Cow’s Milk and Constipation in Children
The growth and development of a child is of utmost importance to the parent. It is well recognized that a parent would do anything to ensure proper growth and development. However, it goes without saying that the worries that occupy the highest point in any parent’s mind are the fear of ailments. This is especially considering that they not only have a bearing on the overall welfare of the child, but may also have fatal consequences. Of course, there are variations as to the seriousness of any condition that affects young children. Nevertheless, one of the most common ailments in young children is constipation.
Constipation may be defined as the difficulty or delay in defecation that occurs for a period of two or more weeks. It is worth noting that constipation may have functional or organic causes. Functional constipation is arguably the most common category of constipation. It is diagnosed based on an individual’s physical examination and history and is also referred to as nonorganic constipation, fecal withholding or idiopathic constipation. There are various causes of nonorganic constipation including bathroom avoidance, attention deficit disorder, sexual abuse, coercive toilet training or even fear of the toilet. This category of constipation often starts after the neonatal period.
In the western world, it is common to seek treatment for Chronic Functional Constipation for postneonatal children. It is estimated that 3% of the general pediatric outpatients are suffering from CFC. It also takes up 25% of the pediatric gastroenterology consultations and 36% of the pediatric visits (Crowley et al, 2008. Pp.29). However, it is impossible to determine the real prevalence of constipation, thanks to variations in definitions, as well as management.
Chronic Functional Constipation refers to a condition where an individual has one bowel movement in a period between 3 and 15 days. Its main characteristics include strain in defecation, painful bowel movement, hard stools that have increased diameter. It is usual for an individual to withhold so as to avert the possibility of an unpleasant bowel motion. The treatment of this category of constipation is founded on the principle that lack of exercise, behavioral or psychological problems, low consumption of fluids and dietary fibers are the key causes of CFC, with management incorporating laxatives, fecal disimpaction and toilet training, as well as high intake of fluid and fiber. However, the long and repetitive treatment is often shown as ineffective, which shows that there exists no clarity as to the exact etiology of constipation. The deficiency of a sustainable and effective treatment poses a herculean problem for healthcare professionals and patients.
Nevertheless, there has been increased advances in understanding of the mechanisms that result in constipation with the sole aim of coming up with an effective therapeutic approach. It is well recognized that a third of children suffering from constipation will go on having the problem well into their adulthood. This is a contradiction of the commonly held notion that constipation has to disappear prior to or during puberty. It has always been suggested that lower consumption of residue-rich foods such as vegetables and fruits, coupled with excess consumption of dairy desserts and milk are seen as a likely connection between milk products and constipation. Recent times have seen increased interest in cow’s milk proteins as direct causes of constipation via immune mediated mechanism. This etiology has especially been supported by the resolution of manometric and histological abnormalities in patients who live on cow’s milk-free diets. However, few literary works have been written to examine the influence that cow’s milk has on pediatric, chronic constipation. In addition, the withdrawal of cow’s milk as a treatment option has not impacted on the medical community, as well as the published guidelines pertaining to the management or treatment of patients with this condition. This study aimed at showing that the consumption of cow’s milk has the potential to cause constipation in children.
Hypothesis: Cow’s milk consumption may cause constipation to children.
In the article by Irastorza et al (2010), Investigation into the effects of cow’s milk and the role it plays as far as constipation in children was carried out. The study involved children aged between 6 months and 14 years, who had been referred to a tertiary pediatric gastroenterology clinic for the period between October 2006 and 2007. The study excluded children who had been taking drugs that result in constipation, or those who had previous abdominal surgery, anatomic abnormalities, pilodinal sinus or a sensitive pelvic floor. The study involved 69 children. The history of patients was taken alongside the conduction of physical examinations. The researchers evaluated the consistency of the stools with the use of a semiquantitative scale of 5 points.
The study incorporated four phases. In the first phase, there was no diet change in the first week. The second phase started at the second week and progressed for three weeks. The parents were required to withdraw cow’s milk from the diet. However, cow’s milk was replaced by hydrolyzed cow’s milk-protein formula for children aged less than 2 years while rice milk was used in the case of those older than 2 years. However, soy milk or even products that incorporated soya were excluded as there is heightened prevalence of allergies to soya among cow milk-allergic children.
