The FFF Quick-and-Dirty Guide to Formula Feeding: Recognizing Sensitivity, Intolerance or Allergy to Formula

Those of you who haven’t been following this blog since the beginning may not know this, but my son Fearless Child (FC) has a dairy allergy, which went undiagnosed for the first few months of his life. Having his insides assaulted on a daily basis made him grumpy – so grumpy that he screamed bloody murder for about 20 hours a day. And yet it took us over a month of elimination diets, doctor visits, and late-night consultations with Dr. Google to figure out what was going on. This was partly because FC’s symptoms were slightly atypical, but more so because as new parents, we were utterly confused as to what was “normal” newborn behavior and what necessitated medical intervention.

There’s a good deal of information on dairy intolerance in babies on the Web, but not much specifically geared towards bottle-feeding parents. This is unfortunate, as those of us feeding our kids in this manner actually have a really simple way of figuring out if food issues are at play – and yet so many of us struggle for months, feeling increasingly frustrated and hopeless with our inability to comfort or feed our children adequately.

I always hesitate to offer what might be construed as medical advice, since there’s far too many hacks out there doing just that. So before I continue with this post, let me reiterate: I am not a doctor. I haven’t even played one on t.v. (Does anyone still get that reference? Or does it make me sound old?)  The following information is what I have culled from my own research, talking to pediatricians and pediatric GIs, and from my own experience as the mother of two kids with feeding issues.

Oh, and one more note: I am going to use the terms “intolerance”, “sensitivity”, and “allergy” interchangeably here, even though these three things are entirely different. This is because until you see a physician, you won’t know which of the three you are dealing with. My purpose with this post is to help you realize when something is amiss, and to assist you in navigating a medical system which often ignores the power of parental intuition and knowledge of one’s own child. You’ll have to see an actual MD to get a true diagnosis… and I don’t meant Dr. Google.

 

Behavioral Symptoms of Formula Intolerance or Allergy in Young Babies

Newborns are complicated creatures. Some are calm and sweet (this is the kind of baby everyone else seems to get at least once, but apparently my and my husband’s genetics do not morph in a manner conducive to a docile temperament), others are generally chill except for a bout of colic between weeks 2-8, and others are fussy all.the.time. This last group is the one that we need to worry about. Typically, a calm, contented baby is a well-fed and happy one. This is not to say that food allergies will not strike later in life, once solids are introduced, but a newborn who is sensitive to something in formula will usually express discomfort in a pretty vocal way. Watch out for:

- Extreme fussiness. Colic is defined as crying for a period of 1-3 hours, at least 3 days a week, typically in the evening. A baby who is sensitive to formula will cry constantly, throughout the day. They can sometimes be comforted, but only by extreme measures like continuous movement (we had to bounce FC so vigorously that once, while shopping for a new car, a man came up to us in horror and told us we should stop shaking our baby; a friend’s dairy intolerant breastfed baby was only comfortable while being vibrated in his bouncer – all night long), specific holds (the Harvey Karp /Happiest Baby hold is magical for babies with tummy issues). The difference between a “normal” fussy baby and one with potential allergy or intolerance is that they have 2 settings: sleep and screaming. The fussiness is the default, rather than the exception.

- Trouble sleeping. While many young babies sleep erratically, they usually sleep a lot cumulatively.  A newborn with a formula intolerance will often be too uncomfortable to sleep.

- Trouble eating. This one gets tricky, because other issues can cause trouble with feedings – sensory issues, reflux, dislike of the type of bottle or nipple you are using… but one common symptom in babies experiencing formula intolerance is fussiness around eating. They may pull away from the bottle and scream; or eat only small amounts at a time. Reflux can also be associated with formula intolerance, so spitting up an excessive amount after every feeding (especially if there is curdled formula or blood in the spit up) might signal a problem. Some babies might develop an aversion to eating, associating the formula with pain, and refuse the bottle altogether. Others may “comfort feed” and want to eat constantly (more on this later).

- Inability to connect or bond. Again, this can signal a far more serious issue, but it should be noted that babies who are in constant pain have a rough time chillaxing enough to focus on their parents or begin engaging in social interactions. I’ve had numerous parents tell me that they had secretly worried their baby “had no soul” or “wasn’t all there” prior to diagnosing and solving a severe allergy or intolerance. If your baby is screaming constantly or is noticeably stiff, writhing, or doesn’t seem to be comforted by touch, see your doctor.

