Ep 203: Making sense of milk intolerances in infants, with Pediatric gastroenterologist, Dr Victoria Martin, MD, MPH

In this podcast episode, a pediatric gastroenterologist, Pediatric GI expert Dr. Victoria Martin joins me to demystify milk intolerance in babies—what FPIAP and cow’s milk protein intolerance really mean, why these diagnoses are tricky, and how families can find practical, evidence-based solutions.shares her expertise on milk intolerances in infants. 

Dr. Martin emphasizes the importance of supporting breastfeeding mothers, addressing misconceptions about milk allergies, and the potential benefits of early allergen exposure. Additionally, Dr. Martin and the host discuss the role of lactose intolerance, and nutritional considerations for infants. 

Dr. Victoria (Tori) Martin is an Assistant Professor of Pediatrics at Harvard Medical School, Co-Director of the Pediatric Gastroenterology Section of the Food Allergy Center at Massachusetts General Hospital for Children, and Associate Program Director of the MGHfC Pediatric GI Fellowship. Her research focuses on early-life GI health, food antigens, and the infant microbiome.

Key takeaways

• “Lactose intolerance” is not a typical infant diagnosis; infant concerns are usually protein related.
• Microscopic stool blood alone has limits—treat the baby, not just the test.
• For breastfed infants with visible blood and discomfort, consider short, targeted milk-protein elimination, then a re-challenge in ~1 month to confirm diagnosis and avoid unnecessary long-term restriction.
• Hypoallergenic formulas are an option; prioritize growth, feeding comfort, and family well-being.
• Early, safe introduction of other allergens (e.g., peanut, egg) should still proceed on schedule unless otherwise directed by your clinician.

Your Child is Normal is the trusted podcast for parents, pediatricians, and child health experts who want smart, nuanced conversations about raising healthy, resilient kids. Hosted by Dr. Jessica Hochman — a board-certified practicing pediatrician — the show combines evidence-based medicine, expert interviews, and real-world parenting advice to help listeners navigate everything from sleep struggles to mental health, nutrition, screen time, and more.

Follow Dr Jessica Hochman:
Instagram: @AskDrJessica and Tiktok @askdrjessica
YouTube channel: Ask Dr Jessica

If you are interested in placing an ad on Your Child Is Normal click here or fill out our interest form.

-For a plant-based, USDA Organic certified vitamin supplement, check out : Llama Naturals Vitamin and use discount code: DRJESSICA20

-To test your child's microbiome and get recommendations, check out:
Tiny Health using code: DRJESSICA

The information presented in Ask Dr Jessica is for general educational purposes only. She does not diagnose medical conditi...

Transcript

Unknown: 0:00

Hello listeners. This is Dr Jessica Hochman. I'm excited to share that I am now booking sponsorships for your child as normal for this fall. If you have a product, service or a message that you think our listeners would benefit from, whether it's for parents, kids, healthcare or family life in general, this could be a great opportunity. You can find details on how to sponsor by checking the show notes. Just click the link that says how to sponsor an episode, and I'll let you know for a good match and get back to you. Hi everyone, and welcome back to your child is normal. I'm your host. Dr Jessica Hochman, so today we're tackling a situation that actually comes up all the time in pediatrics, milk intolerance in babies. My guest is Dr Victoria Martin, and she's an Assistant Professor of Pediatrics at Harvard Medical School and the Associate Program Director of the pediatric gi fellowship at Massachusetts General Hospital for Children. In this conversation, we dig into food protein induced, allergic proctor colitis and cow's milk protein intolerance, a condition that I realize may not sound familiar, but it is surprisingly common in one large Boston Area study, for example, about 17% of otherwise healthy infants were given this diagnosis when blood or mucus was found in a stool. We'll talk about why these diagnoses are tricky and how we can best support babies and families through them. So whether you're a pediatrician or a parent, this episode will offer clear, compassionate and practical guidance. Dr Martin, I'm so grateful that you came here on the podcast and to everyone listening. Thank you so much for spending part of your day here on your child is normal. I want to take a moment to tell you about tiny health. Tiny health is the first and only at home microbiome test designed specifically for kids. So as a pediatrician, I'm often asked, Should I give my child probiotics? And if so, which one? And the truth is, everyone's microbiome is unique, so without testing, it's nearly impossible to know what your child may actually need. So that's where tiny health comes in their Easy at Home test gives you a clear snapshot of your child's gut microbiome, and you'll get back personalized science based recommendations. The results help you know exactly what supports may be helpful. And sometimes you'll find that your child doesn't need anything at all to try tiny health for your family. Go to tinyhealth.com and use the code. Dr Jessica, D, R, J, E, S, S, I, C, A for an exclusive discount. Dr Martin, thank you so much for being here on the podcast. I'm really looking forward to this conversation. Thanks so much for having me. I have to tell you I heard you on another podcast vowel sounds, and oftentimes I listen to podcasts that reinforce what I'm thinking, or you might learn some new ideas, but your podcast actually changed the way I practice medicine today, and I'm so appreciative of the work that you're doing. Oh, thank you so much. I love hearing that people are finding it helpful. So first, tell everybody a little bit about yourself. What kind of research do you do, and what kind of a doctor are you sure? Yeah, so I'm a pediatric gastroenterologist out of Mass General Hospital for Children in Boston, and I became really interested in understanding the earliest places in our body, that food and antigen, which are things that can cause allergy and microbe like the bacteria, all live and interact very early on in the infant GI tract, and how that might set us up for various types of health and disease as we get older. And so that's predominantly what I've been studying. What a relevant topic I do. Think there's a lot that we want to know and understand about the gut microbiome, and we also