Dr Mattias Larsson. Photo courtesy of Family Medical Practice

Dr Mattias Larsson* 

Thuận is a happy mother who gave birth to her first child, Tâm, a month ago. The delivery was ordinary, Tâm was born full-term after 40 weeks pregnancy, 3,4kg birth weight, vaginal delivery. Tâm initially had some jaundice that did not need phototherapy. Thuận’s milk production enabled her to exclusively breastfeed Tâm, and after just one week Tâm had successfully gained above birth weight.

However, with the rapid increase in milk production Thuận developed pain and rash in one breast as well as fever. She went to the gynecologist who diagnosed milk stocking, was prescribed antibiotics, and advised to stop breastfeeding until the infection subsided.

During the time she fed Tâm with formula milk, initially he seemed to tolerate that well, but after about one week he became grumpier, vomited more, and had loose stools. When Thuận reintroduced breast-feeding Tâm’s symptoms subsided.

When Tâm was six weeks old he started to get a bit grumpy after breastfeeding, vomited and cried more and more frequently with stools with large amounts of mucus. When this had been ongoing for one week she also could see that Tâm decreased breastfeeding and she took Tâm to the local doctor.

The doctor did an investigation and took a stool sample that showed an increase of white blood cells in the stool, concluded infection and prescribed antibiotic treatment.

However, the symptoms did not improve but got worse, Tâm vomited more, had more frequent diarrhea and even some blood in the stool, he was constantly grumpy and reluctant to breastfeed. As he also started to lose weight Thuận became really worried. She had heard that Family Medical Practice had good international pediatric doctors, so she decided to go there.

When she met the paediatrician she explained the problems, the doctor found that he reacted with discomfort when examining the abdomen, ordered an ultrasound and a stool examination. The results showed that Tâm had white blood cells in the stool and the ultrasound found gas in the abdomen. Thuận wanted to do blood tests (CBC and CRP) that showed no infection but inflammation, low hemoglobin , hence anemia, small red blood cells and no other deficiencies.     

The paediatrician asked about Thuận's diet and especially if she used dairy products. Thuận said that she usually drinks one glass of milk per day and eats some yogurt, had heard that that is good for milk production. The doctor explained that Tâm most likely suffered from cow’s milk protein intolerance, difficulty digesting cow's protein milk that then accumulated in the intestinalis and triggered an immune reaction, cow’s milk protein allergy.

The allergy causes injury to the stomach and intestines, blood in the stool, poor nutrition uptake in the intestinalis that can cause poor growth and failure to thrive. The doctor also explained that the cow milk is used by the body to produce mothers milk including the cow milk proteins that trigger the intolerance and allergic reaction.

Symptoms will usually develop within the first week of starting formula based or or cow milk in the mothers diet, hence might have started when Tâm used formula milk. The antibiotic treatment was most likely based on misdiagnosis and might have worsened the diarrhea and killed the good bacteria, in Vietnamese lợi khuẩn, that is important for digestion and decreased nutrition uptake.

The paediatrician recommended continuing breastfeeding and to eliminate all dairy products from the diet. Breastmilk has several advantages; it is not only food but also protects Tâm from infections as antibodies are transferred with the breastmilk, also has probiotic properties including lợi khuẩn to help digestion and is adapted to need of the child and facilitates brain development.

In case the breastmilk is not enough, Tâm might add hydrolysed formula milk, formula with broken down cow milk proteins is recommended, as Nutramigen. Other types of milk such as soy milk / goat's milk / sheep's milk are not appropriate alternatives for most children. Thuận asked if this was related to  lactose intolerance, as the father had that, the  doctor emphasised that it is not the same.

The paediatrician also explained that Thuận needs to stay on a dairy free diet, if not sufficient  use hydrolysed formula, until about 12 months of age. At that point, Tâm can be challenged with cow’s milk as most kids will outgrow cow milk protein intolerance by one to three years of age. For the anemia, most likely due to the cow milk protein induced malnutrition, the doctor gave iron drops and recommended follow up in one month.

After one month Thuận came back with Tâm, now he was breastfeeding well, not vomiting, no diarrhea, CBC did not show any anemia and the iron drops could be abrupted, he had grown fast and was a happy child, Tâm was satisfied although he still longed to drink some milk. Family Medical Practice

 *Dr Mattias Larsson is a paediatric doctor at Family Medical Practice and associate professor at Karolinska Institutet and has a long experience in research on infectious diseases. He has worked with the Oxford University Clinical Research Unit and the Ministry of Health of Việt Nam. He is fluent in English, Swedish, Vietnamese, German and some Spanish.  

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