Tummy troubles are commonplace amongst kids. Furthermore, paediatric clients often require a whole new set of skills for the practitioner.
Today we welcome back Alessandra Edwards to share her vast clinical experience in treating little ones with digestive disorders.
Alessandra covers off important areas of naturopathic care in paediatric cases, from safety considerations and assessment techniques to navigating the palatability of treatments and working effectively with their doctors and parents.
You will be able to take away many pearls from Alessandra's safe, common-sense and systematic approaches to getting to the bottom of illness in children.
Covered in this episode
[00:36] Welcoming back Alessandra Edwards
[01:40] Today's Topic: Treating gut disorders in kids
[02:16] How to approach consultations with kids
[07:12] Red flags in paediatric care
[10:24] History-taking and examinations
[11:18] Proton pump inhibitor use in infants
[14:11] Top 5 things presenting in children
[14:51] Food intolerance and restrictive diets
[19:00] Encopresis in children
[21:59] Reviewing and refining treatment
[26:04] Cultivating a mindset of self-care
[27:06] Assessing sources of infection/reinfection
[30:54] Treatment programs and maintaining motivation
[32:08] Pre-screening clients before taking them on
[34:20] What happens when you are confounded?
[38:15] Treatments to avoid vs. favourite therapies
[47:14] Mentoring, research and reading
[48:20] Last question: Alessandra's 5 favourite foods
[50:55] Final summary and invitation for Alessandra to return
Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. Joining me on the line today all the way from sunny, wintry Melbourne is Alessandra Edwards. She's a clinical naturopath, Western herbalist, and nutrigenomics specialist with a specific interest in digestive health, mental health, and their interaction with the microbiome. Born and raised in Italy from a French family, and having then fallen in love with Britain, you get the immediate sense that Alessandra Edwards is not one given to the status quo. She's a searcher and researcher of natural options for complex disorders. She's worked with the natural health industry for over 10 years, both in the UK and Australia, where she runs Reclaim Your Health, a busy nutrigenomic and nutritional clinic in Melbourne, Bayside. Alessandra utilises an integrative approach to practice, combining specialised blood testing, genetic profiling, and gut and microbiome sequencing to formulate personalised health plans. She works with a number of highly-regarded integrative medical doctors, and speaks regularly on nutrigenomics, gastrointestinal, and mental health.
Today we're discussing how to treat kids with GI conditions, no small subject. Welcome back, Alessandra. How are you?
Alessandra: I'm great, thank you. I'm wearing my thongs and a jumper.
Andrew: I can't get over Melbourne. We're having a heat wave in Sydney. It was supposed to be the Eastern states, and you've gone from what temperature down to...did you say "17?"
Alessandra: It was 16 this morning, and it was 33 last night.
Andrew: Oh, my goodness! Wow!
Alessandra: That's Melbourne.
Andrew: Yeah, that is. But, I've gotta say, a fantastic place on earth. I love Melbourne.
Alessandra: Oh, it's wonderful.
Andrew: Now, onto our subject. And, as I said before, this is no little kitten, this subject. This is...kids don't have the faculties to describe what's going on, even in their tummies, let alone anywhere else. So, I've got to ask the beginning question, and that is, how do you start with a consultation with kids with gut issues?
Alessandra: Okay, I cheat. I usually speak...I speak to the parents.
Andrew: Yeah.
Alessandra: It really depends on the age of the child.
Andrew: Yeah.
Alessandra: So, if we are talking about toddler age, so, you know, anything below at the age of two, then generally the parents have been alerted to the fact that something's not quite right, and typically the child seems a little bit off colour, perhaps they seem like a little bit fussy in their eating habit, or they've lost their appetite, or typically, in that age group, the parents have noticed that there's something not quite right with the bowel movement, so either they're a little bit constipated or they've noticed some loose stools or offensive smell, something like that.
Andrew: Yep.
Alessandra: The other side of it is that, often I see children who have chronic digestive issues, and so, in that case, often is actually the integrated GP who has contacted me ahead of time, and so we've had telephone conversations. So, I already know, you know, what I'm looking for. And thirdly, I tend to always speak to potential clients before agreeing to work with them. So, in the case of children, I always, always have a conversation before even the initial consults on the phone, and I do this because I'm acutely aware of the things that can be missed in terms of children's health. And so, I do this as part of my onboarding triage process where I can quickly work out red flags…
Andrew: Yes.
