Have you ever had an instinct? An instinct that begins as a gnawing...Then grows into a raging burn; a burning instinct that something is wrong...
Your baby continues to get sick from the very foods he is supposed to thrive on. I did. I am a mom of a little boy just diagnosed with FPIES.
And that burning feeling now? Extinguished. My instincts? Stronger than ever. Guiding me, with my faith, as we navigate through the murky waters of our new world created by something called FPIES.
"Faith is not about everything turning out OK; Faith is about being OK no matter how things turn out."
Friday, December 31, 2010
In this world, of a chronic illness like FPIES, the journey has taught me more about taking the moments and stealing what you can from them. Little Man loves music, as most toddlers do. Music can turn a mood around, turn a day around. Music can inspire and draw up meanings, remind us of times gone by, and put words to moments in life. There are a few songs that will likely always remind of 2010 and the ups and downs of our FPIES journey. This one "Stuck Like Glue" by Sugarland is one of those songs. So, click on the link and dance with us....
....because no one knows (Little Man) better, no one can make (him) feel so good, no one thought we could....and just when I think I've had enough.....you give me that look, baby....there you go making me feel like a kid....Whutooo whutooo, Stuck like glue. You and me baby we're stuck like glue. Whutooo whutooo....Some days you know I wanna just give up. When it doesn't matter who's right, thought about it all night had enough, You give me that look...You do that thing that makes me laugh....just like that....there you making me feel like a kid....Melodies that get stuck, Up in your head whutooo whutooo. Up in your head, whutooo whutooo...... Stuck like glue, you and me together, it's all I wanna do.....
I hope you enjoy it as much as Little Man, his brothers and I do.
Happy New Year!
Wednesday, December 29, 2010
Inflammation healed, villous atrophy gone. Christmas wish (and many months of prayers), answered.
We now have a head start, a real chance at passing foods, at expanding his tiny menu -- or just staying still with the formula that has sustained him since stopping the Neocate. The only catch is, he needs some vitamins to fill in what his hemp milk formula is missing. He needs a multivitamin/mineral supplement. Having this will complete his daily needs -- to assure us his nutrition during breaks, during trials, during reactions, for proper growth and development. Taking away the Neocate and starting him on hemp milk formula stopped the daily assault on his gut, and his daily pain and random vomiting but the damage of corn had been done, other food trials did and left their "damage" and then there is the villous atrophy (from soy?, we still are not sure). But, taking away the Neocate also took away our complete vitamins/minerals. This was supposed to be filled in my a tiny menu- but we couldn't get to a tiny menu. So, next steps....to trial a vitamin. My searching has continued and thanks to some great dietitians- we have found one that is the "lesser of all evils"...apparently a 100% corn and corn derivative free vitamin does not exist. We found one that is worth trialing....to give him that complete component he needs in his diet.
But, trialing a vitamin with corn derivatives does not come without it's concerns. We are reminded of how quickly, and how severely he reacted to a Vit.C derived from tapioca (a previous fail from bloody dumping diarrhea resulting in acidosis), such a minute amount hit his system so hard and we landed in the hospital being evaluated for a blood transfusion. Not a lesson easily forgotten.....
But he needs the vitamin....
Our GI has assured us that we will do a 2 week trial of the vitamin (as we know trace amounts will potentially bring on a myriad of symptoms and not a full "reaction" of violent vomiting and diarrhea, lethargy. The plan is to push through the symptoms, noting them as we go and if they do not subside, build or continue to be worrisome- she will re scope him to be sure we haven't lost his baseline of NO inflammation and NO villous atrophy before we continue on the vitamin or onto food trials. The vitamin was ordered yesterday, will arrive at the end of the week, we will start it Monday.
But in the meantime.....we are weaning off TPN and we plan to go home from the hospital (after 25days) tomorrow!! We are SO ready to have him home again, to enjoy his baseline, to re-establish a "home" routine.
Little Man has been weaning off his TPN while reintroducing his hemp milk formula - which he has been taking really well. In fact, he has started to ask for his "bat-ba", he also asks for his "night" (translation blanket) when he wants his bottle, or a nap. He has learned other words such as chair, door, car, bye, thank you. He has added knowing where his eyes, ears, mouth, tougne, nose, feet, and belly are. He adapted to hospital life and we made the best of it, taking any moments as teaching moments and play time. His brothers visited when possible. We will all be very glad to have him home....we were able to take him home for 4hrs on Christmas Eve and on Saturday and Sunday evening as well - he LOVED every second of it!