 

Physical Symptoms of Formula-Related Food Intolerance or Allergy

The physical manifestations of a formula intolerance are more straightforward, but they also tend to suggest a more serious problem (i.e., clinical allergy versus sensitivity). In terms of getting a diagnosis, they do make life easier, but they can also be scary when first encountered. These include:

- Weight loss, or extreme weight gain, from comfort feeding.  I’ve heard of more than a few cases where babies who are overeating are misdiagnosed with the excuse that “milk protein intolerance causes failure to thrive”. This is true; many kids will have aversions to formula or breastmilk caused by associations with pain, and refuse to eat; these conditions can also cause malabsorption, so the baby isn’t getting the necessary nutrients to grow. But some babies find the liquid comforting as it goes down (especially those who have reflux associated with the intolerance or allergy), or like the sucking action, and want to eat constantly. The offending food causes more distress, which then creates a need to comfort feed more… and suddenly you’ve got Jabba the Hut, Jr. on your hands. Their girth may cause doctors to dismiss discomfort and symptoms as “overeating”(which can certainly cause a whole list of problems, but my point is that sometimes, the overeating is a symptom, not a cause).

- Blood in the stool – this can appear looking like strawberry jelly (red) or like coffee grinds (black). If you see blood, drop everything and call your pediatrician.

- Mucous in the stool – this is a biggie, because often the blood will be invisible to the naked eye, but mucous is easy to spot. Mucous looks like stringy, gelatinous strands, usually white or clear in color.

- Rashes – these can appear in a variety of forms, and may be hard to differentiate from normal newborn skin issues like diaper rash or infant acne. Sometimes the rashes might look like hives, but they can be atypical. FC would get petechia-type red dots on his cheek, right next to his eye, and down his cheek. (This same reaction continued as he grew into toddlerhood, and was a great way for us to know we’d screwed up and allowed for accidental exposure). Other parents have told me that the rashes congregate near the joints, or as a red ring around the anus. All lovely and comforting things to see on your precious newborn, right?

- Vomiting up blood. Again, this merits a panicked call to the doctor. Stat.

Something you should also know is that milk protein allergies come in two forms: rapid onset (immediate reaction) or delayed onset (reaction within 7-10 days of ingesting milk). This may explain why some babies don’t start reacting to formula until a week or so after birth/switching over from breastfeeding. Rapid onset looks more like a “classic” food allergy – hives, wheezing, bloody diarrhea. The rapid onset form is far more dangerous, as allergies can worsen with every exposure, eventually leading to anaphylaxis, so if you see these sort of symptoms, do not pass go, do not collect $200, just dial your pediatrician.

Which brings me to….

Seeing Your Doctor

There are a lot of fabulous pediatricians out there. There are also some really crappy ones. And in the middle, there are doctors who have seen thousands of neurotic new parents who freak out at the first sign of slight fussiness in their babies, and also a slew of legitimately concerned parents dealing with the untreatable hell that is infant colic. Considering that in the majority of cases the babies they see are either healthy and just waking up to the world (it’s normal for a baby to be impossibly easy and sweet for the first few weeks and then wake up one day with an attitude. Think of it as good practice for the teen years), or are unfortunate victims of colic and just have to wait it out (excuse my tangent for a moment but I cannot for the life of me understand why no one has figured out this colic thing. Seriously? We can clone sheep and we can’t figure out why some babies cry inconsolably for exactly 3 hours at the same time every night??!), it is understandable that some pediatricians have dismissive or patronizing attitudes towards those complaining about fussy babies.

I have seen parents who do overreact to sudden onset of mild spitting up, fussiness, or constipation- it’s hard not to, considering the lack of sleep, the hormones, and the lure of the Internet (Dr. Google is an alarmist). But for the most part, every parent who has emailed me with a laundry list of weird symptoms and a general, foreboding sense that something is “not right” with their newborn, has later followed up to confirm diagnosis of an allergy or intolerance. I’m a big believer in mommy/daddy “gut” when it comes to your baby’s gut.

So, here’s what I would suggest: before you go in for your child’s appointment, write down a list of every symptom you have observed. If you’ve been noticing mucous or blood, collect a stool sample, and show your doctor the craziness that is coming out of your kid’s tush. If your doctor starts talking about colic, explain to him/her that you are well aware of what colic is, and colic does not explain the other symptoms you are noticing (you might also want to mention if your child’s crying doesn’t follow a colic-like pattern – meaning that it is not sustained crying for a specific period of time, but rather constant fussiness throughout the day).