Alessandra: …so that I can refer them to the GP and say, "Look, I really think that you should, you know, discuss this with the GP because you need to do this kind of testing, and then come back to me once the GP has given you the all-clear.”
Andrew: Great.
Alessandra: And, I think that, in this kind of current climate, particularly this year, it's really important that we uphold, you know, really high professional standards when it comes to paediatric health.
Andrew: I could not agree with you more. And, it was actually one of my questions I had to ask you as a registered nurse, because, you know, we've seen the issue with Marilyn Bodnar, who...you know, I can't agree with that sort of treatment with anybody, let alone a child.
Alessandra: Yeah.
Andrew: And, what annoys me, though, is the way that the media picked up on that she was a "naturopath." Well, she's never done any form of study on that as far as I can determine, but she was apparently a midwife, nothing about that in the media. And, by the way, she doesn't appear on AHPRA…
Alessandra: Yeah.
Andrew: …so she's certainly not a currently registered registered nurse/midwife. So, I don't know what they mean by the term "midwife." But, to me, I was quite annoyed at the way that they, you know, targeted naturopaths, properly trained naturopaths who were trained in safety, and blamed her actions for an industry which actually has a better standing of what she was doing.
Alessandra: Yeah, I completely agree. I think that it was a bit of a shock to many people in the industry how the whole thing was portrayed. And I think, you know, from my point of view, I think what we need to do is really, you know, raise our profile as complimentary professionals. And, to do that, we really need to uphold the highest standards of practice in our own professional life. And so, I think, even more so now, more than ever, we need to question everything that we do, including everything we say, and particularly now in Victoria, you know, with the new Victoria Health Complaints and General Code of Conduct, and there has been a lot of people not happy about this in the industry. But, actually, I think it's important that we have these codes of conduct…
Andrew: Absolutely.
Alessandra: …because we're not registered as a profession.
Andrew: Absolutely.
Alessandra: And so, having these codes of conduct really makes you think in terms of, "Well, you know, I could be open to litigation, and I really need to think carefully about what I do, and the kind of treatment, and first, do no harm, and remember that, you know, we're not general practitioners, but we are complementary practitioners." So, I think that, if we defined...it helps to define scope of practice even more, and I'm all for it. I think it's a great thing.
Andrew: Yeah. And, I think it's a good line…a demarcation line for our industry. We are not doctors. If you wanna be a little doctor, go and do medicine, and take on that responsibility.
Alessandra: Yes.
Andrew: But, can I ask first about these red flags, these kids are renowned for going off the boil quickly. They can't often tell you or demonstrate to you where the pain is or what's actually happening in their body, and indeed you can't see that, even on the best examination. So, what sort of things might you suspect with certain symptoms, things like, you know, intussusception, like, let's say, Crohn's, even rheumatoid arthritis can present with gut symptoms? So, how do you look at red flags? What do you sort of look for?
Alessandra: The main things that I really look for are, first of all, diarrhoea, how long it's been going on, how severe it is, and has this been flagged with the local GP? Is there a possibility that it's, you know, a food poisoning case, or an infection kind of case? I ask questions related to appearance of the bowel movement: Is there blood in the stool? Is there mucus in the stool?
Other things that I look for are weight loss, failure to gain weight, you know, sudden fevers. And, with things like intussusception, generally, I mean, I've never had a case like that. I think it's relatively uncommon to look for the severe pain. So, anything where...so even though a young child might not be able to point where it is, they would be aware of severe pain.
Andrew: Yeah, impossible, yeah.
Alessandra: Yes, absolutely. So, those would be the main things. And, the other thing also that might ring alarm bells, even though the child might not present with some of these particular symptoms, would be actually taking a really decent family history. So, if there are things like rheumatoid arthritis or Crohn's disease in the family, then my alarm bells already are a little bit on the...they're a little bit...
Andrew: Heightened.
Alessandra: …what’s the word, activated, yeah.
Andrew: Yeah, yeah. You mentioned, I think, vomiting. There's certain criteria that we've got to look for with regards to how often a child vomits within a certain time period, particularly in an infant so that you can get appropriate intervention before they go off the boil in a really bad way with regards to electrolytes. So, what sort of things do you look for there? What sort of signs do you tell the patients to look for with, you know, skin turbidity, and all that sort of thing?