We are ready to close the door on 2010, and greet 2011 with optimism and health. May the New Year bring us (all FPIES families) a renewed FPIES path!
Friday, December 24, 2010
We got the news that Little Man will need to stay in the hospital over the weekend, and through next week, to continue the TPN full strength for a few more days (until biospy results are posted), and then wean back onto his hemp formula. The change will be the addition of the multivitamin (intended for TPN solutions) added in to his daily regimen. His hemp milk formula has many vitamins and minerals but is missing some, and since we have not (and do not know when) been able to increase his diet to provide for those vitamins and minerals; it is essential that we find a multivitamin that he can tolerate. I have searched every vitamin supplier I can find and can not find one that fits his needs and avoids his allergens. This one is the closest, and since designed for TPN (dissolvable) solutions, there is hope it can be something his body will not sensitize to. As with everything else, only time with tell- it will be a trial. We discussed that it would be a 2week trial, we would push through minor symptoms and if there is questionable symptoms at the end of the 2weeks, he would be re-scoped to be sure we haven't lost his baseline before proceeding.
The villous atrophy is what scares me with proceeding...the silent damage that was being done- and we don't know what from. Was it soy? Was it from corn and his inflammation never healed? Was it millet? Is millet too closely related to wheat? Is it a small bowel bacterial overgrowth? (aspirates were taken for that). Without knowing for sure, can we really just push through small symptoms? Are we risking villous atrophy again? All questions only time will tell....and Faith. Faith that I will continue to be led in the right directions with my instincts, instincts that connect me to my little man like nothing I've ever experienced. I have no doubt where this Gift comes from.
Tonight, we would celebrate this great news of healing-- but we are a little busy preparing for another celebration. We will celebrate our Christmas early, tomorrow. Both Little Man's daddy and I work on Christmas Day....we both have been on FMLA so much over the past year (most recently the past 7weeks) and Little man is stable, with my sisters here to help with him and his brothers, so we can honor our commitments to our jobs. To the fellow co-workers who have given so much of their own time to make up for our many absences.
So, Santa Claus comes tonight....he has already visited, his elves work fast when little boys slip into slumber. The best Christmas present will not be under the tree....we arranged for Little man to have a pass for 4hrs tomorrow morning so our family can have our Chirstmas celebration, together....even if just for a few hours. It will all be part of the surprise for his brothers tomorrow morning. They will wake up to presents under the tree and this letter, from Santa:
Dear Meyer Boys,
Desperate times call for desperate measures. Not many kids understand that I start delivering presents
the morning of Christmas Eve. Where it is Christmas Eve for you it is Christmas Day to others. I know both your mom and dad will be working Christmas day, so I made a little detour to your house. I want you to know that I have kept up on how little Sam is doing. Although little boys can always be better, the Meyer boys are some of the best behaved boys I know. Your strength, courage, and loyalty to your little brother shows the depth of love you have for him. It is not easy to have brothers sometimes, but it would be a very lonely place without them. So I have made your Christmas Eve into Christmas Day. Have a very Merry Christmas and a Happy New Year.
St. Nicholas (aka Santa Claus)
Merry Christmas Everyone!
Tuesday, December 21, 2010
We spent the first week adding components to his TPN: dextrose, amino acids, Iron Infusion, then fats and finally vitamins/minerals. His body showed us weird "off baseline" symptoms at every addition- nothing serious enough for "red flags" so, of course we pressed on....he needs this gut rest with concentrated nutrition. It is our ultimate hope, pray, wish that this is what he will need to "reset" some of the wrong steps we have taken on this journey....a fresh start for better management of this allergy.
The second week we spent working him up to 100% of his needs from the TPN. He has still been able to drink his plain, unflavored, original Hemp milk - as "icing on the cake" and takes in 200-400calories a day, as his "icing". We have seen good weight gains, but at this point still too early to calculate how much of that is "true" weight gain, or "dry" weight as he is very well hydrated from the TPN solution. I have good hopes though that some is true weight gain, and that it not only means he is doing some catch up time (from concentrated nutrition bypassing his inflamed gut) but also that his villi have repaired/rebuilt themselves enough that they aren't stealing all the nutrients.
Little man has received 5 IV Iron infusions, initially his body responded really well to it by bringing up his hemoglobin a whole point (from 6 to 7 now). His body does seem to over-react to the infusion though, he becomes hyper (crazy hyper) for the infusion day and following day; then he gets a "strung out" look, pallor look to him the day before he is due for the next infusion. I have yet to figure out if it means anything, or if it is "just" a side effect. He has 5 treatments to go, so hopefully it isn't something that continues to build.
