Eczema News – Hydrolyzed Milk Impact on Childhood Eczema

What milk to give a baby with eczema or a baby who is at high risk of eczema is ONE question that all parents ask – there are various options when it comes to milk:

(i) Breast milk – Recognized as the milk for babies up to six months of age, due to the natural protective benefits of breast milk and its ease of digestion, coupled with no artificially added sugar, salt and fats

(ii) Cow’s milk – An alternative to breast milk or supplement for breast milk; however, cow’s milk protein is the most common food allergen in young children (where the protein size is 10kD and more to act as an allergen)

(iii) Partially hydrolyzed milk – Commercially available, whereby the milk protein is broken down to protein size of less than 5kD; however, there is no strict definition of what qualifies as partially hydrolyzed formula and some partially hydrolyzed milk formula have about 20% of the peptides exceeding 6kD (kD is a measurement of its molecular weight)

(iv) Extensively hydrolyzed milk – Not commercially available in some countries, on prescription, whereby the milk protein is extensively broken down to protein size of less than 3kD.

(v) Other non cow’s milk formula, excluding goat’s milk as the goat milk protein is similar to that of cow’s milk

The Key Question is whether partially hydrolyzed milk protein is effective in preventing eczema. This is often examined alongside the questions of (i) whether it is cost effective to be put on hydrolyzed formula and (ii) inferior nutritional value of hydrolyzed formula.

Limited evidence (there's still some evidence) of protective effect of partialy hydrolyzed formula for high risk babies

Limited evidence (there’s still some evidence) of protective effect of partialy hydrolyzed formula for high risk babies

Let’s examine the research on whether partially hydrolyzed milk protein is effective in eczema prevention.

  1. I have briefly looked into this in 2011 (post) and the research then showed that partially hydrolyzed milk is recommended for high-risk babies but not if there is a proven milk allergy. For those interested in learning more about hydrolyzed formula, refer to FDA archived presentation.
  2. In 2013 (post), research’s recommendation was for high-risk infants who cannot be 100% breast-fed, partially hydrolyzed milk is recommended.
  3. Other more recent research: Allergic manifestation 15 years after early intervention with hydrolyzed formulas – the GINI Study where it is concluded that eczema is reduced in children who took partially and extensively hydrolyzed formula, with lower prevalence up to adolescents (11 to 15 year old).  The GINI Study is German Infant Nutritional Intervention program study of birth cohorts, with many other interesting allergic conditions’ studies here
  4. In a paper published in Clinical and Translational Allergy, Partially hydrolysed, prebiotic supplemented whey formula for the prevention of allergic manifestations in high risk infants: a multicentre double-blind randomised controlled trial, it was found that there was no preventive effect to early feeding with a partially hydrolyzed formula with added prebiotics.
  5. In a paper published in the Expert Review of Clinical Immunology, The Role of Partially Hydrolyzed Whey Formula for the Prevention of Allergic Disease, authors warned that due to limitations on studies on partially hydrolyzed milk, the recommendation should still be ‘breast is best’.

On the question of costs,

In a paper published in the Annals of Nutrition and Metabolism, Cost-Effectiveness of Partially Hydrolyzed Whey Protein Formula in the Primary Prevention of Atopic Dermatitis in High-Risk Urban Infants in Southeast Asia, the finding was that overall costs (even after including the cost of milk formula) of taking partially hydrolyzed formula (as opposed to cow’s milk formula) for high-risk infants would be lower than the costs of managing eczema.

On the question of nutritional value,

Dr Sears (this blog has featured several of his and his sons’ talks, tweet chat and collaborated blog series), Dr Sears’ view is that unless recommended by doctor, parents should not opt for hydrolyzed milk on their own due to

  • High content of sweeteners to make hydrolyzed formula palatable
  • Artificially carbohydrates in the form of corn syrup, sucrose, corn starch or tapioca
  • High salt content
  • Artificially added fats

It seems though that partially hydrolyzed milk formula is in practice recommended by doctors due to cow’s milk being the most common food allergen in infants. Research wise, there has yet to be a conclusion due to difficulty of conducting unbiased studies with sufficient (mother and baby) participants. What’s your experience in this? Do share in the comments!