know that we're seeing an increase in GI issues like intolerances to various foods. We're seeing a lot of eczema on the rise, and we're trying to figure out how it all ties in. And I think there's a lot of help that we need in that area of research. I agree. Thanks. So what I'm looking forward to talking with you about today is, as a general pediatrician, I find that a lot of parents have questions when it comes to milk and how the body tolerates milk in general. So first, I wanted to talk to you about a very common scenario that comes up with babies in my practice, and that is finding out that babies may have intolerances to milk. So can you tell me a little bit about this? How common is a milk intolerance to a baby? And what does that mean? Exactly, what symptoms should parents be noticing in their babies? Yeah, it's such a great question. So one of the things that's tricky in that oftentimes, when we hear these symptoms, a baby is drinking either breast milk or maybe an infant formula product, and we make assumptions if they don't seem to be tolerating that well, the milk proteins, or some part of the milk is the problem, but we don't really know that. Oftentimes, there are so many other ingredients in both of those things that it can be a little hard to know. I would say babies that come into the office and are really fussy, really miserably uncomfortable, usually around a month or so of age when this starts, and have blood that parents can see in the diaper and maybe really mucus. Stringy stool. Those are probably the easiest to say. This seems like this thing called we call it allergic practically this, or food protein induced allergic practically this. Those are probably the easiest to feel confident that we know what's going on, although we can talk more later about the fact that we actually don't understand how it works. I think the kids that are harder are the kids that come in with some less obvious symptoms. They're a little fussy, maybe they're spitty or refluxy. They're really kind of uncomfortable with feeds. They don't sleep well at night, and very often, we suspect a milk protein may be causing part of the problem or something in its diet, but we don't really know that, and it can be quite hard to be sure. So to answer your question about how commonly we're seeing this in a large population that we studied in the greater Boston area, this was being diagnosed in 17% of healthy children. That's a lot, and that was when we required that they had some amount of blood or mucus in their stool. So that didn't include that second category of kids who might get this diagnosis. But it might be less clear. I think this topic is so it's so interesting to me, and I'm so glad that you are trying to get to the bottom of it. No, no pun intended. Sorry, bad joke. But I would say, as a pediatrician, what I see all the time is parents come in with a fussy infant, which invariably kids that are a month two months old, they're fussy. They're not sleeping well. Everybody's tired, and they notice that the stools are on the mucousy side. There might not be visible blood, and maybe babies are spitting up a little bit, which also was normal, and then we end up looking for solutions to help the family. So we will check their stool, and very commonly I'll notice microscopic amounts of blood in the stool. Test so it's not visible to my eye or to their eye, but we test it, we find microscopic amounts of blood. And then this is where I struggle as a pediatrician, because then we make recommendations to families that seem really hard. We're telling breastfed moms to take milk out of their diet, to take nuts out of their diet, to take soy out of their diet, which is really hard for a new mom, or we're telling them to make formula changes. And I always question how much we're really helping families. You know, we check back in a week or two weeks later, and sometimes the fussiness is still there, and so I guess I hope that I'm making recommendations that are making the baby feel better, but I'm also not certain that we are. Yeah, I'm so glad you bring this up. I think this is one of the hardest parts about management here. I think something important to know is that in other types of diseases, when we recommend a treatment. Even in pediatrics, someone's done a study where they took a bunch of kids with a problem and they randomized them into kids who get this, let's say, a medicine, and kids who don't, and then you really prove quite rigorously that the medicine or the treatment helps. So I think it's important for everyone to know that that's never been done for this. And so what we're going on is things that collectively, people feel like might be helping. But the problem is that, as you mentioned, so many babies are fussy at this age, and so often in one month or two months, they get less fussy. And so if we make changes, we often attribute those to the changes we made, both because we want that to be true and because that seems to make sense, but it also could be that they would have gotten better if we just gave them some more time or some other types of support. And so I think you're right to be skeptical about how often we're doing the right thing. I try really hard to think about these kids in two really distinct categories, kids who come to me, who are breastfed, my job as the pediatrician, I think, is that if their family is motivated to continue breastfeeding, I want to do everything in my power to make that happen. And so if giving mom or the family dietary restrictions that are going to be challenging is going to get in the way of that, I almost never think that that's the right thing to do. Formula is a little different because you're already on infant formula. I'm not sure. There's a tremendous amount of evidence to say that a hypoallergenic formula, meaning one that the milk protein is broken down in versus not, are much worse or less good from a growth nutrition outcome standpoint, than a cow with milk based formula. And so negatives I notice are the cost. Sometimes it's hard to find and they don't smell as good. Otherwise the difference in that recommendation, I agree, yes, yes, there are some differences across ingredients that parents are starting to ask me about. Those formulas tend to have corn syrup in them, for example, maltodextrin, non lactose sugars. We can talk a little bit about sugars and lactose a little later on, but and recognize some of those concerns, but I think that when I have a breastfeeding parent, I spend a lot more energy trying to not disrupt that than I do trying to think