His scope is on Thursday and everyone is anxious for that. Biopsy results won't be analyzed/read until Monday due to the holiday weekend; so we will wait patiently (some more) and begin cycling his TPN so he can be weaned off (and hopefully be home by this time next week!)
My Christmas wish? Gut healing, no inflammation visual or on biopsy; repaired and restored intestinal villi and true weight gain. Oh, and a healthier 2011!
Thursday, December 16, 2010
The full report is 84 pages long. The first glance I took of it, of course I skipped through to where it mentions FPIES. Yes, that is right- it gives an entire section for FPIES. It is a very real diagnosis and having it mentioned here in the new guidelines for food allergies is a big step for the future of these children affected by it. But the report is, of course, not limited to FPIES. I have begun to read through it and am impressed with the information it provides, updated information that is needed as this country's food allergies are on the rise daily. In fact, that is one of the reasons they developed the new guidelines.
The first thing I notice is in Section 2 (pg7): Definitions "A food allergy is defined as an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food." This is updated terminology to address both IgE and Non-IgE food allergies. Typical immediate onset allergies are IgE, that is IgE-mediated mechanisms are involved. Non-IgE are delayed and thought to typically involve cellular mechanisms. "The terms Allergy and Allergic Disease are broadly encompassing and include clinical conditions associated with altered immunologic reactivity that may be either IgE mediated or non-IgE mediated".
It goes on to describe terms such as Food Allergen, this addresses foods or specific ingredients and components in a food (typically proteins). It also addresses cross-reactivity definition and significance in food allergy. Food oils are considered low allergenicity if virtually all food proteins have been removed in processing (note low, not non-allergenicity).
I am pleased to see that there is a lot of language in this report to describe diagnosing food allergy- not limited to serum levels of IgE, but in response to tried-and-true elimination and challenge of the foods. Things to be considered is the level of reaction, the quality of life - the balance of benefit and harm..."identification and avoidance of foods responsible for food-induced allergic reactions improve quality of life and potentially prevent life-threatening reactions and disorders. With the appropriate evaluation, there is a low risk of erroneously diagnosing someone as food allergic and adversely affecting his or her nutritional well-being and social interactions".
This is an important moving forward (and over due) step in the world of Food Allergy. And as not only a mom of an FPIES child, but a Dietetic professional as well, this is of critical importance -- to properly recognize, diagnosis and treat food allergy's not only so that diets are not over restrictive but also, on the other end of the spectrum, so that proper identification to symptoms can be made, and treated with removal of the offending food(s). This is important because as of now, allergy's are only considered "true" if they produce an IgE and immediate immunological response. These guidelines are helping to redefine, and hopefully reshape how adverse reactions to foods are viewed, and thus diagnosed and treated. It is very important to be able to treat so many growing number of protein intolerant infants and toddlers, to have recognition that not all food allergies are IgE response, that Non-IgE food allergy's exist, are prevalent and a significant adverse health effect on children suffering from them.
Food Protein Induced Enterocolitis (FPIES) and Food Protein induced allergic proctocolitis (AP) are initially described on the bottom of page 8.
A table (in section 4, pg 20) for "Diagnosis of food allergy: when should a food allergy be suspected?" and includes delayed GI reactions as well as other cutaneous, ocular, and respiratory delayed symptoms (as part of the cascade of symptoms)- it should be noted that the expert panel notes that food allergy rarely causes isolated respiratory symptoms such as asthma and allergic rhinitis.
Included in section 4 (page 22) is an outline for Differential for Diagnosis of Food Allergy, which include addressing adverse reactions to foods that are not allergenic in origin.
A few pages later (page 27) is the discussion on Diagnosis of non-IgE-mediated immunologic adverse reactions to food. This is where FPIES and AP are described as Guideline for diagnosis, rationale and the balance of benefit and harms. It is a good synopsis of the research on FPIES thus far. I am happy to see it has it's place here and described so well for the clinicians. There are additional research articles on FPIES, and additional research is being done to further understand this diagnosis, and ultimately (hopefully) find better treatment options to provide to the families struggling with a severe protein intolerant child.
I am still reading through the rest of the report, it covers a lot of new language, encompasses newer research, clarifies IgE reactions. In general, it is well written report and hopeful that with FPIES and AP being included; it will begin to be in the differential diagnosis for more kids presenting to the doctors offices with feeding intolerance's.
