pregnant, they reflux Then it hurt. And so, in adults, you get heartburn when you reflux. So, they assume that the baby does the same thing.

And I think, partly, those of us who are paediatric gastroenterologists, popularized this, this, theory about, 40, 30, 40 years ago. And we're sort of reluctant to admit that we're wrong. But what it turns out to be actually true is that gastroesophageal reflux is very common in babies. They spit up a lot and they spit up because the, the lower oesophageal sphincter is sort of like a pop off valve. If the baby eats too much, it comes up the other way. And that's how he regulates his food intake. And in formula fed babies. You know, if the mother. Yeah, she buys this formula. By God, you know, I paid for this. You're going to drink all of it. And then, of course, the baby doesn't need that much. And up comes the rest. And that's normal for a baby. That's the way it's supposed to work. But somehow, mothers don't appreciate that. That babies supposed to spit up, and so they also make this association. Well, that that spitting up must be causing this baby to cry all the time. So, what's the evidence?

So, are there any studies that show that gastroesophageal reflux causes irritability in babies during the. Anybody think that there are any such studies raise your hand so. Well, there aren't. However, there are some studies that show quite the opposite. And this one, I think is one of the best ones. And this was done by, Susan Orenstein in the US. And what, what Susan did was she gave, she took a bunch of fussy, spitty babies, and she put half of them on a PPI and half of them on a placebo, and, and the and she watched, to see what happened. And did the babies cry any less? No, they cried exactly the same. Did they spit up or vomit any less? No. They spit up or vomited the same. And they fed the same. There was no difference. And in fact, the only difference between these two groups of patients that she saw was that the babies that had, the got the PPI, had more infections, more gastrointestinal infections and more respiratory infections because the primary function of the gastric acid is not to help you digest the food, it's to kill viruses and bacteria that that's what it's really therefore and consequently, you took that away. So the babies experienced that problem.

Well, are there other studies? Yeah. Well, here's a nice little study, looking at, using, studies showing that there was no correlation at all between when babies reflux and when they cried. And then I've heard, I hear a lot of times, oh. Well, look at how he's arching his back. That that means he's caught. He has reflux. I've actually heard some of our attendings say this. And in Boston, and I saw that's not true. And so I found this little, reference that said, yeah, there's no, correlation between back arching and reflux. That's more of a, a colicky thing. So, so, so you can kind of say you put, put, put it aside, fussiness in your ability or caused by reflux and consequently treatment with a PPI or an H2 receptor antagonist for a fussy baby is something that we shouldn't do.

Everybody knows that if you give a baby, antibiotics, during the first year of life, a couple times during the first year of life, you will screw up the baby's microbiome. And this means, after you heard all about the microbiome yesterday from Roberto, and he told you, how you know, how much, a disk biotic or, inappropriate microbiome, can be in inducing allergy. And sure enough, babies, they get a lot of antibiotics or more likely, allergic. But did you know, that a PPI will do the same thing? PPI will also, disturb the microbiome because you get all of this extra, bacteria, that is normally killed off by the stomach acid down into the small bowel and colon. You change how the baby's colonized and you get more, more allergy. So, so this is, you know, not only, giving PPI use to babies doesn't help it. It actually causes harm. And I'm really trying to, spend a lot of time trying to get people not to do this.

So, the other reflex, that, paediatricians often hear is to change the formula. There may be some logic here, but, but one of the one of the logics, that people use is, well, take the lactose out of the formula, because the baby must be lactose intolerant. Babies never are lactose intolerant. If you think about it, this would be a lethal gene for a baby. Until about 50 years ago, when we had infant formula. Because lactose is present in all breast milk. And if lactose intolerance were common in breast milk, you'd have a whole lot of babies, that would die, because they were lactose intolerant. You never see that. You never see that, because of course it doesn't happen. So, babies are not lactose intolerant. And if you look at this little study, taking the lactose out of formula, does not, help make a baby, less fussy. However, we've all seen, times when there are babies that are quite fussy, irritable, and you take them off cow milk protein, and they get better. And if you go back, so, Oh, I have a couple of little cases I want to present to you.

So let me ask you about this. A two-month-old formula fed baby with crying, irritability and loose stools, poor feeding and slow weight gain, blood flex noted in the stool. Sigmoidoscopy reveals a friable mucosa and the rectal biopsy shows yeast in filly colitis. And you look at and say this is a cow milk protein allergic baby with allergic colitis. And we're going to put this baby on an extensively hydrolysed formula. And sure, enough he gets better. And then this was actually this was actually something that happened to me very early in practice. I saw a baby like that.The next baby I saw was exactly the same, except he had no blood in a stool. And I did a sigmoidoscopy and biopsy on the baby. And sure enough, he had exactly the same lesion that the other baby had. And he also responded to an extensively hydrolysed formula. And that's how I learned that they don't necessarily have to have blood in their stool, that some of these fussy, irritable, crying babies, can have allergic colitis. And you don't see any visible blood in their stool. All their cow protected baby up real high. And they may have seen positive stools, but they may look normal. So, you have to take that that piece of history into account.