It is also well within your rights to request allergy testing, but here’s the thing: with this sort of testing, only a clinical allergy will show up. If your baby has an intolerance or sensitivity, the testing will probably come back as inconclusive or “normal”. Additionally, there is some controversy on whether allergy testing in young infants is even accurate.

Luckily, there is another, non-invasive way to see if the formula you are using is the problem, which is what I like to call…

The Miracle Cure

I could write a Shakespearean sonnet for hypoallergenic formulas, and I’m sure the folks who like to think I’m paid off by formula companies will find fodder for this conspiracy theory in how often I hawk Alimentum on here. But I just love the stuff. And not just Alimentum. Nutramigen, and Neocate, and whatever comparable product is on the European/Asian markets. The stuff is stinky, expensive….and utterly lifesaving.

If you suspect that your baby has a milk protein sensitivity, and the symptoms are not severe enough to necessitate medical intervention, you might want to consider doing a 48-hour hypoallergenic challenge. This is a 4-step process:

1. Get thee to thy nearest drugstore/grocery store

2. Purchase a commercial hypoallergenic formula (please read my post on types of hypoallergenic formula to ensure that you are choosing a true hypoallergenic and not simply a “sensitive” brand)

3. Serve said formula to thy infant, and observe for the next day or two

4. Thou shalt be singing high praises to the heavens by yonder morning, otherwise the formula probably wasn’t the problem in the first place.

While milk and soy protein allergies are the most prevalent in young infants, there are some kids who are sensitive to corn or other ingredients in formula. And for children with severe milk protein allergy, a commercial hypoallergenic isn’t going to cut it – they will need an amino acid-based formula, which is available by prescription only. But for most babies suffering from mild to moderate sensitivities/intolerances, a hypoallergenic formula is truly a godsend. You should see a marked improvement within 2 days if the problem is food related and not due to some other underlying medical condition (cough*call doctor*cough) or- and I seriously hate to say this – if it’s just colic or fussiness, in which case you really do just need to give it time, and start drinking heavily to get through the next few months. Kidding. (Maybe…)

If you are dealing with colic or normal infant fussiness, the good news is that you can skip the following section, and not have to worry about a childhood without ice cream and birthday cake. But if the formula does make a dramatic difference, you may want to consider….

What the Future Holds

If the hypoallergenic works wonders, you can continue to use the formula and try re-introducing a normal or sensitive formula at about 6 months, once your baby’s system has developed a little more. If symptoms return, then you simply return to the hypoallergenic.

That said, hypos are quite costly, and if your child does have a true milk protein allergy, you might be able to get the formula covered by your insurance. You’ll need to see your pediatrician to get the right paperwork filled out in order to do this.

I’d also suggest that you do ask for a referral to an allergist and/or pediatric GI, just so you will have someone in your corner when you start solids. While most children outgrow a milk protein allergy or intolerance as they become toddlers, some take longer than others. It gets really difficult to figure out a delayed-reaction allergy once they start solids, because the exposure could have been anytime in the week or so prior to the reaction. Also, weaning off formula looks a bit different in a dairy intolerant/allergic child. Sometimes, pediatricians will want you to stay on formula a little longer since it’s harder for kids to get the nutrition they need when they can’t eat or drink dairy products. In other cases, using a milk substitute like soy (unless your child is sensitive to soy as well, which many milk protein intolerant kids are), rice, almond (as long as you’ve seen an allergist and been tested for nut allergies), oat. or hemp, can be a perfectly acceptable option. My kids have both thrived on unsweetened almond milk, which is fortified with so much stuff nowadays that the only thing milk trumps it on is protein content and fat (and we incorporate other foods into their diets that compensates for this).

You’ll get very good at reading labels, and creative with recipes, and become a master at surreptitiously pulling vegan cupcakes out of your diaper bag at birthday parties so your kid won’t feel left out. You’ll probably do “challenges” with your kid every so often to see if his or her body has decided to make friends (or at least frenemies) with dairy, and when that day comes, you may even get to see a face like this:

Fearless Child’s first time eating cake & ice cream at a friend’s birthday. And yes, I cried.
Until then, remember- you are the expert on your child. You are also your child’s best advocate. Formula can be changed at any time, so there is no reason to suffer stoically if you suspect an intolerance or allergy to the one you are using now.
Great Links/Sources
http://kidshealth.org/parent/medical/allergies/milk_allergy.html
http://www.allergy.org.au/patients/food-allergy/cows-milk-dairy-allergy
http://foodallergies.about.com/od/dairy/a/babymilkallergy.htm
http://adc.bmj.com/content/92/10/902.full.pdf
http://www.kidswithfoodallergies.org/resourcespre.php?id=140&
http://www.medscape.org/viewarticle/563463

