Eczema Blues

This is a 4-topic series focused on nutrition for babies and toddlers with eczema. It was originally spanning 7 posts, and combined to 3 longer informative posts.

• What’s Reliable Nutrition Information
• Newborn Nutrition – Just Milk, but Complicated
• Breastfeeding – Impact on Eczema Babies & Infant Reflux

Breastfeeding – Does it Prevent Baby Eczema?

MarcieMom: Judy, thank you for joining me today! Now, on breastfeeding’s impact on eczema, it appears to be still a controversial conclusion if it helps prevent eczema (I did a quick online search, and here and here already present varying conclusions).

Are you aware of any definitive study on whether breastfeeding (i) prevents eczema and (ii) lessens the severity of eczema?

Judy: Okay, this gets technical, so bear with me. One of the papers you’ve mentioned comes from a collaboration with the International Study of Asthma and Allergies in Childhood (ISAAC), which is an ongoing survey across several countries for inflammatory conditions in children. Given the large numbers in the study, the finding of “lack of benefit” from breastfeeding was puzzling. It also puzzled me that other papers from ISAAC have been equally muddled on benefits of breastfeeding relative to asthma.

Sounds impressive – a “study” with over 50,000 subjects? But this was a weakened tool in many ways: It is a survey, not a study; it is retrospective, not prospective; it is uncontrolled (no control subjects to compare who had only formula); it is based on voluntary parent reporting, which may be faulty or biased some of the time; and I did not see that there was a comparison of exclusively breast fed to exclusively formula fed children. It appears that the survey may only have looked at degrees of breastfeeding relative to eczema.

How can we measure the impact of a variable (breastfeeding), if nearly all of those surveyed got some of it? You need an exclusively formula fed population as a control to really find the answer.

Also, the abstract doesn’t allow us to see detail for methodology. It mentions that over 50,000 children with asthma and allergies were evaluated somehow, but doesn’t say much about the breastfeeding survey, methodology or numbers, or introducing solids, which is another big factor. It says that the benefit of breastfeeding that was noted disappeared after age four months – which is when many babies are first given some solid foods. The authors state that benefit of breastfeeding for eczema disappeared at that point. There is no mention of introduction of solids here – was this observed in any way?

I think it is over-simple to state that benefits cease at this point. If the survey only looks for “ever” breastfed and “any eczema ever”, it is weakly designed and can’t give very clear information. It also takes a somewhat trivializing tone on the finding that breastfeeding lessened “sleep disturbed” eczema, which is a significant benefit for weary families and babies struggling against inflammation. Having your baby wake in pain or bleed from scratching is pretty unpleasant.

To make this survey powerful, the authors would have needed a control group of over 100,000 matched children (8-12 year olds with asthma or allergy) who were exclusively formula fed ever, that is, never breast fed at all.

When I see information gathered in this way, I am skeptical – Why go to such lengths to collect or evaluate data in a weak fashion? Surveys are useful to point researchers toward next questions. But I think this survey almost does a disservice, by casting doubt on benefits of breastfeeding for eczema, without careful controls. Even with the design flaws in this survey, the authors still found a small benefit to breastfeeding. Breastfeeding is so important for so many reasons.

Childhood Vaccinations’ Impact?

A further dilemma here, the elephant in the room, is the influence of vaccination, which strongly correlates with more allergy, asthma, and eczema (the authors of that study inexplicably attribute this effect to doctor visit frequency). Earlier vaccination correlates strongly with asthma, another inflammatory condition. There is meanwhile a compelling ongoing survey that shows less allergy, eczema and asthma in unvaccinated children (and better health over all). This too is limited by voluntary parent reporting, no true controls – but the difference in the two groups is so dramatic that a true trend appears to exist. It certainly needs closer study. A prospective study comparing exclusively breast fed babies to exclusively formula fed babies, vaccinated and/or not, would be fabulous. We need robust prospective design to really answer these questions. But there is considerable opposition to work in those areas.

Probiotics in Breastfeeding Moms’ Diet

All that said, there are still other studies that show weak or little impact on eczema for breastfed babies. We may simply be looking at the wrong parts of the puzzle, or looking at it in too narrow a way. For example: A baby’s gut biome may be quite predictive of who gets inflammatory conditions like allergies, eczema, and asthma. This well controlled and blinded study found a dramatic reduction in likelihood of eczema for babies who were breastfed by moms supplemented with probiotics. And, breast milk supports a different, healthier gut biome than formula. Bifido species bacteria appear so far to be more useful at lessening eczema for infants than Lactobacillus species, which may play more of a role as the baby grows toward childhood.

Do Allergens Go into Breast Milk?

MarcieMom: As mentioned in the previous Q&A, allergy testing is not accurate for an infant. Many moms with eczema children feel really stressed about whether it’s what they eat, that ends up triggering the rashes via the breast milk.