So then if you go back here, into the, into the early 1980s, you find the original descriptions of how cow milk protein, can cause, fussiness and irritability and crying and babies and, and these were studies that, the purpose of this study was actually to, to, to tell whether or not cow milk protein could cause colic, even though I think they're very different things. And, and sure enough, these studies from Sweden, definitely showed that when you fed these fussy, irritable babies, a cow milk, formula. They were they had colic and a lot of them had it on a soy formula. But if you put them on an extensively hydrolysed formula, it seemed to go away. And, subsequent studies were done, and I, I may have a copy of that maybe I don't where they actually put they, they took, the soy formula or the hydraulic weight formula and spiked it with whey protein and, and reproduced the symptoms to, it begins to show that it wasn't in just a placebo effect.

But if you looked at what happened when they challenged these babies in the study later on, these babies not only cried, but they had other GI symptoms, like vomiting, diarrhea, rash and so forth. And then basically what this I think shows us is this is more than colic. There are some generalized inflammatory process going on in these kids. And these kids are reacting, with a with an inflammatory response. They're not just crying, they're something else going on. And if you as a practicing physician, when you evaluate babies, think and think in these terms, you can pretty much tell a colicky baby, from an allergic baby.

Yes. Again, this is from one of these early, Scandinavian studies, which basically showed, not only do you get crying, but you get a lot of these other symptoms as well. When these babies are challenged. Well, what about, breastfed babies? They're always one thing that we always do. And we see these babies with these symptoms in, in and they're breastfed. We say, well, we take them off milk, and we get all of the milk protein out of the babies, out of their mother’s milk and maybe that'll make the baby better. And there, there, there is one study. This is an Australian study which demonstrated that, in fact, there is some statistically significant improvement in these allergic babies when you do that. And there is some rationale for doing that. And I know I have certainly made a lot of these babies better. But you do see this in breastfed babies. And the reason why you see it is because, during breastfeeding, the mother's, intestinal epithelium can actually, select and pick up macromolecules and transport them, to the, from the bloodstream or through the bloodstream to the mammary gland and secrete out these, the, these intact proteins into the breast milk. And I suspect, the reason this happens is so that the baby can develop immune tolerance to a lot of these different antigens. So, it's a normal process. And for some reason, some babies can react to multiple foods through the breast milk. And that's why this works to get it out of there.

So, this is a picture, and I want to show you this picture because I think it helps you understand what's going on here. This is an endoscopy showing, what is this little pointer work here that doesn't. Okay. So, you could see how bumpy and lumpy and inflamed that duodenum looks. And this is, this is what a baby with cow milk protein intolerance. This is what his small bowel looks like. And if you think about that, and you think what happens when, when you have an inflamed small bowel and you eat something and you've probably at one point had norovirus in your life or something, and you and you what get went through the, 12 hours of vomiting and then you start to eat something and, and then Oh, God, I wish I hadn't had done that. And it really hurts. This is what's going on in these babies. Whenever you feed them, you'll see, they'll act like they're hungry and they eat in about 5 to 10 minutes later, after they took that first bite, they start to cry and scream. And they don't want to eat anymore because that's when this stuff got into the small bowel.

And that's when the crying started. And that's when the hurting started. And so, these babies are not just crying in the evening. They're crying every time you feed them. And this is why they're crying. So, this hurts. And that's where they get the pain. And their response to that is, is to not want to eat. And to cry. And a lot of times, the response is for the stomach not to empty. And, and as a consequence of that, the babies’ stomachs will get shredded it and the baby will vomit, and it looks like gastroesophageal reflux. And that's why the assumption. Well, the reflux must be causing thing. It's not. It's delayed gastric emptying. And that's what's causing these babies to vomit. It may look the same, but it's not.