Tuesday, December 14, 2010
An intolerance (such as lactose or fructose intolerance) is a lack of tolerance, the body lacks sufficient enzymes or digesting particles to sufficiently breakdown components of the foods for proper digestion. This causes pain, cramping, diarrhea, constipation, and general dysbiosis and possibly some malabsorption as the foods pass too quickly and improperly digested through the GI tract. It is a limited response, and it does not cause a systemic allergic reaction in the body.
FPIES is not just an intolerance. It is an allergy, not an antibody producing allergy but it is a full system response -- ask any FPIES mom....it is not restricted to "just" the gut. It is an allergy of the gut but it is not limited to the gut. The allergic response is a gut response but the allergy is system wide. There is a brain-gut connection, recent years research has come a long way to show more and more connections to the brain-gut connection for such things as Autism, Crohns, Fibromyalgia, and....allergies. Maybe that is the only connection....but why, in a reaction (before or after or during) does my little man experience eczema, asthma, disturbed sleep, hyperactivity, mottling of the skin, edema/puffiness, etc?? This is not just an intolerance.
Celiac disease is an allergy to gluten. FPIES is an allergy to proteins- any proteins can fall in this category. Gluten proteins in Celiac disease cause villi damage in the small intestine, resulting in atrophy of the villi and malabsorption of the nutrients. Mild villious atrophy, inflammation, gastritis, colitis are all seen in FPIES- it is why it is so named Enterocolitis (entire intestines are affected).
A good article was shared today from http://www.celiac.com/: Unglued:The Sticky Truth About Wheat Dairy Corn and Soy and also discusses the malabsorption of nutrients in response to allergy from proteins.
Little Man is receiving nutrition via IV- his calories, protein, fats, and carbohydrate plus vitamins and minerals are going into his body directly into his bloodstream. He has villous atrophy and has been unable to absorb his nutrients sufficiently. He also has inflammation, furthering his malabsorption of nutrients. We anticipate this to heal his intestines so he can once again have the chance to absorb nutrients properly, and hopefully begin to pass more foods to include in his tiny menu. His IV nutrition has corn derivatives in it. He is allergic to corn, has confirmed FPIES trigger response to corn. Dextrose is derived from corn. Mannitol in his multivitamin is corn derived. These are broken down, hydrolyzed. These are not going in the gut, but through the vein. FPIES is thought to be a T cell response. T cells are the gate keepers....are we sneaking by the gate keepers by not going through the gut? I want to believe we can....but something tells me we are not completely. My main hope right now is that we are sneaking by enough and that his body doesn't continue to build this response we have been seeing, that it can "tolerate" it long enough to continue to provide him the other nutrients he needs - giving his gut the rest it needs.
Dextrose and Mannitol are hydrolyzed to be broken down to be very low protein....FPIES triggers recognize trace proteins, cross contamination of proteins. This is understood in Celiac disease in the medical community (although still new, it is recognized and understood- why not FPIES?).
Nutramagin is a formula that has hydrolyzed whey proteins (dairy), less allergenic dairy proteins. Little man could not tolerate (and had full blown vomiting reactions from this formula, on two separate trials) hydrolyzed dairy proteins. We know his dairy trigger is sensitive (his vomit covered my kitchen floor from sucking on a McD's fry that has dairy in it's seasoning). We know he can not tolerate even trace amounts of dairy protein, and we don't even try to give him something that has a chance of trace or cross contamination of dairy protein in it. Dairy intolerance, dairy allergy is better understood than a corn allergy.
Corn syrup solids are broken down to not contain corn proteins, but trace proteins can remain. Corn syrup solids were still causing random vomiting and ongoing gut inflammation for my little man. Citric acid induces violent vomiting. Gypsum board (sheetrock made from corn derivatives) caused a full blown vomiting reaction. Same for cardboard, and paper. His corn allergy is as sensitive as a celiac's allergy to gluten. Would a Celiac be able to tolerate wheat proteins (even broken down or hydrolyzed) in their IV?
Little man is primarily doing well, he is getting nutrition he needs, he is getting the only treatment plan that is an option left for him at this point in the road. The side affects this may cause (even re sensitizing his body to corn) may have to be par for the coarse, the risks outweigh the benefits.....if it is healing his gut. I can't help but worry....what else is going on in his body in the meantime?
Monday, December 13, 2010
It was brought to my attention yesterday that someone thought that an Allergen-friendly recipe for a cookie was comical. It is a recipe for: Inoffensive Cookies: Recipe for Gluten Free, Dairy Free, Egg Free, Soy Free, Nut Free, Fructose Free Cookies. This author provided her commentary for the well-thought out recipe someone provided. To her, it was comical that someone would need to follow such restrictions. Even going as far as to say that if they had to follow these restrictions, that she felt sorry for those people but her comments were anything but sympathetic. They are condescending and even ignorant. Her opinion doesn't offend me in the least, it is her opinion. She is entitled to it and I always welcome people to voice their opinion...how else can we learn? How else can we see just how much we need to teach others.