about dietary elimination that may get in the way of a happy, healthy, thriving breastfeeding relationship. Otherwise. Yeah. Yeah. So I guess I have two questions that I want to ask you about. First is, if we find that there's microscopic blood in the stool, a lot of parents worry that must mean that there's some inflammation going on the body that can't be good. Is there any knowledge that we have that having a little bit of microscopic blood can be harmful to the baby? In other words, if we let it keep going with microscopic blood. Is that a bad thing? Do we know if that's a bad thing? Yeah, thanks so much for asking this question. Our study where we followed 1000 kids in the greater Boston area. We're following them for 18 years, but they're around 10 now. We took all babies born into a healthy practice. This is called the G map study, and then we followed the ones that developed allergic colitis and the ones that didn't. And because this question has come up so much, I went back, and we decided to pull out of our freezer the stool samples we had collected from babies that had no symptoms. So never had parents had any concerns, but from that time, like from around one month of age, and when we tested their stool for blood, and this is after having been in the freezer for a while. So this is probably quite an underestimate. The rates of blood in their stools was at least 10% so 10% of babies had microscopic blood in the stool, if we checked when there were no concerns and there was no reason to check in a research setting, these results haven't been published yet, but they're coming soon. So I can't tell you where to look yet, but it's coming soon. It totally makes sense to me, because we're not checking every baby, of course, microscopic bud in the stool, so there must be babies that have it that we're not finding out about, and they're doing right. And so just like I mentioned about how there's never been like a randomized, controlled trial for the dietary intervention, there's also never been a validation study to say that checking stool guacs, which are those tests for microscopic blood, are actually helpful in identifying kids who have colitis or a milk protein allergy or problem. You know, I think that from a logical perspective, if kids are having a lot of symptoms, and we're seeing blood and mucus in their stool, that's really obvious. Then you start to imagine, or even better, if the child has had a sigmoidoscopy, which we used to do more often years ago, where you actually could look in a with a camera and take a biopsy. I think if they really have an inflamed GI tract, that's important to know, and something we probably shouldn't leave alone. But I'm not sure that microscopic blood testing tells us that. And so we're imagining that that may be true, but I think that the times are changing a little bit, and how much we feel confident about that assumption, and just to help clarify what we're talking about when we talk about allergic procto colitis, or I'm going to say AP for short, just to make it easier on people that want to understand the terminology. Are we talking about a milk protein allergy? Are we talking about a milk sugar allergy, like lactose? Are we talking about generalized inflammation from milk what is the body responding to negatively? We don't know. We know what it's not. So it's not lactose, in the sense that sugars don't cause allergies, proteins cause allergies. And so we know that lactose intolerance, while that happens a lot in older kids, like after kids are three, and then certainly many grown ups. It doesn't happen in little infants. It almost never happened. It would be an exceptionally, exceptionally rare genetic disorder, and that's because lactose is the sugar in breast milk. So we've all evolved for millennia to initially be fed milk from our moms, and that milk doesn't have cow's milk protein in it a lot, although there are some if that mom is drinking cow's milk or eating cow's milk product, but it does have lactose from the body, and so it would really be evolutionarily unwise for us to have a lot of people that can't tolerate lactose, because that's the first sugar that you get exposed to as an infinite breast milk. I think that's such helpful terminology to explain the difference in because a lot of people call it a lactose intolerance, but that's really, as you pointed out, something that we never see in babies because we need it for survival. Wouldn't make sense if we were having frequent issues with the sugar in breast milk. So, yeah, interesting distinction. I think it's made extra complicated by all the marketing that young parents are exposed to, much worse than pre social media era, I have to say. And some of that marketing comes from companies trying to sell products, info, formula, probiotics. We'll get to lots of those topics, but many of them talk about things being lactose, low lactose or lactose reduced, not because we think medically, or any of the medical staff think that that's an important feature, but because it's such a confused term, that they decided that removing lactose from some products might help parents feel more comfortable with the product. Yeah, or I also find that there's some parents that have lactose intolerance themselves, so they think, oh, maybe this is genetic. Maybe my baby also has this issue, but it doesn't come up in babies. It comes up as you get older. I find minimum like the teenage years is really when lactose intolerance presents. Yes, we see it occasionally in school aged children, but much more commonly as they get older. That's right. Okay, so when we're talking about infants and babies, and we're finding that they're having some sort of intolerance, or their GI tract isn't agreeing with milk it is likely the milk protein, yeah, I mean, certainly for allergies that are life threatening, it's always the protein. I think what's tricky is that this entire entity we don't really understand, and that's why our research team has been working really hard to try to dig deeper, because it's really common, and yet we really don't understand how it works. So we think it's probably protein mediated because other subsequent food allergies are the life threatening kind, and also because we've learned that these kids seem to be more allergic in general, often the kind of kid that might go on to have asthma or eczema or other food allergies later. And so the idea is that probably it's a similar mechanism to some of those other diseases, but those mechanisms aren't totally perfectly understood yet. Okay, so in my mind, you've