So, we put this little slide together, and this is the algorithm that I run through, my head when I see a fussy baby. Because I have the same problem. You do, and that, you know, I have way more patients to see than I have time to see them. So, we have to do them fairly quickly. And so, I run this through my head, and I said, if you if this is a colicky baby and needs the colic talk, and the and all of the discussions about how to sooth the baby and how to relax and all that, these are babies with normal stools. They gain weight. Normally, they feed fine. They cry mainly in the evening. They spit up, but not a lot. And they're suitable. I mean, if you if you take these babies and wrap them up and sooth them, or you put them on top of the washing machine in a little kind of a seat and, and jiggles a baby, you know, where you take him for a ride in the car in the United States, that's usually taking him to the emergency room, and you put him on the car, and the car bounces up and the baby quits crying. Allergic baby doesn't do that because he has pain. So, what you have with an allergic baby, they can be constipated. They can have diarrhea. But oftentimes they have abnormal stools which comes from inflammation and poor weight gain. And that comes from not eating. They refuse to eat because they hurt. And then they get failure to thrive. They feed poorly because they hurt. When they eat. They cry after there they eat their cry after they start to eat. Because of that food entering the small bowel, they spit up a lot because their stomachs don't empty. And you can't distract, distract them because they're hurt. So why wouldn't they hurt?

So, so if you have a baby like this with failure or failure to thrive, or unremitting symptoms or other gastrointestinal symptoms besides you just trying crying, put them on a hypoallergenic formula for two weeks and see if they get better. It's a nice diagnostic test, but you have to wait two weeks, and the reason you have to wait two weeks is you have to wait for the inflammation to go away.

So, a little worried about LGG. And I think when people have talked about, probiotics and I have a longstanding interest in, in, probiotics, if you ever heard of culturelle. I was one of the inventors of culturelle. I've been doing this for many years, and I and I could tell you that LGG does some really neat things, in terms of reducing inflammation in the bowel and inducing tolerance to calomel protein. Here's a little paper that shows that LGG works in colic. But if you read through this, it says that the well protected levels went down and the LGG Group. What does this tell you? It tells you that there may be some inflammation in the gut. And maybe these were more than just colicky babies, don't you think? Otherwise, why would there protecting me up? And why would they have gone down with the LGG more than any other baby? So, I don't know. But I think when you've got any kind of colic related to LGG, there are ample, are related to cow milk protein intolerance or ample data to suggest that LGG is helpful. And remember that probiotics are specific, their effects are specific to that particular strain and probiotic. Two strains of canis lupus familiaris. They're totally different.

Same thing is true with Lactobacillus Rhamnosus. The benefits of LGG are specific to that particular strain of Lactobacillus Rhamnosus. So in general, what we're talking about here is a careful history and physical run that algorithms through your heads, establish a differential diagnosis. Then you can take an appropriate action. And either there you try the extensively hydrolysed formula or you give them the colic talk, or something else.

If either one of those diagnoses’ fits. But what you don't do is put them on a PPI or take the lactose out or whatever. So, question number one. Which of the following would you do if you suspect a fussy baby has cow milk protein allergy?

Place the baby on a proton pump. Inhibitors.

Place the baby on an extensively hydrolysed formula.

Place the baby on a lactose free formula.

Tell the mother of the baby will out go the problem in a few weeks.

What happens next? If the. I have to wait, I don't I'm waiting is not one to play, so that's the correct answer. I saw it number four here. An old paediatrician once told me. Says I have nightmares about all the mothers. I told to go home. What? A kid would outgrow it before you taught me about cow milk protein allergy.

So, next question.

Goodness. A good way to tell if a formula fed baby has cow milk protein allergy is to one:

Check the baby's blood for IGG antigens to cow milk protein.

Two check a baby or place a baby on an extensively hydrolysed for milk for two weeks and see what happens.

Three check two baby stools for recalled blood and help protect 10 or

Four culture of the stool for enteric pathogens.

Oh, wow. I'm impressed. Either I'm good or you're good. So? So this is right. And, you know, I think you have to remember that, that most of these are non-IGG allergens, these things that cause inflammation in the gut. So, the IGG test won't help you. The cow protections are always elevated in babies. And I think you can probably tell an infection from, from an allergic baby, by history.

So next question. Next question.

Babies with cow milk protein allergy cry because:

-         They are hungry.

-         They have reflux.

-         They have inflammation in their GI tract. Or

-         They're lactose intolerant.

Wow. All right. Question number four. I think they get harder here, don't they? All right, well, I have to do the whoops I can. Okay.

Babies with cow milk protein allergy grow poorly because:

-         inflammation interferes with their growth.

-         They have reduced caloric intake and poor feeding.

-         They have malabsorption.

-         They have trouble metabolizing cow milk.

Well, I told you this one was harder. But that's it. That's the correct answer. They don't actually mel absorb that much. Of course they can metabolize this stuff. Fine. Inflammation interferes with growth a lot in Crohn's disease, but probably not so much in these babies. Although I can't guarantee you that it's not, a part of the factor.

But mainly they refuse to eat so they don't get enough calories. So okay, thank you.