Abstract
Objective
Cow’s milk allergy manifests differently in children and might result in functional bowel symptoms such as recurrent constipation. The goals of this research were to look at the function of cow’s milk allergy as a cause of chronic constipation in children and the influence of a cow’s milk free diet (CMFD) on its treatment.
Methods
We conducted a randomized clinical trial comparing CMFD to cow’s milk diet (CMD) in two groups of 70 patients (aged 1-13 years) with persistent functional constipation. (defined as Rome III criteria). All individuals had been sent to a pediatric gastrointestinal clinic and had previously been treated with laxatives for at least three months without success; also, all 140 children had a skin prick test conducted. For four weeks, the case group got CMFD. They were then given CMD for a further two weeks. CMD was given to the control group for the whole 6 weeks. following 4 weeks of CMFD, a response was defined as a reduction in signs and symptoms that did not meet Rome III criteria and returned to Rome III criterion following 2 weeks of CMD challenge.
Findings
After 4 weeks, 56 (80%) of the case group patients reacted, compared to 33 (47.1%) of the control group patients (P=0.0001). According to Rome III criteria, 24 out of 56 (42.8%) respondents in the case group suffered constipation following a two-week challenge. In other words, cow’s milk allergy was found in 80% of constipated individuals. Only one patient tested positive for cutaneous pricks.
Conclusion
Chronic constipation in youngsters might be a sign of a cow’s milk allergy. Although various issues need to be examined further, a therapeutic trial with an elimination diet is now recommended in all children with constipation who are refractory to proper laxative therapy.
Introduction
Chronic constipation is a gastrointestinal (GI) disorder that affects roughly 20% of the general population. It is also highly frequent in youngsters, with a prevalence ranging from 3% to 16%[2]. When treating with this sickness, it is critical to ensure that it is not caused by another condition, such as thyroid disease or a congenital GI tract defect. In persistent functional constipation, lifestyle changes may be the primary line of treatment. If no reaction is obtained, a treatment trial with fiber and/or mild laxatives is recommended. Despite these interventions, many patients do not react. It has been observed that at the conclusion of a 5-year follow-up trial, 35-45% of patients showed no improvement.
Children with persistent constipation who do not react to laxative medication may have additional reasons, one of which being cow’s milk allergy.
Buisseret identified a link between cow’s milk allergy and persistent constipation in 1978. Iacono et al. found that a cow’s milk free diet (CMFD) helped 21 of 27 individuals with refractory constipation in an open but not placebo-controlled study.
Many studies found a link between persistent constipation and cow’s milk allergy, while others were skeptical. In children with chronic constipation who had a history of cow’s milk allergy and were on CMFD, Loening-Baucke found no improvement in the symptom. Yimyaem et al analyzed the outcomes of 10 cow’s milk allergy patients investigated between 1997 and 2001 and found no link to constipation.
To understand these seemingly contradictory findings, we decided to investigate the impact of CMFD on our chronic constipation patients.
Subjects and Methods
All consecutive kids under the age of 14 who were sent to Shiraz University of Medical Sciences’ Pediatric Gastroenterology Clinic with persistent constipation between April 2009 and April 2010 were assessed in this randomized clinical research. We defined functional constipation using Rome III criteria, which are two or more of the following in a kid with a developmental age of at least four years and inadequate evidence for inflammatory bowel syndrome diagnosis:
- Two or fewer defecations in the toilet per week.
- At least 1 episode of fecal incontinence per week.
- Retentive posture or excessive volitional stool retention in the past.
- History of painful or hard bowel movements.
- Presence of a large fecal mass in the rectum.
- There has been a history of huge diameter stools obstructing the toilet.
Criteria met at least once each week for at least two months before to diagnosis, and one month of at least two of the following in babies up to four years old:
- Two or fewer defecations per week.
- At least one incident of incontinence every week after the learning of toileting skills.
- History of excessive stool retention.
- History of painful or hard bowel movements.
- Presence of a large fecal mass in the rectum.
- Large diameter stools have the potential to clog the toilet.
Anatomical reasons of constipation (e.g., Hirschsprung’s disease, spinal illness), constipation owing to other conditions (e.g., hypothyroidism, psychomotor retardation), past anal surgery, and usage of drugs that might induce constipation were all excluded.