helped me separating the two groups, the group that has the microscopic blood fussy infant between one and two months, I'm going to try my best to reassure families that this is likely something they're going to outgrow. We'll keep an eye on it, but if the child's doing okay, the best thing might be just to hold off and not make any changes, especially in a breastfed mother. But as a pediatrician, what would your advice be to advise a family where the child is fussy is showing visible blood in the stool? What should we be advising at that point? Yeah, that family. So then we recommend milk protein elimination from the mother's diet, because the milk proteins get transmitted into the breast milk, and that means that the mom would read labels and avoid anything that has any type of milk protein in it. And usually it takes somewhere between three to seven days for those milk proteins to get totally cleared from the breast milk. It's probably within a couple of days, but we say a couple longer than that to be sure, and then it might take a week or two or even three for the baby's GI tract, if that's the protein they were reacting to, to actually heal and for the symptoms in the baby to get better. So I try not to make more than one change per month. So if I make an elimination from milk, I try really hard to wait a full month before we decide it didn't really help, or it made a really big difference. The next food to consider eliminating, most people think is soy, because soy proteins and milk proteins look kind of similar to our immune system, and there's a lot of kids who would be allergic to both, but I don't recommend starting with both, because, again, in the spirit of wanting to keep things as supportive as possible. For breastfeeding moms, I want to make that diet as easy as possible. The trick is, let's say you do that and everybody thinks that the baby is much better. One of the mistakes I think we make is that we then say, okay, let's do this for a really long time, because everybody's finally feeling better, but all of the international guidelines tell us that one month after that, after you've had that baby who's feeling much better, you should put the milk protein back into the mom's diet, or the formula, if this is a formula fed infant, and prove that the Symptoms all come back. That's called a challenge. Surprisingly, I think maybe even less than half of kids, when you do that, will actually have a real reaction that second time around. And so it's really important that for that other half who don't that we can make everybody's lives easier. Mom can go back to eating ice cream, and baby can go back to being happy but not having to be on a restricted diet. And so we really want to restrict the formal diagnosis to kids who react to that challenge, and then those kids are meant to avoid that allergen for a bit longer. It's a little debated, but maybe three, six or even nine months. And then is there a certain point in time when you notice that most kids outgrow this allergic proto colitis or AP. So nobody's done this in a systematic way, right? So we've never had a study where they said, Okay, we're giving you it now. Now we're giving it to you, and we're gonna see that earliest moment that you're ready. So we've been walking back when we've been introducing and I would say there was one paper pretty recently that found that even as early as three months after the diagnosis was made, children were already ready to tolerate the allergen or the antigen again, so already ready to tolerate the milk that it seemed they weren't tolerating three months before, I find this information so helpful, because, as you pointed out, it's a difficult challenge for mothers. Have to take out dairy from their diet. I have so many moms that they're struggling as it is, having a newborn, and then when our advice is to take out their favorite dessert or take out their daily cappuccino that they look forward to, it's hard, and it makes what's already hard even harder. And so I'm so grateful that you've taught me to try to reintroduce milk a month later, because I think that's doable. I feel like for somebody mentally to know, okay, in a month I can retry this, and there's a better than half chance that it's gonna be okay when we reintroduce it. Because before I heard this advice from you, I was waiting, honestly, until about six months to tell moms to reintroduce the milk. Yeah, many people were waiting nine or 12 months, which is what the guidelines say, if you did the challenge, and they reacted to the challenge. And I think that if is the part that many of us kind of missed or have had a hard time implementing, but is super, super important, and I've been doing this now for some time in my clinic, these babies come to see me very often, and I'm often surprised by the kid that I was sure so clearly responded to milk elimination just a month ago. Don't seem to care when we put it back in. And I don't think that means we were wrong the first time. I think it's really possible that there's a rebalancing of the GI tract, of the microbes that live there, of the health of the barrier, such that one month later, they're better. And so I don't think if the challenge is negative, so to speak, that we were wrong, I think more often, and maybe it just means that it's over already. Just to be clear, what would the symptoms be that we should be concerned about when the milk is reintro reintroduced, because babies, in general, have some time that they're fussy. So what would a failed challenge actually look like? Yeah, I think it would mean certainly if there's, you know, a diaper full of blood and mucus, those are helpful and obvious, but also pretty rare. I think a baby that goes from being content to miserable, really difficult to settle, difficult to put down with sleeping through the night and isn't sleeping at all, is vomiting a lot, is taking less volumes of their breast milk or formula, or isn't gaining weight as well. Those would all be symptoms that would at least make me think about it. But you're right. Sometimes kids are also teething or also having a sleep regression, and so I try not to rely on any one symptom to make this decision, but more of a global assessment of how we're doing. What I also really appreciate about your recommendation is that I find once we notice microscopic blood in the stool, a lot of the advice has been so restrictive for moms to take out so many proteins out of their diet that they end up giving up on breastfeeding altogether because it's just so challenging. So this is really