Her opinions do not offend me. Her inaccuracies do. Such as: "if someone can't have gluten, dairy, eggs, soy, nuts or fructose, then they probably have more to worry about than baking cookies". Well, you're right about that, but does that mean they don't deserve a cookie too? She goes on to give the recipe (thanks for sharing because I think I could use this in a modified way for my son soon), stating "The comments in the parentheses are mine. If you are offended by my comments, then you need to get a sense of humor. Or you desperately need some Inoffensive Cookies."
Inoffensive Cookie Recipe (for people who can't eat squat)
1/4 cup plus 1 tablespoon golden flaxseed meal (we're off to a good start)
1/2 cup dairy-free, soy-free vegetable shortening (I can probably find that) This would be her first ignorant comment....dairy and soy free vegetable shortening is not easy to find....where do you think the vegetable comes from?
1 cup xylitol birch sugar (okie dokie) Really, because you have to special order this. I know, I've checked in hopes that it is something my son could eventually tolerate since he can not have anything from corn or tapioca.
1 teaspoon pure vanilla extract (ahhh... something I have!) No, you probably don't....ignorance again- pure, meaning free from soy, dairy,corn...not just one that says "pure" on the package.
1/2 cup plus 1 tablespoon Authentic Foods GF Classical Blend flour (I'll put it on my list)
1/4 teaspoon xanthan gum or guar gum (I don't think they mean chewing gum). She's right- they don't. And you'll have to be careful because xanthum gum can be from either corn or soy.
1/2 teaspoon baking soda (I know what this is)
1/2 teaspoon double-acting baking powder (I know what this is too). Yes, but again- you would never guess that there are additives such as corn in baking powder.
1/4 teaspoon cinnamon (this is getting better by the minute)
1/4 teaspoon fine sea salt or table salt (I better stick to table salt) If you did, you'd be adding corn to your recipe (not that this recipe claims to be corn free)- but just to point out it's not as simple as it may look, or as she appears to think. It's not as simple to make fun of, because it is simply not funny.
1 1/2 cups gluten-free old-fashioned oats (they are starting to confuse me again) Well, let me educate you then. Oats are contaminated with gluten in this country...it comes from the growing stages as well as the production of it. A gluten intolerant person will react to gluten in the size of a crumb. This reaction will begin to attack the small intestine villi, which will in turn result in malabsorption of nutrients, which in turn will result in more villi being flattened from poor nutrient absorption....all from minute amounts. So, assuring it is gluten free (usually from another country- such as Irish Oats) is essential for the health of a gluten intolerant individual.
1 and 1/4 cup dairy-free, soy-free, gluten-free chocolate chips (they make that?) Yes, they do. Enjoy Life is one of such brands.
Preheat oven to 350 degrees.
Line two baking sheets with parchment paper.
Combine 1 tablespoon of flaxseed meal with 3 tablespoons of warm water, mixing well. Set aside. This is your "flax egg" (I'm so glad to know that).
In the bowl of a stand mixer fitted with a paddle attachment (I'm confused enough as it is), cream the shortening, and the birch sugar, mixing on medium speed for about 3 minutes.
Add the vanilla extract and the flax egg (that's the stuff you made in the first step, I guess). Mix about 30 seconds on low speed until combined.
In a separate bowl, whisk together flour, the remaining 1/4 cup flaxseed meal, gum (remember, this isn't the gum you have in your mouth), baking soda, baking powder, cinnamon, and salt (I'm beat!).
Add oats and mix. Add dry mixture to stand mixer bowl, and mix on low speed until combined.
Add the chocolate chips (hopefully you didn't eat them all while mixing the rest of the stuff), mixing on lowest
possible speed until just combined.
Using a 2 tablespoon scoop (can't I just estimate?), place dough balls on a baking sheet and flatten them slightly (I will flatten them, I promise).
Bake in the center of the oven 13 minutes, until lightly golden. Let cookies cool for about 5 minutes before transferring to a cooling rack (then transfer to your mouth).
Source for the ridiculous cookie recipe: http://www.wholeliving.com/
This is the end of her article. She was leaving an area open for comments but has shut it down, after a few fellow FPIES mom's attempted to leave her some feedback to her article. These comments were not negative, just informative and raising awareness to the people (in our case CHILDREN, who by the way go through enough in their lives, no one deserves a cookie more) who may come across this article. I have included one comment from Mama of B (that so far has escaped her from deleting).