How does the mom’s body process the food that she eats into breast milk? Do the proteins (or whatever else?) in common food allergens like cow’s milk, wheat, egg, peanut and soy go into the breast milk and therefore capable of producing the same allergic reaction as if it’s ingested directly by the baby?

Judy: I was one of those moms whose baby could not tolerate my breast milk. It was devastating. I agreed to a trial of hypoallergenic formula and had mixed feelings when it helped my son. In my training, there was no explanation for this. I was taught that there was no such thing as a baby allergic to breast milk, but here we were. What I ate clearly affected my son too. So when I did go back to nursing him, because I wanted him to have all the benefits of breast milk, my diet was limited to rice, meats, some vegetables and fruits, and nuts for fats. I ate a lot of pecans and walnuts, and a little peanut butter, because I craved fats and was shirking all the fish I loved to eat (this was 1996, and we lived near the ocean). Well, those are the only tree nuts that my son is still quite allergic to at age sixteen, even though he has never eaten them himself! His only exposure to pecans, walnuts, and peanuts was via my diet through breast milk. He has shown IgE reactivity to these ever since.

I was taught that there was no such thing as a baby allergic to breast milk, but here we were.

I don’t know if we can confidently say that we know everything about how we process dietary proteins into breast milk, but we can likely assume variation across individuals. There is an interesting conversation here on this topic. Certain things don’t seem to vary much – like how much total protein is in mom’s milk, mineral levels, or total calories – these can waiver very little – but vitamins, types of fats, or amounts of fats can vary quite a bit relative to mom’s food intake, and toxins certainly do too.

Leaky Gut – Mom & Baby

One of the emergent pieces is the gut biome, again – that is, what microbes populate the mom’s gut, and the baby’s gut, and are either of their intestinal lumens compromised in any way? Is there any permeability that shouldn’t be there? If mom harbors a suboptimal biome that allows for “leaky gut”, then larger fragments of food proteins may enter her blood and will be picked up by breast tissue, which is richly vascularized with high blood flow. If on top of that, the baby’s gut biome is weak or his gut wall is leaky, you have a double hit for increased odds for eczema and allergy.

So, again, several moving parts to this puzzle: The mom’s diet, mom’s gut biome, digestion, and intestinal wall integrity; mom’s toxicity level, stress, fatigue, and endocrine functions that regulate her milk production. Then we have the same factors to consider for the baby, including stress. 

The mucosa that lines a baby’s throat and gut is less developed and more permeable than an older child’s or an adult’s, so mom having a healthy gut may be the best prevention, to keep larger food peptides or proteins out of her milk in the first place. Antibiotics, certain toxins, heavy metals, and vaccines can interfere with intestinal wall permeability and function too – and infants now get more exposure to these than ever.

Is there an Ideal Breastfeeding Diet?

MarcieMom:What about some foods that a mom ought to eat more when breastfeeding? I understand that the field of epigenetics is gaining more attention as results of studies on animals are promising – the eating and health habits of one can reduce the chances of an individual being diagnosed with a disease he is genetically predisposed to. 

Should a mother who is breastfeeding then consume more anti-inflammatory foods, probiotics or foods that aid skin repair? If yes, which foods would you recommend and how to ensure that moms don’t over consume?

Judy: Anti-inflammatory, probiotic foods are good for everyone. Though there is plenty of debate on this topic, this generally means eating a plant strong diet: Lots of fresh raw organic vegetables, greens, and fruits, along with traditional fats like those from organic meats or dairy products, butter, whole unprocessed, unsweetened organic coconut milk, olive oil, and oils from organic raw nuts and seeds. Humans have always made and eaten fermented foods. If you don’t like or can’t eat yogurt, kombucha, kim chee or sauerkraut, naturally cured meats, poi, or other fermented foods, or if you don’t have access to safe raw dairy products (which contain healthful fats and enzymes that are altered or lost when pasteurized), you can supplement with probiotics. There are now hundreds of probiotics products available.

Look for diverse strains and high potency, over 15 billion colony forming units (CFUs) per dose.

I often use much higher doses than that in my practice.

Anti-Inflammatory Foods for Eczema Children

Beyond that, if there are still skin symptoms, then work with an experienced provider to identify the trigger foods. I usually use an ELISA IgG food antibody profile for this in my practice. There is debate about that too, but used in the context of a total nutrition assessment (which should always include signs, symptoms, a food diary, and a medical history – never just lab tests alone) I can use that lab result as a jumping off point to make a good elimination plan for my clients. Then we add in anti-inflammatory supplements if more is needed: Things like nettles, curcumin, fish oils, N-acetyl cysteine, and of course the right probiotic.

Dealing with Reflux in Eczema Infant

My baby had from drinking more than 100ml per feed, it dropped as low as 20ml due to the reflux. I don’t even know what type of reflux it was – sometimes she simply seemed not hungry and refused milk; other times, she would drink all (after much coaxing) only to vomit a flying trajectory of milk over her head about 30 minutes later.