refreshing advice to me, because I think whatever we can do to support moms more to be successful breastfeeders, I think is a great path forward. Yeah, and I think that, you know, we're still working really hard to understand the mechanism, but we have lots of promising data suggesting that some of this really has to do with the microbes that live in baby's gi tracts, and we know that the healthiest way to set up a healthy microbiome in a baby's GI tract is breast milk. So it hurts my heart a lot when I meet patients who come to me and have already given up on breastfeeding because the diet they were put on was too hard and now we're on formula. That's the right choice for some people, probably for quite a small minority, but I never want that to be the goal standard. And I had one patient with a baby who was quite sick, so really, clearly had colitis. Actually had a colonoscopy, because there was so much blood, we were trying to figure out where it was coming from, and it was this allergic disease, but her mom was really motivated to breastfeed, and so we had done a really complex diet. Mom was great about doing it. Baby still wasn't getting better. And so mom took a break and just pumped for one month while we did an elemental hypoallergenic formula. And one month later, when we gave that breast milk back, it was completely healed, and that baby did awesome for the rest of infancy. And so even in that super severe case, we briefly interrupted breastfeeding, but we didn't disrupt the relationship, and that baby got six more months of breast milk after that. And so I think even in the most severe cases, there's a lot of opportunity to continue breastfeeding if moms want that, and babies want that too, and I'm assuming from what you're saying, if the baby was able to handle breast milk a month later, were they also able to handle the stored breast milk? In other words, I think a lot of moms think that stored breast milk that's been put in the freezer, all that hard work, then has to be thrown away. But can they use it? Is it usable? Yes, as a mom who really struggled with every single ounce that made it to my freezer, those stories also hurt my heart. That milk is almost always usable, and so it's one of the first questions on my intake. When I meet parents of new babies like this, is to save that milk, label it well, so label what you remember your diet was or wasn't at the time that you pumped. It, but it's actually really awesome for introduction or for a challenge, for example, if you wanted to expose the baby to breast milk that had milk in it, but you didn't want the effects of that to last a week or two, you could use frozen milk for a challenge, for example, and then only open up mom's diet to new foods if that went well. And similarly, even if kids react a lot in a month, sometimes three months from now, that milk is perfect for them, so it is very rare. In fact, I don't think I've ever told a mom that her milk should be donated or given away. We've almost always found good ways to use it. Ultimately, wonderful. Now, what if there's a situation where a family feels hesitant to do a challenge in a month. Is there any harm in waiting three, six months before they reintroduce milk into the diet? What is the benefit of doing a challenge a month later? I think the first benefit of doing the challenge is that it makes moms do the diet for less long as they can, right? So I think that's the number one that, like you said, it's an achievable goal, something we can do, but not necessarily, really prolonged. We know that early introduction and exposure to allergen to babies directly once they get a bit older, 4567, months, helps prevent food allergies. So there was that big study called the LEAP study, about 10 years ago now, that really changed everybody's understanding of how food allergies happen, and made us realize that introducing peanut in the case of that study, in a safe way for babies, starting at four months, for babies who are at risk, prevented peanut allergy develop in a lot of those kids, we don't have the same information to say that that's true in breast milk, another word moms who eat peanuts versus don't eat peanut and have peanut in their breast milk, it doesn't have the same protective effect, although you can imagine those are a little harder to control, because moms who are avoiding peanut might be avoiding peanut because they're allergic and then that has genetic complexity as well. So the short answer is, I don't think there's a big risk to waiting two months or three months for a challenge in a one month old. Let's say if that feels more comfortable to a family, as long as it's not leading to ending a breastfeeding relationship. But I do think that once kids are old enough to tolerate foods like starting to think about solids, it's a good time to start talking about those allergens. And that could start with other allergens like peanut and egg, but then maybe should also include something like yogurt that has milk protein. Yeah, I think this is a great point to make, that the earlier our immune system is exposed to a variety of foods, things in the environment, the more tolerant we become. And so I think it's an easy temptation for us to just want to avoid all of the foods that may potentially be bothering our children, but it actually behooves the child to be exposed early and often if they tolerate it, because we can avoid allergies potentially in the future. Yes, and there's been this term for a long time, the allergic or the atopic March, and we've known for a while that diseases like eczema of the skin that show up very early might be one of the first signs of an allergic kid, and then can progress later by a couple of different mechanisms to subsequent allergies like food allergy and asthma. We have growing data, and there's a fair number of papers after ours saying that we think this allergic procto colitis might actually be the first step on that atopic or allergic march. And so I think it's an especially important population for us to be thoughtful about, because the elite study where they introduced peanut early on was in kids who had moderate to severe eczema and a few other criteria for enrollment, because that was their risk factor. But I suspect that these babies that have this allergic procto colitis early in life are similarly at risk, and yet, before we were having them, avoid a lot of things for a long time. And I also think we sort of maybe inadvertently, historically made parents worry about foods, and so they were probably later to introduce other foods. And