Expert insights into managing common gastrointestinal symptoms in clinical practice

By Dr Pedro Alarcon
Pediatric Gastroenterologist, Chicago, USA

Most regurgitation episodes are physiological and should not pose a health issue. When does spit-up become a clinical concern, and what is the role of nutrition in managing mild to severe regurgitation?

Infant regurgitation is defined as regurgitation two or more times per day for 3 or more weeks without retching, hematemesis, aspiration, apnea, failure to thrive, feeding or swallowing difficulties, or abnormal posturing.1 It should almost never be an indication to stop breastfeeding. Management of regurgitation generally includes dietary measures, frequent small meals, positioning (elevating the head of the crib in the supine position), and medications.2

Thickened anti-regurgitation formula has been shown to relieve regurgitation symptoms and decrease the frequency and total volume of vomiting.3 Commercial formulas commonly use thickening agents such as processed rice, potato starch, or guar gum.

Although thickening may be done at home with rice, corn, or wheat cereal, home-thickened formula can increase caloric intake and lead to weight gain.4 Furthermore, home thickening of regular formula increases the osmolarity, which may in turn increase the number of lower esophageal sphincter relaxations, inadvertently leading to more reflux.

Babies with cow’s milk protein allergy (CMPA) can present with regurgitation and vomiting. The elimination of cow’s milk protein (CMP) from their diet can significantly reduce symptoms.5

The cornerstone of treating diarrhea is oral rehydration therapy and rapid refeeding. What are different nutritional interventions that address acute and prolonged diarrhea?

Acute diarrhea (AD) in babies is mostly due to microorganisms; usually self-limiting, AD symptoms resolve within 3–5 days.6 Breastfeeding should never be stopped in babies with AD. For those who are formula-fed, low-lactose or lactose-free formulas are acceptable alternatives, since some babies with AD develop transient low lactase activity.7

Persistent diarrhea (PD) is defined as the passage of three watery stools per day for over 2 weeks, which is typically associated with weight loss. It is mainly caused by bacterial, viral, or parasitic infection, inflammatory bowel disease, immune deficiencies, or celiac disease.8

Treatment of PD is dependent on the underlying cause. Children with PD lasting for weeks or months may suffer from a degree of macro- or micronutrient malabsorption, resulting in weight loss. In these malnourished children, nutritional rehabilitation is essential, independent of etiology; it is beneficial to their general condition, intestinal function, and immune response. Lactose-free extensively hydrolyzed formula may be successfully used in most children but amino acid-based formula may be needed for very severe cases of diarrhea and malnutrition.8,9

Diet is known to play a key role in influencing stool pattern of babies. What would be appropriate nutritional strategies in managing constipation in daily practice?

Constipation in babies is defined as difficult or delayed defecation lasting for at least 2 weeks.10 The majority of reported constipation in early years do not have an organic cause. Compared with formula-fed babies, functional constipation is relatively uncommon in exclusively breastfed babies (9.2% vs 1.1%).11

Constipated babies on breast milk should continue on breast milk without any changes to the mother’s diet. Those who are formula-fed can continue with the same formula. Depending on the baby’s age, juices containing sorbitol, such as prune, pear, or apple juice may be helpful. If constipation persists, switching formula is recommended.

Partially hydrolyzed formula containing no palm oil and fortified with prebiotics and/or probiotics have been shown to be effective in managing functional constipation.12,13 On the other hand, formula marketed as ‘anti-constipation’ has high levels of lactose and/or magnesium with limited evidence of safety.14

Recent reports have associated severe constipation that is nonresponsive to therapy with CMPA. As such, breastfed babies should remain on breast milk, but their mothers should avoid consuming CMP. Extensively hydrolyzed or amino acid-based formulas are indicated for formula-fed babies.15

Colic is often a source of parental stress. Beyond reassurance, what dietary advice should pediatricians give?

It is important to differentiate babies with infant colic from ‘colicky babies’. Infant colic has been defined in the Rome IV criteria as ‘recurrent and prolonged periods of crying, fussing, or irritability reported by caregivers, that occur without obvious cause and cannot be prevented’.1 Even though the etiology is unknown, transient low lactase activity, CMPA, gastroesophageal reflux are potential causes of colic.

For breastfed babies, mothers should continue breastfeeding but avoid CMP in their own diet for at least 2 weeks; this should be maintained if the baby responds well. For those who are formula-fed, elimination of CMP is recommended by switching to either an extensively hydrolyzed formula or an amino acid-based formula. The elimination of CMP is effective in approximately 20–25% of babies with infant colic.16

‘Colicky babies’ refers to babies with fussiness, frequent crying, and excessive gassiness. If diarrhea and diaper rash are observed in addition to these symptoms in formula-fed babies, transient low lactase activity may be suspected. Formula with low or no lactose, or low-lactose partially hydrolyzed formula containing prebiotics, is therefore recommended.17

1. Benninga MA et al. Gastroenterology 2016;150:1443–1455.e2.
2. Horvath A et al. Pediatrics 2008;122:e1268-1277.
3. Hegar B et al. Acta Paediatr 2009;98:1189–1193.
4. Aggett PJ et al. J Pediatr Gastroenterol Nutr 2002;34:496–498.
5. Vandenplas Y et al. Acta Paediatr 2012;101:1105–1109.
6. Lo Vecchio A et al. Acta Paediatr 2016;105:e384-389.
7. MacGillivray S et al. Cochrane Database Syst Rev 2013:CD005433.
8. Giannattasio A et al. F1000Research 2016;5:1–11.
9. Allan Walker W. Pediatric Gastrointestinal Disease: Pathophysiology, Diagnosis, Management, Volume 1. Hamilton, ON: PMPH-USA; 2004.
10. Biggs WS & Dery WH. Am Fam Physician 2006;73:469–477.
11. Tunc VT et al. Eur J Pediatr 2008;167:1357–1362.
12. Koo WWK et al. J Am Coll Nutr 2006;25:117–122.
13. Moro GE et al. Acta Paediatr Suppl 2003;91:77–79.
14. Vandenplas Y et al. Acta Paediatr 2015;104:449–457.
15. Miceli Sopo S et al. Int Arch Allergy Immunol 2014;164:40–45.
16. Shergill-Bonner R. J Fam Health Care 2010;20:206–209.
17. Vandenplas Y et al. Nutrition 2013;29:184–194.


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This article is authored by Dr Pedro Alarcon, and the opinions, views and positions expressed in this article are those of the author.

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