Can we treat the cause of infant reflux with maternal milk elimination?
There has been a longstanding problem among zookeepers: The gorillas were throwing up all of the time. “The practice of regurgitation has never been reported in wild Gorillas but it has unfortunately been accepted as normal by many keepers of captive animals.” What were they feeding them? Gorillas are big, strong animals, so they made sure to feed them a lot of protein—cottage cheese, meat, eggs, and milk—until a zoo in Germany got the radical idea of feeding them their natural diet of “leaves and vegetables.” And, the “change…following the alterations to the diet was astonishing.” Before the change, a silverback had been regurgitating and vomiting during most of the day. But, by the third day of eating what they were supposed to eat, he and the rest of the troop were miraculously cured. Even just removing milk from the diets of the captive gorillas led to significant improvements. Cow’s milk was “historically considered an essential item in the captive gorilla diet,” but researchers showed that eliminating it may reduce such “undesirable behaviors…and may be a step toward better approximating the natural diet for captive gorillas.” The zookeepers were giving them animal milk after weaning—that is, giving animal milk to adults. Milk is for babies. What’s more, they were giving milk from a bovine to a primate. What were these zookeepers thinking?
I’m reminded of a landmark study I discuss in my video Treating Reflux in Babies with Diet. Eighty-one children presenting with gastroesophageal reflux disease (GERD) were given drugs, and two-thirds got better, but 27 kids did not. So, the researchers eliminated cow’s milk from their diets. Within one month, all 27 were cured.
“Symptoms of acid regurgitation, heartburn or both occur at least once a week in 10–20% of adults belonging to the western world” and up to about 25 percent of all infants. It’s normal for babies to spit up occasionally—that’s not what we’re talking about. It can actually get quite serious. Up to a quarter of “infants present with regurgitation severe enough for parents to seek medical help,” and it may just be that they’re sensitive to cow’s milk. The symptoms of cow’s milk protein allergy “overlap with many symptoms of GERD, or may coexist or complicate GERD,” or reflux. Even if there’s no formal dairy allergy per se, there appears to be some kind of cow’s milk “hypersensitivity” among many infants and children with severe reflux.
There are all sorts of invasive tests, such as sticking pH probes down the baby’s throat, but probably the most practical test in routine pediatric practice is just a trial of a cow’s milk protein elimination diet for two to four weeks in infants with reflux.
The gold standard is what’s called an elimination and rechallenge protocol, where there is a “full resolution of symptoms via strict elimination followed by recurrence [of symptoms] on reintroduction of cow’s milk protein.” Two hundred or so infants diagnosed with reflux were put on a cow’s milk–free diet, then were given the challenge tests. Eighty-five of the 204 infants with reflux were actually suffering from a cow’s milk allergy or hypersensitivity.
So what’s happening? We think our immune system understandably considers the bovine proteins as foreign and attacks, triggering an inflammatory response, which irritates the nerves lining the digestive tract. That then results in abnormalities in the rhythmic contractions of the stomach, triggering the regurgitation. We’re not just talking about formula-fed infants either. Cow’s milk protein allergy “can occur in exclusively breastfed infants,” too, “as intact cow’s milk proteins can be secreted in breast milk.” If the mom drinks milk or eats eggs, the proteins can get into her baby. Cow’s milk protein and other foreign proteins can pass into human breastmilk. So, “breast-fed infants with regurgitation and vomiting may therefore benefit from a trial of withdrawal of cow’s milk and eggs from the maternal diet.”
Indeed, that is now the consensus recommendation of both the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Anytime you see reflux, the first thing to try is a therapeutic trial of either a cow’s milk protein–free formula or, for infants who are breastfed, a strict maternal cow’s milk protein elimination diet. Then we can potentially treat the cause without using unnecessary medications and certainly before considering anti-reflux surgery.
For older children with reflux, see my video How to Treat Reflux in Children with Diet.