Life of Eczema Girl – Night Scheduled Milk Feeding

Night Milk Feeding Eczema Baby

What’s going on during those night feeding?

I don’t know about you, but I struggled so much with milk feeding – from (my own lack of) breast milk, to switching from normal to partially hydrolysed milk, to reflux, to changing milk bottles, gosh… thinking back it’s NIGHTMARISH.

I do think if I’d to start over, one change I’d make is forget about scheduled feeding, my baby and I just need to sleep. Also, later I read it’s better to feed as and when the baby is hungry, but who knows the right way, just take heart that this phase will pass!

The lead eczema girl from last week is at the top left of this cartoon, and fyi, 20% of children have eczema, those who have (I suppose) have a darker world, hotter, crankier…well, we all have to go through life no matter what, we’ll see how it works out for our little eczema girl.

This is the 6th of my 2nd cartoon series, ‘LIFE OF AN ECZEMA GIRL’. For more cartoon in this series, check out here.

Eczema and Diet Studies

Eczema and Diet on EczemaBlues
This post is just what it is – The investigative bug has caught up with me and given that there are (i) more studies on impact of diet on eczema, and (ii) more people (experts or not) claiming that their diet is ‘proven’, I’m setting out in this post to POUR THROUGH ALL THE ECZEMA and DIET studies I can find and make sense of it for you here; Let’s see my investigation report!

Studies on Pregnancy Diets

Impact on Preventing or Reducing Severity of Eczema in Newborn

Antigen Avoidance Diet during Pregnancy

In a trial conducted with 952 participants, there was no evidence of protective effect of maternal dietary antigen avoidance during pregnancy on the incidence of atopic eczema during the first 18 months of life. Another two trials that had 523 participants similarly did not see benefit of avoidance of antigen during pregnancy for babies up till 18 months nor on their skin prick test results up to 7 year old.

Probiotics

In a review article of 21 trials from 1997 to 2007, there was evidence that probiotics prevented the onset of pediatric atopic dermatitis. In another article covering up to 2011, there was evidence of probiotics for the prevention of atopic dermatitis in infants, and this benefit was seen both for mother and child, and whether taken during pregnancy or early life of child.

Studies on Children Diets

Impact on Preventing or Reducing Severity of Eczema in Young Children

Timing of Introduction of Solids

In a consensus document, the conclusion from reviewing 52 studies from 1998 to 2006 was that early introduction of solids can increase food allergy. The recommendation was to introduce at 6 months, dairy products 12 months, hen’s egg 24 months, and peanut, tree nuts, fish, and seafood at least 36 months for those with higher risk of food allergy. An update on a study on early introduction of eggs done in August 2015 showed that the elevated immune responses to egg were established prior to egg ingestion at 4 months and were not affected by whether eggs were introduced early.

Using Hydrolyzed Milk Formula

In a review article of 12 studies up to 2006, there was (i) no evidence to support hydrolyzed formula to replace exclusive breastfeeding, and (2) limited evidence that supported hydrolyzed formula for high risk infants who could not be 100% breastfed. One article that provided such evidence concluded that partially hydrolyzed formula is more effective than standard formula for high risk infants.

Prolonging Breastfeeding

In a trial of close to 14,000 mothers, there was no evidence of protective effect of prolonged and exclusive breast feeding on asthma or allergy.

Using Soy Formula

In a review article of 3 studies up to 2006, there was no evidence of reduction in allergies for children fed with soy formula.

Adding Prebiotics to Infant Formula

In a review article covering 13 studies up to 2012, there was limited evidence of prebiotics added to infant formula can prevent eczema, but the authors cautioned that further research is needed prebiotics can be routinely prescribed.

Adding Probiotics to Infant Formula

In two review articles (one of 12 studies up to 2007, the other up to 2008), there was insufficient evidence to recommend adding probiotics to infant feed.