140 children were enrolled: 73 boys and 67 girls (52.1% and 47.9%, respectively), ranging in age from one to thirteen years (mean, 4.62.7 years). They were all given cow’s milk, dairy products, or commercial cow’s milk formulae. All patients had previously failed at least three months of therapy with various laxatives such as lactulose, Mg(OH)2, paraffin, and PEG. When the patient was first seen, a thorough physical examination, including a rectal examination, was performed, and a detailed chart was created that included the results of the physical examination as well as medical history information such as breast feeding during the first months of life, acceptance of formula at weaning, and, most importantly, the presence or absence of Rome III criteria. The patient was given a Skin Prick Test the next day.
In contrast to the control group, the diagnosis of cow’s milk allergy induced constipation was based on increased frequency of defecation or reduced number of signs and symptoms after 4 weeks of CMFD and returning to Rome III criteria following 2 weeks of challenge with CMD. We describe CMFD as a diet that excludes all dairy products derived from cow’s milk.
During the first appointment, parents were asked to document their child’s signs and symptoms, and all drugs were stopped. The patient was then allocated to receive PEG solution 0.5 gram/Kg/day and CMFD for the following 4 weeks, or PEG solution with the same dosage and CMD. All kids were given PEG by their pediatric gastroenterologist. A computer-generated approach randomly allocated the order of dietary therapy with the individual patient as the unit of randomization, and the patients were advised to get CMFD or CMD by a pediatric allergist based on this randomization. The protocols were re-evaluated at the conclusion of the therapy by a pediatric gastroenterologist who was unaware of the kind of food. A researcher assessed the youngsters at the beginning and conclusion of the first study periods. During the research, the parents kept track of the number of bowel movements, the appearance of the feces, and the child’s difficulty passing them. The parents were given a list of the most common milk-containing items to avoid in order to guarantee that the children did not get any other kind of milk or milk-containing meals throughout the trial. They were instructed to report the quantity and kind of food their kid ate each day throughout the research period. We evaluated these diaries at the conclusion of the trial to assess diet adherence and milk consumption. The parents could contact us anytime they needed to, and phone calls helped to guarantee that the diet was followed. Following the initial research period, the children on the CMFD were administered the CMD for an additional two weeks. During the two-week challenge period, the parents noted any clinical symptoms, and the patients were reexamined in the hospital for any adverse response, and they were assessed for the existence of constipation again at the conclusion of the challenge time. The parents of all patients participated in the research provided informed permission. Shiraz University of Medical Sciences’ Institutional Review Board authorized the project. Fisher’s exact test was used for frequency analysis. To compare the Rome criteria, the Pearson Chi-Square and McNemar tests were employed, as well as the Student’s t-test for parametric analysis. P-values were all two-tailed, and P-values less than 0.05 were deemed statistically significant.
Findings
At the time of study enrollment, two groups were matched for age, gender, length of illness, frequency of breast feeding at birth, and signs and symptoms of constipation. Tables 1 and 2 indicate the baseline characteristics of the 140 patients. Eighty-four (60%) of the youngsters suffered stomach discomfort, but only seven (5%) developed anal fissures. After 4 weeks, 56 (80%) of the case group patients reacted, compared to 33 (47.1%) of the control group patients (P=0.0001). Table 3 compares the Rome criteria in the case group before trial and 4 weeks after CMFD. Table 4 compares these criteria between the case and control groups. For two weeks, all patients in the case group were subjected to a CMD challenge. Table 5 shows the comparison of Rome criteria in the case group before and after the trial. None of the CMD patients had an acute response. According to Rome III criteria, 24 out of 56 (42.8%) respondents suffered constipation after this time. In other words, while 80% of constipated patients had cow’s milk allergy, 34.3% had cow’s milk allergy-induced constipation (increased frequency of defecation or decreased number of signs and symptoms after 4 weeks CMFD and returning to Rome III criteria after 2 weeks of challenge with CMD).