this baby that they had eliminated milk from, and I think probably the reverse is true, that these kids, we should be paying extra attention to making sure they get peanut for example, even if we haven't done the challenge for milk yet, or even if we don't feel ready to proceed on the milk or soy train, I would say peanut or egg or these other known allergens should probably be happening early, like kids with moderate to severe eczema. I think this is a great point to make, because I think if a parent sees a child react in their infant's early life to milk, we can make the assumption that, oh, this is best to avoid for a long period of time, but the opposite is actually true. We want to think about reintroducing it as soon as possible to potentially avoid lifelong allergies. And I know we don't have something like the LEAP trial for milk, but I have read studies where kids that do have milk allergies if we expose them. Or to milk in different forms. You know, in baked forms, they actually can outgrow the milk allergy sooner than if they weren't exposed. Yeah. I mean, we certainly don't recommend exposure in someone who's had anaphylaxis, right? So if you've been diagnosed with a milk allergy and you went to the emergency room and got an EpiPen, then we don't do exposure until your blood tests and skin tests might tell you that you're ready, but there's conflicting data about how early the exposure to cows milk protein and in what form may or may not help prevent IGE mediated milk allergy later. It's interesting, right? Because we're the only mammal that consumes milk from another one, right? And so there are a lot of really interesting evolutionary discussions around whether we should be drinking any cow's milk or anybody else's milk, but human milk. I think that that can be a nutritional decision and a family decision and a cultural decision, but it makes sense that we may have a little bit of a harder time getting used to or tolerating cow's milk sometimes, and so I don't think it's the only show in town, particularly as kids get older, if it's something that folks aren't tolerating. Well, in your opinion, is it your sense that the allergic proctor colitis is increasing overall, or do you think we're just diagnosing it more? Yeah, this is really hard. I would say both. I think that we're paying attention to it more. I think people are looking at it more. I think people are testing more stools than they used to, and parents are asking more questions about that. And so I think we're probably noticing it or diagnosing it more, and I think it's also happening more, and that would be consistent with every other allergic disease on the map. Right in parts of the world where we have rising rates of allergy, we have high rising rates of lots of allergic conditions, IGE mediated food allergy in particular. So just to make sure I understand your thoughts on this, if a family comes in with a child who is slightly on the fussier side, has some microscopic milk in the stool, your advice would be to make changes as slowly as possible. Is that what I'm understanding? Yes, yes. I think my advice is to make changes slowly and to have our opinion of those changes and how they're working be based on how the baby seems, and not focused on whether or not there's a microscopic test showing blood in the stool. I really would follow lots of mucus, lots of diarrhea, obvious blood weight, faltering, feeding challenges, symptoms like that. But in a child who's sort of a little bit fussy but generally thriving and doing well, I often think we can do nothing and watch and see what happens. And I think that if those kids aren't going to tolerate milk protein, they'll let you know they will get worse, they will get more uncomfortable. And I'm not saying that we want that, but I think making sure we know that we're dealing with something pathologic that needs to be addressed is important too. Now, you mentioned that we're the only species that consumes another animal's milk, so I notice a lot of growing interest in my families, in being vegan. From your perspective, is there any harm in babies avoiding milk altogether? Babies under 12 months need certain nutritional factors. Those can come from milk, which, of course, then wouldn't necessarily have cow's milk if mom was vegan. So that would be totally fine. There are a few formulas that aren't cow milk based, that are available in the United States and meet all the nutritional criteria. And so I would say those are safe. The FDA reviewed all of those to make sure that they have the micronutrients that kids need once we get into like over one then kids don't need milk at all of any kind, but many rely on it for really important nutritional aspects of their diet, fat content, protein content, calcium, vitamin D. And so I would say that anybody who's going to be on a restricted diet for any reason, allergies, preference, culture, it makes good sense to see their pediatrician and maybe a nutritionist to make sure that they're ticking those boxes and that they don't need a multivitamin to get enough calcium or making sure that they're getting vitamin D sometimes in kids who are slightly pickier ways to make sure they're getting protein and fat in the right proportions, which some kids rely on cow's milk for. So yeah, there's no reason we have to have cow's milk in our life, but we do have to meet our nutritional needs, and so sometimes we need help making sure our kids are doing that. As you mentioned, there are some nutritional benefits from milk, but all of those nutritional benefits we can get from other foods, right? Like vitamin D, there's not a ton from milk, it's mostly sun. I live in Southern California, so it's easy for me to say, but I know it's added into milk. There's protein. We can get protein from other sources. There's vitamin A, we can get that from fruits and vegetables. There's calcium, which we can also get from beans and broccoli, and there's other milk variants out there. But the thing that I get concerned about is I don't want to induce a lactose intolerance in a child, and let me know if this is an incorrect assumption. But. I worry that a kid could grow up to be in their elementary school years, go to a birthday party, try a pizza for the first time, and have a difficult time digesting it, and then they're that kid that can't eat like all the other kids, and so I don't want to impose an issue on a kid that we might be able to prevent. Yeah, I don't know if there's literature about the long periods of avoidance and induction of lactose intolerance in particular. So