Consumption of Omega 3 and 6

In another review article covering 10 studies up to 2009, there was no evidence for reduced risk of allergic sensitization or a favourable immunological profile.

Impact on Minimizing Eczema Flare-ups for Children already diagnosed with Eczema

Elimination Diets

In a review article, the conclusion from reviewing 9 studies (up to 2006) was that there was (1) no evidence of benefit to an egg and milk free diet, (2) no evidence of benefit to an elemental or few-foods diet, (3) some benefit to egg-free diet for infants with positive IgE to eggs, with improved eczema.

Dietary Supplements

In a review article covering 11 studies up to 2011, there was no evidence of benefits of supplements in the treatment of eczema. The background of this study was that many patients turned to supplement to avoid steroid treatment, fearing long-term effects. However, there was no evidence for supplements like fish oil, olive oil, corn oil placebo, zinc sulphate, selenium, selenium plus vitamin E, vitamin D, pyridoxine, sea buckthorn seed oil, sea buckthorn pulp oil, hempseed oil, sunflower oil (linoleic acid) and DHA.

The Conclusion

1st, I’ve made it a point to look at the studies themselves, rather than articles that refer to studies (so that I minimize the lost in translation effect). I also urge parents who are taking the leap to try a specific diet to ask your doctor and read up on studies, instead of relying on fad posts or personal testimonies.

2nd, I must make it clear that I’m no expert in reading studies, the review articles mentioned were all written by medical professionals. Should any medical professional coming across this post and see any misinterpretation, do point it out to the rest of me.

3rd, after this investigation, the following seem to be actionable take-away that we parents can ask our doctors on and decide if we should apply them:

1. Consider Probiotics

2. Not to introduce solids before 6 months’ old, and check with doc on timing for other more common food allergens

3. If you can’t breastfeed exclusively, consider partially hydrolysed milk formula

References (from PubMedHealth and The Cochrane Library)
1.    Food allergy and the introduction of solid foods to infants: a consensus document
2.    Meta-analysis of clinical trials of probiotics for prevention and treatment of pediatric atopic dermatitis
3.    Probiotics for treating eczema
4.    Dietary supplements for established atopic eczema in adults and children
5.    Effect of prolonged and exclusive breast feeding on risk of allergy and asthma: cluster randomised trial
6.    Omega 3 and 6 oils for primary prevention of allergic disease: systematic review and meta-analysis
7.    Meta-analysis of the evidence for a partially hydrolyzed 100% whey formula for the prevention of allergic diseases
8.    Probiotics supplementation during pregnancy or infancy for the prevention of atopic dermatitis: a meta-analysis
9.    Dietary exclusions for established atopic eczema
10.  Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating atopic disease in the child
11.  Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants
12.  Prebiotics in infants for prevention of allergy
13.  Probiotics in infants for prevention of allergic disease and food hypersensitivity
14.  Soy formula for prevention of allergy and food intolerance in infants

Hangout with OzSuperNanny – Baby Food

My second hangout with Angela Jacobsen on Baby Food!

My second hangout with Angela Jacobsen on Baby Food!

This is my second Google Hangout with OzSuperNanny, Angela Jacobsen and it is the real deal, with a film crew! See Angela on camera and my own little spot (for nice lighting). The first hangout with her was on Travel with Baby here.

OzSuperNanny Google Hangout

The topic is on Baby Food, and in the top picture you can see Angela’s copy of the book ‘Baby Food – Angela Jacobsen’s EZ Recipes’ and clicking on the link will bring you to the Google Plus post of the Hangout with the video.

So, below are the questions I asked:

MarcieMom: I read in your book Baby Food that should the baby doesn’t take to the selected formula after 3 days, to get another brand and see if baby prefers that. When my baby has eczema, she also had reflux and we went through a period of trying different brands; in the end, we switched milk bottle and it seemed to work a little. Would you recommend switching milk brands or switching milk bottle?

Angela’s reply was to try both if the parent thinks it’s the bottle more than the milk – can try different teats and sizes. But also to consider different milk and stick to trusted brands.