Table 1
Before the experiment, the clinical features of children with persistent constipation
| Parameter | Patients on Cow’s Milk Free Diet (n = 70) | Patients on Cow’s Milk Diet (n = 70) | P-value |
|---|---|---|---|
| Age [mean (SD)](months) | 54.7 (32.2) | 55.5 (34.1) | 0.887 |
| Sex (Male/Female) | 39/31 | 34/36 | 0.501 |
| Breast feeding at birth (%) | 23 (32.9) | 17 (24.3) | 0.348 |
| Duration of illness [mean (SD)](months) | 26.3 (22.7) | 26.1 (19.3) | 0.955 |
| Abdominal pain | 40 | 44 | 0.606 |
| Anal fissure | 5 | 2 | 0.447 |
Table 2
Before the experiment, the Rome criteria were compared in children with persistent constipation.
| Parameter | Patients on Cow’s Milk Free Diet (n = 70) | Patients on Cow’s Milk Diet (n = 70) | P-value |
|---|---|---|---|
| ≤ 2 defecations per week | 56 | 63 | 0.2 |
| 1 instance of incontinence each week after the development of toileting skills | 28 | 25 | 0.7 |
| Retentive posture or excessive volitional stool retention in the past | 61 | 58 | 0.6 |
| History of painful or hard bowel movements | 69 | 66 | 0.4 |
| Presence of a large fecal mass in the rectum | 40 | 63 | 0.0001 |
| History of large diameter stools | 69 | 66 | 0.4 |
Table 3
Comparison of Rome criteria in children with persistent constipation before and after a cow’s milk-free diet for 4 weeks
| Parameter | Prior to the trial, patients (n = 70) were on a cow’s milk-free diet. | After 4 weeks on a cow’s milk-free diet (n = 70), the patient | P-value |
|---|---|---|---|
| ≤ 2 defecations per week | 56 | 3 | 0.000 |
| 1 instance of incontinence each week after the development of toileting skills | 28 | 2 | 0.000 |
| Retentive posture or excessive volitional stool retention in the past | 61 | 7 | 0.000 |
| History of painful or hard bowel movements | 69 | 9 | 0.000 |
| Presence of a large fecal mass in the rectum | 40 | 2 | 0.000 |
| History of large diameter stools | 69 | 9 | 0.000 |
Table 4
After 4 weeks, the Rome criteria were compared in children with chronic constipation on a cow’s milk free diet versus a cow’s milk diet.
| Parameter | Patients on Cow’s Milk Free Diet (n = 70) | Patients on Cow’s Milk Diet (n = 70) | P-value |
|---|---|---|---|
| ≤ 2 defecations per week | 3 | 20 | 0.0003 |
| 1 instance of incontinence each week after the development of toileting skills | 2 | 15 | 0.002 |
| Retentive posture or excessive volitional stool retention in the past | 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 diameter stools | 9 | 32 | 0.0001 |
Table 5
Comparison of Rome criteria in children with persistent constipation on a cow’s milk free diet before and after a cow’s milk diet challenge.
| Parameter | Prior to the trial, patients (n = 70) were on a cow’s milk-free diet. | 2 weeks following the Cow’s Milk Diet Challenge, the patient is on a cow’s milk-free diet (n = 70). | P-value |
|---|---|---|---|
| ≤ 2 defecations per week | 56 | 11 | <0.001 |
| 1 instance of incontinence each week after the development of toileting skills | 28 | 7 | <0.001 |
| Retentive posture or excessive volitional stool retention in the past | 61 | 10 | <0.001 |
| History of painful or hard bowel movements | 69 | 20 | <0.001 |
| Presence of a large fecal mass in the rectum | 40 | 7 | <0.001 |
| History of large diameter stools | 69 | 20 | <0.001 |
At the start of the trial, there was a tendency toward a high frequency of negative skin prick tests among patients with functional constipation, and just one kid with cow’s milk allergy caused constipation had a positive skin prick test.
Discussion
Cow’s milk allergy manifests itself in a variety of ways. According to several research, persistent diarrhea is the most common GI symptom of cow’s milk allergy in children, with constipation being another but less common symptom. It is not yet shown that a cow’s milk allergy may produce refractory persistent constipation.
Several clinical investigations in pediatric cow’s milk allergy have had inconclusive outcomes. Constipation seems to be caused by hypersensitivity to cow’s milk proteins, according to recent research. A new research looked at the role of allergies in the genesis of constipation in children. Ninety-nine out of 136 (72.8%) constipated children under the age of three had a cow’s milk protein allergy as the reason of their constipation, and all children improved clinically when the elimination diet was introduced. Cow’s milk allergy, the authors found, is the most prevalent cause of constipation in the first three years of life.