About the Author:

Suzanne Barston is a blogger and author of BOTTLED UP. Fearless Formula Feeder is a blog – and community – dedicated to infant feeding choice, and committed to providing non-judgmental support for all new parents. It exists to protect women from misleading or misrepresented “facts”; essentialist ideals about what mothers should think, feel, or do; government and health authorities who form policy statements based on ambivalent research; and the insidious beast known as Internetus Trolliamus, Mommy Blog Varietal.

Suzanne Barston – who has written posts on Fearless Formula Feeder.


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9 thoughts on “The FFF Quick-and-Dirty Guide to Formula Feeding: Recognizing Sensitivity, Intolerance or Allergy to Formula

  1. I love this post, I so could have found a post like this really helpful about 5 weeks ago. I remember scanning all your tags and reading the one on hypoallergenic and giving the 24 hour test a shot. It worked wonders, she became so much more calm. I can also speak on the comfort feeding side, she did that. She'd eat about 6 ounces over 2 hours and screaming or crying in between. We tried to give her a paci and tried so many other techniques too. I thought it was so strange to see her eat that much. She still eats a bit more than my son did, but she's back down to between 3-5 ounces a feed with 3 being more common.

    Also, we brought her to a chiropractor that specializes in infant adjustments out of desparation and surprisingly it helped. She calmed down even more and some of her silent reflux symptoms decreased. She still has her fussy periods, but she's not crying and screaming off and on all afternoon!

    On a side note, if you are in California and your insurance won't cover hypoallergenic formula you can bring the denial to WIC and they will cover it. There's a process to it, but that's what I have heard from someone recently.

  2. Our baby has reflux (he takes prevacid) and was very colicky. Alimentum really did work wonders. He is almost 4 months old, and the ped said we could try to switch him back to regular formula at his 4 month checkup. We also give him rice cereal in his bottle at bedtime so he won't spit up too much, I have switched to a rice cereal with probiotics in it, I am hoping these will help get his tummy ready for regular formula! I am so ready to stop spending the money on hypoallergenic!

  3. My daughter had pretty severe reflux (alone with a host of other medical problems) and it took a visit to the pediatric ER for doctors to realize what it was. I thought my daughter was having a seizure and called 911 (mostly due to her other severe medical issues). They put her on medication for it which helped. After she finally recovered from her surgeries from her other medical issues, she finally started getting over her eating issues. She's very healthy now.

  4. An awesome, and much-needed article. For all that there are resources out there about solutions–particularly the elimination diet for BFing, but also some info on various kinds of formula–there are not a lot of concise guides to determining if a child has a problem with food, especially if the child is not verbal. The standby with food allergies–hives–doesn't actually apply to a lot of children, as you've pointed out. We need people to know the universe of what food allergies, intolerances, and sensitivities look like, because that universe is quite large. You're missing something if you think it all boils down to hives. Unfortunately, I've seen a lot of breastfeeding bloggers minimize food allergies, intolerances, and sensitivities, I guess because they're trying not to booby trap people out of BFing. But for some babies, breastmilk is riskier than formula, and it's intellectually dishonest to claim otherwise. Even if that's only a small number of babies (which I have a hard time believing; 1 in 13 kids in the States are allergic to food and we're at 1 in 10 in Australia), they're worth protecting. Rare does not mean nonexistent or not worthy of proper support and information.

    About the only thing I'd add is that most folks don't know what anaphylaxis looks like, and it can manifest differently from person to person. If you suspect a child (or anyone else in your life, like a friend or coworker) has any issues with food, it's a good idea to read something like this: http://www.kidswithfoodallergies.org/resourcespre.php?id=149&title=anaphylaxis_symptoms_and_treatment to familiarize yourself with what to look for. It's just like choking, heart attack, or stroke; everyone should know what these things look like.

    Parents of children with food allergies should to talk to a doctor, preferably a board-certified allergist, about the possible need for an epi-pen or epi-pen junior, and if it's determined the child should have them (they are usually prescribed in pairs these days), wrangle as much detail out of the doctor, nurses, anyone on staff about when and how to use it. This article explains why epinephrine is so important for people with anaphylaxis: http://theallergistmom.com/2012/01/12/the-science-of-anaphylaxis-an-allergic-storm/ .