MarcieMom: Getting babies to start on first food is an exciting time, but it quickly turned stressful because of the eczema rashes. Keeping a food journal is a good for tracking allergies because allergy testing on an infant is not accurate. What do you recommend as safe first foods and if you are to keep a food journal, do you have a minimal stress way to do so?

Angela’s Baby Food book has a food journal, and also include safe foods. Also Angela suggested trying a food later to see if the observations differ from the original date.

MarcieMom: Here’s a question for me to boast! I faithfully introduce a new fruit and vegetable every week till my baby is about a year old. Now, she loves vege and fruits, and broccoli and mushrooms are her favs (both superfoods!) Does introducing a new vege/fruit help the baby to like them?

Angela: Yes, the more, and the earlier better. Also introducing spices at about 12 month old can get the baby to be used to them, and prevent fussy eaters.

Please refer to the rest of the fab ladies’ questions here.

Also introducing the chef who is cooking up Angela’s recipe of Zucchini and Eggplant bites is Vivian Pei. Vivian is a food writer, editor, stylist and cooking instructor who authored “Awakening the Appetite”, a cookbook by Parkway Cancer Centre with recipes especially for cancer patients and their caregivers. She has run her own restaurant, catering business and worked with esteemed chefs in famous restaurants internationally.

Vivien Pei cooking

The zucchini and eggplant tasted great, soft for babies and tasty and fresh too! The ingredients are 1 zucchini, 1 eggplant, 3 tablespoons of plain flour, 1/2 finely chopped onion, 1 egg, 1/2 cup of grated cheddar cheese, 3 finely chopped basil leaves and a little oil. A simple simply delicious recipe that I got to savour.

SOMEONE managed Infant Feeding

Connie shares how she manages her daughter’s eczema & feeding.

Connie shares how she manages her daughter’s eczema & feeding.

This is a new series focused on personal journey with eczema while managing a certain aspect of life. Today, we have Connie, whose daughter has eczema since infant and shares how she manages feeding (infant). Connie blogs at rayconniebaby.

Marcie Mom: Hi Connie, thanks for taking part in my new blog series ‘Someone has Eczema’! Let’s start with you sharing a little of your daughter’s eczema, when did she first have it and what was the most difficult part of managing her eczema?

Connie: We first noticed this rash appearing on her cheeks when she was a few weeks old. We thought it was milk rash but it was confirmed by the doctor that it was not milk rash as he explained that eczema rash will appear dry and crusty and what appeared on my daughter’s face was exactly what the doctor had described. The most difficult part of it was that it recurs on every couple of days despite me using cool boiled water to cleanse her face after every feed.

Marcie Mom: I know that you had a difficult time figuring what milk works for her. For those of you in the same situation, you can refer to nutritionist Judy Converse’s interview here. So Connie, do share with us your journey – what makes you suspect milk as a trigger, and did you subsequently get confirmation from any doctor?

Connie: We didn’t suspect anything unusual as my elder son had a similar symptom (dry and crusty skin on the cheeks area). But for my daughter it seemed like her condition was worse and recovering time takes longer than compared to her brother. The doctor then confirmed her situation as eczema and strongly suggested that we switch her milk to either soy based or hydrolysed milk as an alternative and asked us to observed if her situation will get better. Our first choice for her switch was to soy, her skin condition did improve a little. Then we finally switched her to hydrolysed milk and the situation never comes back!

Marcie Mom: I know that I have stocked many types of brands and many types of milk, and I’m sure Connie and many other parents with eczema children went through the same issue. Do read nutritionist Judy Converse Q&A on ‘Just Milk, but Complicated’ here. Connie, did you eventually settle on a type of milk, say cow’s milk/ hydrolysed milk/ goat’s milk? (Rice milk is of inadequate nutrition, do avoid.)

Connie: Yes we did. We gave her hydrolsed milk and there is no turning back. Now at 13mths old, she is still on hydrolysed milk.