In Greece, Syrigou EI et colleagues found that eliminating APT-positive foods for 8 weeks alleviated constipation in 28/32 constipated children with positive atopy patch test (APT). In almost one-third (34.3%) of the patients, we discovered a link between cow’s milk product consumption and constipation. In a Spanish study, 35 of 69 constipated children (51%) improved during the first CMFD period, 8 of these did not develop constipation when CM was reintroduced, and the remaining 27 children (39%) developed constipation during the CM challenge and improved during the second CMFD phase, which is consistent with our findings.
Only one patient tested positive for cutaneous pricks. A positive skin prick test result reveals a probable link between the meal examined and the patient’s reaction to that particular item. Although a positive skin prick test response simply “suggests” the existence of symptomatic allergy, a negative skin prick test response is a powerful tool for ruling out IgE-mediated food allergy. In this context, Irastorza I et al did not detect an IgE-mediated immunologic mechanism in children with chronic constipation, although further research is required to confirm this. The current research found that removing cow’s milk products from the diet of children with chronic constipation improved the signs and symptoms in 80% of patients. This response rate to the exclusion diet was consistent with earlier studies. In one research, 21 (77.7%) of 27 children with chronic functional constipation who did not react to 2 months of laxative medication were responsive to a 1-month removal of cow’s milk and dairy products, which is analogous to our findings.
We discovered that CMD had a significant influence on constipation symptoms, and that other variables, such as other proteins in different meals and patient and parent compliance throughout the research, may have an effect on these symptoms. It is not entirely acknowledged that 2 weeks of challenge test is sufficient for the return of all signs and symptoms of CMD dependent constipation, and that if it is longer, additional signs and symptoms may reoccur.
In addition, clinical evaluation of the youngsters in our research revealed a low prevalence of severe anal fissures (5%). Because these lesions returned after the resumption of cow’s milk and before the beginning of constipation in several studies, it is postulated that these are one of the processes producing constipation. However, there was no cause and effect association between anal fissure and constipation in our research.
There are several drawbacks to this research. Because our pediatric gastroenterology department is a referral center, children may have been pre-selected by the doctors who recommended them. Furthermore, we were unable to completely rule out psychological variables, which are usually proposed as the cause of persistent constipation. Most prior investigations, like ours, included all patients who had previously been unsuccessfully treated with laxatives; hence, the high prevalence of cow’s milk allergy in constipated children in these studies might be attributed in part to their inclusion criteria.
Conclusion
In children, chronic constipation might be a symptom of a cow’s milk allergy. Although there are many unanswered problems at the moment, a therapeutic trial with elimination diet is recommended in all children with constipation who are refractory to proper laxative therapy.
Acknowledgment
Shiraz University of Medical Sciences’ local research ethics committee has authorized this study.
References
1. Locke GR, III, Pemberton JH, Phillips SF. American Gastroenterology Association medical position statement: constipation recommendations. Gastroenterology, 119(6), 1761-1778, 2000. [PubMed] [Google Scholar] Formalized paraphrase
2. Loening-Baucke V. Childhood constipation: patient characteristics, therapy, and long-term follow-up. Gut. 1993;34(10):1400–4. [Free PMC article] [PubMed] [Google Scholar] Formalized paraphrase
3. Loening-Baucke V. Disagreements in the treatment of persistent constipation. Journal of Pediatric Gastroenterology and Nutrition. 2001;32(Suppl 1):S38-9. [PubMed] [Google Scholar] Formalized paraphrase
4. van Ginkel R, Reitsma JB, Buller HA, et al. Longitudinal follow-up of childhood constipation beyond puberty. Gastroenterology, 125(2), 357-363, 2003. [PubMed] [Google Scholar] Formalized paraphrase
5. G. Iacono, A. Carroccio, F. Cavataio, et al. Cow milk allergy causes chronic constipation. Pediatrics, 1995;126(1):34-9. [PubMed] [Google Scholar] Formalized paraphrase