that's a cool question. I haven't thought about that exact question, but I think that in general, my advice for most things is moderation. So at least in my house, my kids have cows milk. Sometimes, sometimes they'll ask for a glass of milk. We certainly have a lot of Italian blood, so there's a lot of cheese and everything. And I think that's probably some amount of exposure over time may help kids be able to tolerate that, like you said at a birthday party or something like that. But to your point, there are certainly kids who can live long, happy, healthy lives without cow's milk, or even without a replacement, as long as they meet their other needs. And so I try to support families in that if that's what their preference is, yeah. I also have to say I do have plenty of vegan families that are in my practice, and their kids are definitely thriving without having any cow's milk. So I see it working in all ways, and as long as you're paying attention to getting a nice variety of nutrition in the diet, yeah, and I think in the US, I see a lot of kids who are relying too heavily on cow's milk, and that's getting in the way of their ability to learn to enjoy a whole range of really important other food. So I think variety and exposure and building flexibility. You know, we have some oat milk, we have some almond milk, and I love that our kid can take and appreciate all of them, and I do think that allows them to be at someone else's house who has some other kind of milk and not have that be derailing for them socially or otherwise. So I think that that's really wise. It is true that there are some kids out there that love their milk, and I do think if you fill up too much on milk, it can curb your appetite for showing an interest in other healthy foods for the diet. So that's a good point to make. Yeah. So now to circle back, we had touched on lactose intolerance earlier, which is different from the milk protein intolerance. This is the intolerance of the actual sugar in milk. Can we talk more about that? When does that usually show up? And how do you advise parents who have kids that are intolerant of the milk sugar, the lactose. Yeah, so lactose is the sugar in milk and in usually broken down by specific bacteria that are in the GI tract. And when that's not working correctly, then you can become lactose intolerant, meaning that some amount of that sugar then really bothers you that presents, usually with really loose diarrheal stools after eating lactose bloating or discomfort. So usually, classically, kids will tell me that they really like ice cream, but they've noticed that when they have that bowl of ice cream, they have to run to the bathroom afterwards, and their stomach feels pretty uncomfortable, and often they'll have an explosive diarrheal stool after that, you can test for lactose intolerance by doing a breath test. So this is kind of a cool test you can do in the office, usually a GI office, where you breathe into a bag, and we can measure the hydrogen coming out of your exhaled breath, whether you have enough lactase, the enzyme to break down lactose, and whether that's being broken down correctly. Is that a pretty accurate test? And is it pretty easy to come in? It's pretty accurate and it's easy to come by. It's not in every lab or in every primary care office, but most sort of hospital based groups, and I suspect many outpatient groups have it too. Actually, during covid, they developed the ability to send it to people's homes as like a kit, and so parents can even have it sent to their home if their insurance covers that, which is pretty neat. So this often present in teenage years, like you mentioned, or sometimes, I mean, very often presents in older adults. But we're focusing on kids here today, some kids find that they have a particular amount of lactose they can tolerate. So, you know, some people can tell me that they can have like, a quarter inch of cream cheese on their bagel, but not like a full inch of cream cheese on their bagel before they have symptoms, and some people really just can't tolerate any at all. Yeah, I definitely find that some people can have some yogurt or some aged cheeses, but if you give them a full glass of milk, forget about it. They're really uncomfortable, exactly. Yeah, this can also be a temporary phenomenon. It's worth noting when kids have a viral illness or an infectious illness. So if you have that terrible stomach bug that goes through your school and then you notice that a week or two later, your kid's having a really hard time, sometimes that's what's called transient lactose intolerance. It's a post viral process or post infectious process, and that just means that those bacteria that are supposed to be doing that job got wiped out by that other illness, and they need a little chance to recover. And so sometimes avoiding lactose for a week or two or three in that post infectious period, and then slowly reintroducing it can help. That's a really helpful reminder, because that's definitely something that I see a lot with families. And so great to know that that's not going to be. Forever? Yeah, usually not. So in general, as you go through your research as a GI doctor who's focusing on milk protein intolerance, is there something that you wish pediatricians or parents had a better understanding about cow's milk in general, I think the biggest thing that I wish is that we all do everything in our power to help new families survive what is a really hard time, which is having a new baby in the house. And I think I didn't fully appreciate it, to be honest, despite impeccable pediatrics training, until I had my own little ones, some of which were more difficult than others in those early phases. And so I think first and foremost, though, of course, it's what we all mean to do, making sure that we're really understanding what parents are worried about. And I think milk protein might be scapegoated more often than is fair. And I think that in an effort to do everything we can to be helpful, sometimes we do too much, changing, changing formula, changing diet, giving more things to do when really, I think sometimes we need reassurance that babies are super fussy, sometimes, sometimes for a while, and that can be okay. And so I think talking to your pediatrician, trusting your pediatrician, sometimes seeing them, often, if that's what you need to feel like you're on the right track over ending a breastfeeding relationship, or feeling really alienated or really struggling with feeding, would be my biggest wishes. Thank you so much for that. I