Marcie Mom: One final question – if you were to turn back the clock, would you have gone through the same steps you took to figure out the right infant milk for your daughter? (for me, I would have started with hydrolysed milk and then not stress over milk till she had her allergy test!)

Connie: Perhaps I would have started her with hydrolysed milk from newborn.

Marcie Mom: Thanks Connie for sharing your journey on infant milk feeding, am sure many can empathize with it!

Friday Dr Q&A with Prof Hugo – Partially Hydrolysed Milk

Prof Hugo Van Bever

Prof. Hugo Van Bever is the Head of National University Hospital’s Pediatric Allergy, Immunology & Rheumatology Department. He is also an active member of the board APAPARI (Asian Pacific Association of Paediatric Allergy, Respirology and Immunology) and has published more than 250 papers in national and international journals. His main research interest areas are paediatric allergy and paediatric respiratory infections.

Marcie Mom: Today’s question is one that I have personal experience with – switching to partially hydrolysed milk when Marcie was diagnosed with eczema.

Some research showed that giving babies partially hydrolyzed milk may reduce chance of milk allergy. I understand that it doesn’t alter the allergic profile of a child but may reduce chances of allergy as part of the milk protein is broken down. What is an allergic profile (is it part of DNA)?

Prof Hugo: Hydrolysed milks can prevent cow’s milk allergy: that’s all. They have no effect on the long-term development of allergy. An allergic profile refers to the clinical presentation of allergy, and has nothing to do with DNA.

Marcie Mom: I also read that restricting a food in early childhood and introducing it later may lead to even more serious allergic reaction. What’s your understanding of how the same food allergy could progress from childhood to adulthood?

This is very individual and still confusing, because an intervention cannot be beneficial for all children, but should be tailored. More research on this is needed.

Marcie Mom: Thanks! It’s good for parents to know that restricting food does not guarantee works for every child. Do consult your doctor before restricting a child’s diet.

Is partially hydrolysed milk worth the money?

Partial Hydrolysed Milk sold in Singapore

Partially hydrolyzed milk formula, such as Enfalac HA and NAN HA, was recommended to my baby girl Marcie when her eczema was diagnosed by the paediatrician at one month old. It was a nightmare getting her to drink the less tasty milk formula and each bottle feed dropped from 85ml to 20ml! It seemed to improve when we made the switch from NAN HA to Enfalac HA but you never know if it was due to the milk or that the reflux or gassiness got better.

The irony is that when I brought Marcie for a skin prick test when she was seven month old, she isn’t actually allergic to cow’s milk! The paediatrician had assumed that Marcie’s eczema was caused by food allergy, when it was intrinsic. So, I began to google whether HA milk was worth the money and whether I should let my next baby have hydrolyzed milk from the start.

So, here’s what I’ve found on this:

1. Partially hydrolyzed milk is non-hypoallergenic

This really confused me since the label clearly stated hypoallergenic. However, it seems like unlike extensively hydrolysed milk (which is not available in supermarket), only part of the cow’s milk protein is broken into smaller pieces.

2. Partially hydrolysed milk is proven to reduce risk of food allergy

So far research suggests that partially hydrolysed milk reduced the risk of food allergy, but it is not recommended for babies which has a firm food allergy. That is, if your child is already tested allergic to milk, giving partially hydrolysed milk can still give rise to allergic reaction.

3. Everyone says the best is breast milk

Naturally, it is cited on all labels that WHO recommends breast feeding for first six months. Problem is, parents like you and I, who are already stressed out with dealing with babies with eczema are unlikely to have the rest or the time to drink fluid or have proper nutrition, to produce enough breast milk! Easy to say, but we all know the effort required to produce breast milk.

I think, given that eczema is hereditary and to spare myself from the trauma of switching baby’s formula from a normal sweeter one to a partially hydrolysed one (should my next baby also has eczema), I would just start off him or her with HA milk.

Update: I’ve interviewed nutritionist Judy Converse on partially hydrolyzed milk about 2 years from this post (time flies!) and click here to read her explanation.

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