Is there any conclusive study linking eczema and reflux?

Judy: I have not looked for that, but I have witnessed it often in my practice. My experience agrees with often finding the two together. It doesn’t matter anyway, because the baby just needs to feel better! My first suspects are always protein intolerance, and gut biome imbalance – and yes, these two problems are often linked. It’s easy to assess and begin treating both, even with just a good history (no lab tests), though at most a stool test may be useful.

In my book Special Needs Kids Go Pharm Free, reflux, colic and eczema are what I address in the first chapter. What amazes me is that many pediatricians don’t seem to realize that while this is quite common, it is not normal, and may not be benign, for a baby to experience all this.

What Infant Reflux Mean?

It can mean that there is inflammation, weak absorption, or gut dysbiosis, especially after ruling out structural or mechanical concerns that cause a baby to reflux. Reflux medications assume that the baby’s stomach is too acidic, when the opposite may be true. If these can give a little short term relief, that’s fine, but I like to see them used only short term, and after a well managed trial of natural steps have failed. Long term, medications for reflux can exacerbate it. They diminish nutrient absorption, and favor colonization of the gut with fungal species – which in turn may worsen gut permeability. Once you have more permeability, you are likely to have more allergy/eczema.

Types of Infant Reflux

MarcieMom: What types of reflux are there? I looked it up online and but got quite confused; could only understand that Gastroesophageal Reflux Disease (GERD) is when the lower esophageal sphincter does not close properly and the stomach reverses its contents back into the esophagus. Judy, what are the common types of reflux affecting infants?

Judy: Many things can trigger reflux in any age group, and a sudden onset of it warrants your doctor’s attention. Your pediatrician or pediatric gastroenterologist can rule out structural or mechanical triggers, or very unusual causes or circumstances that may warrant different treatment. In any case, the norm is to have peaceful digestion – not reflux, spit up, projective vomiting, or chronic hard colic (gas with a hard belly and inconsolable crying). Most often babies with reflux do not have a serious medical circumstance or mechanical flaw causing the trouble, and natural steps may solve the problem. 

It is more common that the baby is not tolerating the feeding well, or has a weak gut biome that does not aid digestion. 

This biome is so important for the baby especially at birth, when the gut is not immune-competent and has limited ability to digest food. Certain microbes appear to “train” the immune system via the gut, and help us digest first feedings. I discuss this in Special Needs Kids Go Pharm Free too. It’s an exciting niche of medicine that I think will become more and more important – what is our relationship to the biome in general, how do we best co-habitate with it, and what are the best ways to nurture a supportive biome in the body? This is where I think medicine needs to go.

Home Remedies for Infant Reflux

MarcieMom: In Singapore, it’s common to burp the baby and if the baby still refuses milk, the common assumption is that there is air in the tummy creating fullness. Remedies that parents use are usually anti-colic drops available in pharmacy and herbal oil that purports to reduce tummy air. Judy, are the abovementioned correct remedies for reflux? (or are these not reflux issues/treatments? My baby’s reflux disappeared at 3 month old, around the time I use Dr Brown, a bottle with a tube insert to release air.)

Also, when should a parent start to be concerned with the reflux, i.e. no longer a common reflux that affects babies, and seek doctor’s advice?

Judy: I’m not sure what is in the drops you mention. One brand called Mylicon (which is simethicone, an artificial compound that helps air bubbles stick together into larger ones, presumably so the baby can burp better) was found to be least effective of all treatments, compared to changing the baby’s primary protein source or using herbal remedies. Meanwhile I have been pleased in my practice with natural measures, like certain herb drops, changing up the feeding strategies and protein source, probiotics, homeopathy, and treatment for fungal species overgrowth in the baby’s gut.

When Infant Reflux Warrant a Visit to the Doc

As for when to intervene, include your baby’s comfort and your intuition in this process. Reflux medications have been overprescribed for infants, at least in the US. Reflux is common, but it has been normalized to a point where placing a baby on reflux medication is considered benign. I don’t agree. A little spit up is normal as the baby is developing coordination in swallowing and in digestive functions. But losing most of each feeding is not normal, nor is it normal for a baby to suffer constantly with hard inconsolable crying and a hard belly, or to drop away from his growth trajectory on the growth chart.

Chronic projectile vomiting is not normal.

Your baby deserves to feel well, comfortable, and happy, to gain and grow steadily, and to pass stools easily every day, eg, soft formed, or wet/mushy for breasts fed babies. Stool that explodes up the baby’s back or runs down the legs, or is dry and painful to pass, or are less frequent than daily or every other day – these are all signs that digestion is impaired and things can be made more comfortable for your baby. If those symptoms occur along with reflux and eczema, intervene for your baby’s contentment and comfort.

MarcieMom: Thank you Judy, once again I’ve learnt much and should I ever decide to have a second baby and he/she has reflux, the first person I think of calling is you!