Mama to the B 12/13/2010
It is sad that you have to delete comments because they refute what you are saying. Our comments were very polite and in a very rude situation. I suggest that you think about the people who will come across your article in a search-- people with severe food allergies or parents of children with severe food allergies. The title alone would cause it to come up in such a search. As a writer, I am shocked that you did not consider your audience. I really hope it was not your intent for people who are actually searching for such recipes to come across this article. That would be pretty mean and I would hate to think that anyone would be that harsh. There is no humor that is worth that meanness. If you would like more information about FPIES and other severe allergic conditions, since you do not seem to understand them, I hope that you will do a little bit more research before judging this community. www.kidswithfoodallergies.com is an excellent place to start.
I'm not sure why this informative language would need to be deleted from her post. I believe in the good in people, so lets just assume she wasn't meaning to offend by her jest....then why not leave the comments given on her post to raise awareness? I will let the reader decide. I simply wanted to share that ignorance is bliss...and I don't blame her for being ignorant about food allergy's....many who do not need to include such restrictive dietary habits in their everyday just for the health and well being of themselves or their loved ones simply do not think that food could also be poison. My thinking has been forever changed by this diagnosis and I do not have the luxury of thinking something like this article/commentary is comical.
Saturday, December 11, 2010
His formula kept him in daily pain and disturbances to his system and random vomiting every few days. I made him a formula that took this daily pain (that had been going on for most of his life) away, but with that I also took away assurances of some micro nutrients. The formula is adequate in calories, protein, fats and carbohydrates as well as many other nutrients; but it lacks about a dozen or so of the many micro nutrients we need in a complete diet (although I challenge you to find a typical 18mo.old who meets all these micro nutrients needs daily, but I digress- Little Man isn't typical). Adding fruits and veggies, a meat and a grain- building a tiny menu, would get him these missing micro nutrients....but he has not tolerated food introductions. Giving him a vitamin may fill in these gaps, but he can not tolerate the additives in most (all?) vitamins- giving him foods and vitamins that his body rejects puts the very real possibility of making him more sick; and thus less able to absorb nutrients from even the formula he gets daily. The formula that is adequate in calories, and yet he doesn't gain great strides of weight (gut inflammation prevents this). The formula that is adequate in iron and yet his iron has only continued to fall (villous atrophy contributed to this- recently and likely a year ago as well, initially causing the low iron that set him behind from the beginning stages).
Today, little man received another dose of IV iron infusion. This will continue 2x/week for the next few weeks. He continues on his plain hemp milk, and his TPN is built up with all ingredients to nourish his body and repair his small intestinal villi; so we will continue with this recipe for the next 2weeks and then the plans are to do another endoscopy to check on his villi; and proceed from there depending on the findings. The hope is that the inflammation will be healed and the villi will be rebuilt so that he can go back to his Hemp milk formula, peaches and millet and re-begin food trials to finding that tiny menu.
Little man is thriving: he plays wildly (a PICC line doesn't slow him down- it only speeds up his parents following behind him tirelessly so his lines don't get tangled, caught or pulled). He builds blocks, puts together puzzles, processes language and follows directions, makes friends, gives "high-5's" and kisses, and learns more words everyday. This week he has added "ice", "car", "love you", "this" to his vocabulary. For 18mo., I still wonder if he isn't a little behind for language- but he doesn't get as much oral motor development so, again- all things considered- he is doing really well for what he has had to overcome.
Wednesday, December 8, 2010
The plan is to build up his TPN (total parental nutrition) each day adding a new ingredient component...thanks to the help of our great Dietitians that helped everyone to see this was a necessary -- although slow -- process to go through for him. It is exactly what I knew he needed, and although it will be slow, I feel it is essential for him. One ingredient at a time for 24hrs at a time, monitor how his body handles it and assess symptoms as we proceed, and move to next steps the next 24hrs.
Monday was Dextrose, so carbohydrate source. I am not sure how his body is truly tolerating the dextrose but it is essential so the symptoms may have to be a "risk vs. benefit" scenario. If we are once again, sensitizing his body to corn derivatives (which I suspect we are)- we will just have to consider 18mo. our last corn ingestion's and remember this date as we look at when we will challenge corn....which at this point, I have no interest in doing it before he is 3 anyway. Once we adapt to a diet of safe foods for him- I have little interest in challenging that for the minimum of 18mo. window that is felt to be the Tcell "memory", or life. This allergy does not build up antibodies as in a typical allergy. The mechanism is thought to be T cell. Tcells "shed" their memory every 12-18mo.(from what I understand); so this along with gut maturity is thought to be the criteria for time period of avoidance for known triggers. Symptoms that I am worried about? Hyperactivity, flushing, mottling, disturbed sleep, decreased appetite, and yesterday- vomiting and loose stools (more on that later).