Children who were not responsive to phase II of the study went through to the end while those whose constipation was resolved after the three weeks went on to phase 3, with cow milk reintroduced for another three weeks. In phase 3, children would be provided with 500 ml of cow milk daily. Children who did not contract constipation in phase 3 completed the study while those who relapsed to constipation had cow milk withdrawn for another three weeks, which made phase 4.
In another study by Andiran et al (2003), two groups comprising of 30 children between 4 months and 3 years were examined. The first group was composed of children suffering from chronic anal fissure and constipation, with surgical causes having been excluded while the second group had normal children. Children in the first group had not been subjected to any previous treatment using laxatives or other therapies. Constipation diagnosis was done based on a history of low frequency of stools, as well as the painful elimination of stool. The children’s daily consumption of CM, as well as breastfeeding duration, were investigated among other clinical features. In both categories, dietetic and clinical parameters were made of height or weight percentiles, breastfeeding from birth to weaning, and daily cow’s milk consumption as either cow’s milk formula or cow’s milk. The consumption of milk was registered in multiples of 50 ml for the dietetic records.
Another study by Crowley et al, 2008 examined the literature that had been written later than 1980 and only incorporated studies on children between 4 and 15 years pertaining to the relationship between cow’s milk intake and the occurrence of constipation in children.
Strengths and weaknesses
All these studies were comprehensive and thorough in the manners in which they were done. However, the first study was limited in the capacity to incorporate conclusive evidence pertaining to other likely immune mechanisms of constipation. The third study was limited on the number of materials from which it sought its information. One of the key limitations of the study by Crowley et al (2008) is that it incorporated children belonging to varied ages. It is worth noting that it is unlikely to have similar conclusions in children belonging to different age groups. In addition, the research faced challenges as to the materials it could incorporate. The study could not rely on research from a single group as its results have not been replicated in other settings. On the same note, this review was limited in the fact that it did not incorporate studies carried out in languages different from English, while there is likelihood that some evidence may have been excluded. Nevertheless, the study incorporated immunological and biochemical analyses indicating an association between cow’s milk protein and constipation, thereby offering a likely, biological explanation for the correlation between the two.
Irastorza et al (2010) article showed a clear cause and effect link between the ingestion of cow milk and chronic constipation in over a third of children who participated in the study. This was shown through resolution and relapsing of constipation in the first five days of cow’s milk withdrawal, as well as reintroduction in the respondent children, which is a suggestion of intervention pertaining to late allergy reactors. This underlines the fact that if constipation is proven to be a presentation of food allergy, it has to be classified as delayed symptoms.
The results in Andiran et al (2003) article showed that, young children and infants who had chronic constipation or anal fissure consume higher amounts of dairy products or cow’s milk than children who had normal bowel habit. The research also showed that, short breastfeeding duration and early bottle feeding on cow’s milk plays a key role in developing anal fissure and constipation in young children and infants. These findings suggest that anal fissures and constipation may, in fact, be secondary results of intolerance to cow’s milk, particularly cow’s milk protein allergies. It is imperative that prospective studies are done confirm or negate this contention. Nevertheless, this argument is supported by the findings pertaining to increased prevalence of other atypical signs.
While Crowley et al, 2008 were limited as to the number of articles that they could incorporate in the study, their systematic review confirmed their hypothesis that cow’s milk proteins incorporate a causal role in the occurrence of chronic functional constipation in children. However, not much research has been done on this area, despite it being a common quandary in pediatric practice.
The three studies showed incorporated conclusive evidence that cow’s milk has a causal role in the occurrence of constipation. This is due to the incorporation of proteins in the milk. The evidence indicated that there was a causal link between the condition and milk protein, with some children showing increased prevalence of sensitivity to cow milk protein.
Andiran, F., Dayi, S, & Mete, E, (2003). Cows milk consumption in constipation and anal fissure in infants and young children. Journal of Pediatric Child Health
Irastorza, I., Iban˜ez, B., Delgado-Sanzonetti, L & Maruri, N &Vitoria, J.C, (2010).Cow’s-Milk–free Diet as a Therapeutic Option in Childhood Chronic Constipation. JPGN
Crowley, E., Williams, L., Roberts, T., Jones, P & Dunstan, R (2008). Evidence for a role of cow’s milk consumption in chronic functional constipation in children: Systematic review of the literature from 1980 to 2006. Nutrition and Dietetics.