6. Iacono G, Cavataio F, Montalto G, et al. Cow’s milk intolerance with persistent constipation in children. N Engl J Med 339(16):1100-4, 1998. [PubMed] [Google Scholar] Formalized paraphrase
Common signs of cow’s milk allergy in youngsters, Buisseret PD. The Lancet, 1(8059), pp. 504-5, 1978. [PubMed] [Google Scholar] Formalized paraphrase
Chin, KC, Tarlow, MJ, and Allfree, AJ. Cow’s milk allergy manifests as persistent constipation. Br Med J (Clin Res Ed) 287(6405):1593, 1983. [Free PMC article] [PubMed] [Google Scholar] Formalized paraphrase
10. Davidson M, Kugler MM, Baue CH. Diagnosis and therapy of severe and chronic constipation and obstipation in children. Journal of Pediatrics, 1963;62:261-75. [PubMed] [Google Scholar] Formalized paraphrase
Cow’s milk with persistent constipation in children, Shah N, Lindley K, Milla P. The New England Journal of Medicine, 1999;340(11):891-2. [PubMed] [Google Scholar] Formalized paraphrase
S. Daher, D. Soleé, and M. B. de Morais. Children’s constipation caused by cow’s milk. New England Journal of Medicine, 1999;340(11):891. [PubMed] [Google Scholar] Formalized paraphrase
Cow’s milk protein intolerance with persistent constipation in children, Daher S, Tahan S, Solé D, et al. Pediatric Allergy Immunol. 2001;12(6):339-42. [PubMed] [Google Scholar] Formalized paraphrase
14 Vanderhoof JA, Perry D, Hanner TL, et al. Allergic constipation and infantile milk allergy. Clinical Pediatrics, 40(7), 399-402. [PubMed] [Google Scholar] Formalized paraphrase
Lymphoid nodular hyperplasia and cow’s milk hypersensitivity in children with persistent constipation, Turunen S, Karttunen TJ, Kokkonen J. Journal of Pediatrics. 2004;145(5):606-11. [PubMed] [Google Scholar] Formalized paraphrase
16. Yimyaem P, Chongsrisawat V, Vivatvakin B, et al. Early gastrointestinal signs of cow’s milk protein allergy. J Thai Med Assoc 2003;86(2):116-23. [PubMed] [Google Scholar] Formalized paraphrase
Childhood functional gastrointestinal disorders: child/adolescent. Rasquin A, Di Lorenzo C, Forbes D, et al. Gastroenterology, 130(5), 1527-1537, 2006. [Free PMC article] [PubMed] [Google Scholar] Formalized paraphrase
A. Carroccio, G. Montalto, N. Custro, et al. Evidence of highly delayed clinical effects to cow’s milk in persons who are lactose intolerant. Allergy;55(6):574-9, 2000. [PubMed] [Google Scholar] Formalized paraphrase
B. Kamer, E. Dólka, K. Pyziak, et al. Food allergy as a cause of constipation in children in the first three years of life – personal observations. Med Wieku Rozwoj. 2011 Feb;15(2):157-61. [PubMed] [Google Scholar] Formalized paraphrase
20. EI Syrigou, C Pitsios, I Panagiotou, et al. The use of the atopy patch test in children with food allergies. European Journal of Pediatrics. 2011;170(9):1173-8. [PubMed] [Google Scholar] Formalized paraphrase
Irastorza I, Ibaez B, Delgado-Sanzonetti L, and others. A cow’s-milk-free diet as a treatment option for persistent constipation in children. 2010;51(2):171-6. J Pediatr Gastroenterol Nutr. [PubMed] [Google Scholar] Formalized paraphrase
MA El-Hodhod, NT Younis, YA Zaitoun, and SD Daoud. Pediatric constipation caused by cow’s milk allergy: adequate milk tolerance time. Pediatric Allergy and Immunology. 2010;21(2 Pt 2):e407-1. [PubMed] [Google Scholar] Formalized paraphrase
Related Questions
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What allergy causes constipation?
The most common cause of constipation among the children studied was allergy to cow’s milk proteins (n=99; 72.8%).
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What are the symptoms of being allergic to milk?
People who are allergic to milk or dairy products develop symptoms because their immune system perceives milk and other dairy products as a harmful intruder. This reaction may result in hives, an upset stomach, vomiting, bloody feces, and even anaphylactic shock, a potentially fatal allergic reaction.
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Is constipation a symptom of allergic reaction?
Allergens. Chronic constipation may indicate a food allergy in certain individuals. A 2011 research on children’s constipation discovered that removing dietary allergens from their diet alleviated their constipation.
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What type of milk causes constipation?
Some soy and cow’s milk-based formulas cause harder bowel movements, whereas formulas containing partially or completely hydrolyzed milk proteins (sometimes referred to as “hypoallergenic” formulas), which may be recommended for infants with a cow’s milk allergy or sensitivity, can cause loose bowel movements.