Monday also brought the news that his hemoglobin is back down to 6 again (blood transfusion had brought it up to 10 from 5 just a little over one month ago). Getting him nutrition, repairing his gut villi, and re-establishing a good supply of iron in his little body are the main goals in his health right now; and this just bumped everything up a notch on the urgency scale. We are right where we need to be....in the hospital, getting IV nutrition, getting monitored for signs and symptoms along the way. He will also have a 4th scope at some point to assess how this is helping, and hopefully get a better grasp on how he is doing and where we are going after so long being "on the edge".
Tuesday was the start of Amino acids (protein) and with the news of his hemoglobin decline; iron was infused in at the same time as well. He will received IV iron infusion two times a week now for the next few weeks; this will help rebuild his own stores, that have been so low for so long...finally. The IV iron has a risk of anaphalxis, so he was monitored closely for the first 20min but presented no anaphalyxis reactions. Although, an hour went by and he began to display some concerning symptoms (face flushing, red eyes, and hyperactivity). This all subsided within an hour though and he went to sleep well. Unfortunately that sleep did not last, a few hours later he was awake and as I was preparing his bottle - he coughed and then came the vomit. It was not just spit up, it was not projectile, it was forceful but not violent and not "garden hose" amounts. However, there was flecks of brown tinged blood in it. This was concerning. It did not continue and he finally ate some hemp milk and calmed down but did not go back to sleep for another 4hrs. It was a long night. He was uncomfortable, tylenol did seem to help some with that. He finally slept a bit from 5-7am and woke up happy and rested-appearing. He actively played all morning and took a nice long morning nap and even squeezed in a late afternoon slumber. He is catching up on sleep and looking better.
Wednesday (today) brings the addition of Lipids (fat). So, now his TPN has: Dextrose, Amino Acids, and Lipids, plus an acid reducer (because of eating less). Tomorrow will be a multivitamin. A multivitamin is an important step but it also does not come without it's own risks as it has ingredients that he would possibly react to orally. But, this is through the IV....
This mechanism I still do not fully understand, the T cell response and the degree of the allergy. It is a gut allergy but T cells are all over the body. Do the Tcells of the gut only recognize the allergenic food? Then explain atopy patch testing....where a food substance is placed on the back under a metal disk where it sits for 48-72hrs to see if the skin responds (being a delayed hypersensitivity reaction). It is not 100% accurate testing but it gives a guide. We have not yet done ATP, and not sure if we will since the places we have been do not offer it. So, the question remains....will his body respond to his known triggers in the IV? The dextrose is from corn, but it is hydrolyzed down....and yet corn allergic patients have had reactions through IV's before, and yet some do not....it is like everything else -- the only way to know is to know. It's all about the trials....
Sunday, December 5, 2010
I was feeling overwhelmed this morning, as I think about the day tomorrow...and the weeks to follow. And yet, a calm and peace came over me...a little bit later I read a poem that puts in words how that peace washes over me, and what helps me to go on...it goes deeper than my own strength, that I know.
It's the symphony to sing.
Friday, December 3, 2010
Pain and vomiting controlled. Check. Adequate calories for growth. Check. Introductions (slowly) of a few foods (millet and peaches). Check. Blood transfusion to rebuild stores. Check. Iron supplement daily. Check. Soy challenge to begin to add more varied protein sources to his diet for iron. Check.
Spiraling begins: Bottom falling out on 4th day of Soy challenge.....villous atrophy and inflammation on scope but happy boy once soy is removed. Omeprezole is started to help heal inflammation, and help with his empty stomach pain. Omeprezole brings on it's own set of side effects. Hemoglobin begins falling again. We were moving right along....we've hit a vicious cycle that we can't seem to break.