    If you suspect someone is going into anaphylaxis, FFF is right: ***trust your instincts.*** People, including small children, have died because the people around them second-guessed themselves and didn't act fast enough. If the person has an epi-pen, use it, and in any case call emergency, or point to a specific bystander and order them to call emergency. (Don't rely on a crowd for help, many times people will freeze unless specifically called upon.) It can be hard to bring yourself to use a needle on someone or call for an ambulance if you're unsure of the situation, but the epi-pen is designed to be as safe as possible, and the needle and drug are tiny when compared to the enormity of losing someone. Speaking as someone with anaphylaxis, I'd rather someone use the epi-pen and call for help if they suspect a problem but aren't sure, than wait till I'm past the point of no return.

  5. My daughter had milk protein intolerance, and Nutramigen was a lifesaver for us. Before we made the switch, she once spent 36 hours straight without a minute of sleep. It was miserable! She had little vegan cupcakes for her first birthday, and we were able to transition her to goat's milk at that time – she was intolerant to casein protein, and goat's milk does not have as much casein protein as cow's milk, so she was able to drink it. Then at age two, we were able to sucessfully introduce cow's milk, and now at 2.5 years old she is able to have all dairy products, even ice cream! It was a stressful and expensive journey, but because we took things slowly with introducing dairy she was able to eventually tolerate it.

  6. “they have 2 settings: sleep and screaming”

    That was my son. Everything was all cool and stuff the first week or or so, when he pretty much just slept. Then, slowly but surely, his fussiness kept increasing, and increasing, and increasing, until my husband and I both looked forward to the brief moments when our son was asleep, because it meant he wasn't crying his little head off. He ate a TON. He ate so much that we kept asking the pediatrician if it were normal for him to eat as much as he did. He was born below the 20th percentile in weight, and jumped up to the 65th percentile by four weeks old. We thought it was silent reflux (he rarely spit up) and were going to bring the subject up with our regular pediatrician, but after he went for six straight hours without us able to console him, we brought him to urgent care.

    That pediatrician blew us off about the reflux because he was gaining weight just fine.

    Okay, sure, he's gaining. But the kid is MISERABLE. He would cry and cry until he was so exhausted from crying that he couldn't even produce his loudest cries anymore, whereupon he would finally, blissfully pass out, for, if we were lucky, two whole hours. Sometimes, three. Then it would start all over again.

    After the waste of the urgent care copayment, we went back to the pediatrician we'd been having our son see. At first, she wasn't really sold on the reflux idea yet, but we'd learned after that blow off from the other doctor. We recorded a feeding (since feedings were huge, epic battles between his pain and hunger at that point) and all his symptoms were classic silent reflux. First, she had us switch to an AR formula. Didn't work. She added a medication. Sorta worked, but he was still a really unhappy, cranky child, and things rapidly started going back downhill.

    Finally, she had us do a trial of Alimentum, even though the stool sample given to the lab had tested negative for microscopic blood.

    Two days later, my son was like an entirely different child.

    We sing the praises of Alimentum daily, because now we can enjoy our son instead of spending all our time unsuccessfully trying to soothe him or calm him down.

    Though we (mostly) happily pay for the Alimentum, we really do wish he'd at LEAST take the powdered version, but he won't have it. Refuses it every time (the pediatrician keeps giving us samples). He'll only take the ready-to-feed version, which is even more expensive. If he decides to go to college when he's older, and asks us about a college fund, we'll be telling him he spent it all on a fancy-pants variety of a fancy-pants formula.

    Every time we go back to the pediatrician, she mentions that soon we could do a trial of regular formula to see how he does. But we're so afraid of seeing that OTHER child again, the miserable, in-pain, woeful baby, that we don't want to risk losing our mostly happy, fussy pretty much when other babies would baby.

    I do wish we'd known more about milk protein allergy/intolerance before all of this so we could've identified it faster and switched sooner. We'll always feel like we missed out on our son's first two months.

  7. Add to this please lots of farting and burping and bloated tummy! And arching back constantly for refluxy babies. Reflux and food intolerances are closely tied, per our pediatric GI specialist. We also now look back at newborn pics and realize there was a lot of redness around the eyes.

  8. And PS – crying AFTER a feed is a strong sign too. Normally after a feed they calm down but for food-intolerance eating makes it worse

  9. A lot of times a milk protein allergy is the misdiagnosis for an oversupply of breastmilk. The symptoms look the same, but alimentum is not necessary, just switching to regular formula should do the trick.

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