think that is a reoccurring issue that comes up, not just with milk protein, but I also find with things like the tongue tie procedure or putting a child on reflux medications, I feel like a lot of times with fussy babies, we want to do something. We want to fix it. We want to fix the problem fast. And oftentimes, I find the most helpful solution is just being a support system for the family, really reassuring them that their kid is healthy and normal and that it's going to get better over time. We just need to get through it, day by day, nap by nap, and sometimes doing less ends up being better for the child and the family. Yeah, and, you know, one of the things I hear a lot in my office that I try to reframe for families is that sometimes I hear parents tell me, I'm here to see you become my pediatrician blew me off or didn't share my concerns. Pediatricians are incredible human beings who are also being asked to do a lot more than is humanly possible in the 15 to 20 minutes that we're allowed to spend with our patients sometimes, right? And so one of the things that I think is really helpful to arm parents with is this question, can you help me understand why you're reassured, or why you're not worried, because we have this whole list in our brain from all the textbooks we memorized way back when and everything we've learned since that allow us to feel confident that this isn't something that is gonna make your kid allergic forever. This isn't something big or bad or scary, and yet, I'm not sure we always articulate all of those things. And so I think sometimes one advice, a piece I would give is to when you're feeling like your pediatrician is telling you that you probably don't need to change anything. That doesn't mean they don't hear you and they don't see you. It means that they've laid all the options and think that the safest, best option is to what we call watchfully wait. And if that feels unsatisfying, I think asking questions about why that is or why they feel that way sometimes can be clarifying for parents, to know that it's not just that we don't believe you that your baby is fussy, it's that we want to do no harm, which is what we're supposed to do absolutely. And that's not to say that sometimes intervening isn't the better option for the child and for the family, but I do think the beauty of having a pediatrician is that you can see them next week, you can follow up into skin and not acting right away. Doesn't mean we're not going to do something at some point, but we have the luxury of having a relationship and checking in on you later, and that's a very, very important tool that I wouldn't forget about, for pediatricians and for families, yeah, and I think sometimes maybe people feel like we're kicking the can down the road. And I think rather, we're using time and observation. And that's why in medicine, it's called watchful waiting, right? Because we know that many things get better on their own with time, with far less risk than whatever we might have intervened with. And so waiting and seeing where we are a week from now and two weeks from now can often be really illuminating, and sometimes kids are much worse, and then we know that it's time to act. And that's really helpful information. And there's nothing to say that waiting a week or two with a diagnosis like this, reflux, milk protein, allergy, allergic colitis, puts kids in any worse a position, and in many ways, that might allow the problem to go away on its own. Thank you. So okay, as we finish up, I just thought I would fire off if you're okay with this, if you milk myths that I'd like you to either tell me true false, or maybe it depends. Is that okay with you? Yep. All right, so the first one, if a baby is fussy, it's probably a milk allergy, true, false, or it depends. I would say either false or it depends. I think it definitely depends, and more often than not, it's probably not okay. Lactose Intolerance is that common in toddlers? No false goat milk? Is that a safe alternative to cow's milk for infants, I would say false, or it depends. So neither goat's milk nor cow's milk are safe for infant if they're not in an infant formula preparation. But if we're talking about an infant's formula, there is one now, FDA approved goat's milk based infant formula on the market, and I would say that that is safe. Is that? Kabrita? Yes. All right, here's a big one. Kids need milk to grow properly, true, false, false, false. We chatted about this a lot, but I think there are lots of other ways to get whatever you might get from milk, but if you need help with that, a nutritionist or your pediatrician can help. Just thought, yeah, why not reinforce that one more time? All right, if a kid avoids milk, they will most likely become calcium deficient, a false or it depends, it depends on what else they're eating, right? So I actually have the calcium requirement chart posted inside my pantry closet, because I find it really helpful to remind ourselves. I think we sort of rely on calcium being in milk for a lot of kids in the US in particular. And though knowing what those amounts are and what other foods you can find them in to make sure you get your appropriate amount of calcium is important. It is a significant amount, so you do have to put some thought into making sure you're getting that calcium from other places, in my experience. But it can be done, for sure. It can be done. My kids are doing it. I have to say, I rarely see a kid that's calcium deficient. Maybe I just don't know about it. But really, yeah, I think that we probably worry about it more than it turns into to a real bone health problem. I think it's one of those things, though, that you're building up over time, and you might not see those deficiency problems until later in life. And we'd love to set people not up for that, for that bone fracture or other thing that gives us that clue later, absolutely Well, Dr Martin, I've so enjoyed talking to you this information I think will be so helpful for many of my listeners, and honestly and for myself as I continue being a pediatrician and guiding families that I meet. So thank you so much. Thank you so much. It was such a pleasure. I love being here. Thank you so much for listening to your child as normal. I'm so grateful you're here and part of this community. If you're enjoying this podcast, it would mean the world if you shared an episode with a friend subscribed and left a five star review. And don't forget to follow me on Instagram at ask Dr Jessica for more parenting tips and updates. See you next Monday. You.