Hematologist consult yesterday morning. Long discussions about his need for iron (yes, I know he needs it and we are giving him all the doses his body can tolerate and he doesn't spit out). He is gaining weight, primarily doing well but his iron is falling again. It is discussed that this is the villous atrophy and that it is evident it is not healing as fast as we would like it to- to restore the villi to be able to absorb the iron we give him, and supplement him with. IV iron transfusion therapy is discussed. He will need 10treatments, 2x/week; starting as soon as possible. We decide we will start tomorrow. We are worried about his reaction to it, but it is pointed out..."we have no choices". Agreed, we are already at the point of TPN discussions; so we are at the "end of the line" for choices/options to get him back on track. Appointment is set up for IV Iron transfusion therapy for Saturday morning. We then proceed to the GI doctor's office for a weight check and further discussions on next steps....
IV iron transfusions 2x/week means he will have IV inserted 2x/week for the next month and a half. GI doctor prefers to have a PICC line placed....if we are going to place a PICC line, then we should also do TPN with that PICC line and see if gut rest with alternative nutrition can get him the "Reset" he needs to get more control of this diagnosis. Admission for Monday morning is planned for PICC placement and begin TPN. He will continue to get his IV iron transfusions during this. We don't know yet how all this will go, or all the details surrounding it. Honestly, we are still processing it all. We know he could benefit from the gut rest, and the nutrition.....
Wednesday, December 1, 2010
This gut pain also has been happening after nap time. It's been increasingly occurring over the past 2mo. or so, we think maybe it is from his iron medicine causing an increase in acid and this acid is washing over his inflammation, preventing it from completely healing after reactions. The GI doctor recommended a trial of omeprezole to help with this - a proton pump inhibitor to take away his stomach acid to avoid having it irritate his intestinal lining.
Despite having this off and on pains, he has maintained a pretty good baseline for the past month. But now, we seem to be losing it. One day will be great, but the next will be bottoming out, followed by a rebounding, and then again a gutter day. The omeprezole was started last Friday, he had a bottom out day on Saturday but he also drank bathwater on Friday night, so maybe he reacted to that (citric acid in soap = corn), because by Sunday he was great again. Sunday night, 2nd dose of omeprezole and Monday was an excellent day; so we were hopeful that Saturday's gutter day was indeed from bath soap ingestion. Then brings on Tuesday and we are in the gutter again. Lab draw on Tuesday morning doesn't help- this always drains him.
Lab draw was for a CBC check, how is his hemoglobin/hematocrit holding after the transfusion a month ago? We did not expect the results we got. Little man has been doing so well, primarily good moods, even a weight gain and we get the news that his hemoglobin is falling again, down to 8 (normal 10.5-13.5g/dl for his age). He is on a twice daily dose of iron. He doesn't seem to be tolerating a second dose if given in the afternoon, so we have to try and get 2 doses in before his naptime. Unfortunately, we haven't been successful in that daily....and to add to that, he hates it so much- he spits it out if I don't get it back far enough in his throat where he has no choice but to swallow at least part of it. It's becoming a struggle, and a syringe aversion! But we know it is essential so we press on. Missing one dose would have this negative of an effect, than we may need a new plan. His iron stores have just been too low for too long and his body is not keeping up. Or he is continuing to malabsorb it since his duodenum is where iron is absorbed and that is where not only his inflammation are but his villous atrophy as well. I am still trying to process how/why this is happening- how we can't seem to get things on a good track for him.
Then, last night was day 4 of omeprezole and he was experiencing insomnia....awake, unable to sleep (and WIDE awake for most of the time) from 10:15pm-3:30am! Thank goodness I wasn't alone, I stayed up with him until 11:30, then woke up little man's daddy....I was so tired and he was no where near going back to sleep! We went back and forth but Little Man's daddy took the brunt of those shifts as I could hardly even stay awake and Little Man wanted his daddy's cuddles.
Symptoms of intolerance to this medication are building, and so is my worry about causing him more harm than good. He needs the help for inflammation healing, the last thing I want is for him to be in unnecessary pain. But, his labs also revealed neutropenia/leukopenia and tonight he has developed a cough (this happened after the 3rd dose of Prilosec 9mo. ago as well). He had the insomnia last night, and he has been hyperactive during the day (primarily happy but a tad hyper -esp for him!); his appetite is dropping and he has more constipated stooling. So far, this symptoms/side effects do not outweigh the potential benefit of intestinal healing. The most concerning though is that his hemoglobin is dropping. How do we give him iron supplement with a proton pump inhibitor? His iron is being absorbed because of the acid his stomach is making to absorb it....until now. We are once again, trapped in a viscous cycle....
We have a hematology consult tomorrow morning to discuss IV iron therapy; and a weigh-in and check in with the GI doctor. So, we hope to have some better plans to continue moving forward and break this cycle.
We gave him half the dose of the omeprezole tonight and I'd better get to bed if tonight will be anything like last night....