Alessandra: Yeah, well look, a gain, it depends on the age of the child. I'm super cautious with vomiting with infants. So, if it's something that has been going on for more than a few hours, and, you know, the baby is appearing to have, you know, sunken eyes, sunken fontanel, eyes starting to look lethargic, I, straight away, I refer that you really need to go to the ER now and get the proper assessment, because I think that it's just not safe, and I'm not in a position to give that diagnosis whereby I can reassure the parent that this is going to be okay in a child that young.
Andrew: That's right. So, given that you're not, you know, emergently concerned about this child, what examinations...apart from a detailed family history, what examinations do you undertake?
Alessandra: Okay. First of all, I would say, in terms of the family history, one thing I would like to flag up is that it's very important to go through a detailed medical history of the mother, and particularly also of the preconception area...preconception time, sorry, and how healthy she was in pregnancy: Were there any medical interventions in pregnancy as well? What type of birth the baby has, whether they were breastfed. Were there other medical or drug interventions in the immediate postpartum period, or certainly in the first three-to-six months also?
I also look particularly for things like utilisation of proton pump inhibitors in babies…
Andrew: Ah.
Alessandra: …which is really, really common practice now.
Andrew: Yeah.
Alessandra: So, I would say probably, you know, four out of five babies, I would see who had seemingly digestive issues have been given the diagnosis of reflux, and has been put on a PPI. And, I think that it's a bit dangerous doing that, and it's a real shame, because often, more obvious things are actually missed. So, I'm finding that, very commonly, breastfeeding issues haven't even been investigated. And so...
Andrew: Wow!
Alessandra: Yeah, and actually I've seen this a lot, and it happens, you know, quite often that I then get the person to...you know, the parent to go and see a proper lactation consultant or pay for it privately, that they discover that actually there are latching issues, and so the child is developing really, you know, severe gas just because of the ratio of sugars that is coming through the milk…
Andrew: Yeah.
Alessandra: …and so it's not really reflux at all, it's a breastfeeding issue.
Andrew: Wow!
Alessandra: And then, we know obviously that intervention earlier on with PPI, it affects the stage for, you know, the follow-up with dysbiosis, and some young children also with more intestinal bacterial overgrowth. So, I would say, let's...you know, keep your radar on for those kinds of things, and don't assume that, just because a paediatric gastroenterologist recommended the PPI, that that was necessarily the correct diagnosis. It's okay to revisit that, and discuss it with the general practitioner, and try these other measures that would be helpful. Obviously we wouldn't recommend for the client to stop the medication. We can't do that. But, so, the same time, exploring the other avenues that could be actually more helpful.
Andrew: Yeah. Just a little bit of good news, I guess, on that front, and that is that Medical Observer...this is 14th December, 2016, a hike in the use of proton pump inhibitors amongst all Australians over the past couple of decades is now tapering off. So, hopefully this will translate...
Alessandra: Oh, that’s great.
Andrew: Yeah. Hopefully this will translate to the younger generations, of course, every...
Alessandra: That'd be wonderful.
Andrew: Yeah, wouldn't it?
Alessandra: Yeah, that would be really, really great.
Andrew: I think it's really interesting that in my day, we didn't have the proton pump inhibitors, but we had the H2 inhibitors, Zantac, and things like that.
Alessandra: Yeah. Yeah.
Andrew: In the memes of the days, they were never supposed to be used for longer than six-to-eight weeks.
Alessandra: Oh, well...
Andrew: Find that. Find that these days.
Alessandra: No, that's right, usually for months.
Andrew: So, what would be the top five most common things that you actually see presenting in kids?
Alessandra: So, in terms of symptoms, usually constipation and diarrhoea, or a combination of both will probably be my top two, and abdominal pain as self-reported, and then things like encopresis, also I see quite a bit of that. I'm not sure how many is that. They're probably five. I also see quite a bit of reoccurring worm infection…
Andrew: Right.
Alessandra: …so the ones that don't clear very easily. There's a number of things, and they're obviously on the right really soothing tolerances. And, if I could get on my soapbox for another two seconds again, I would just like to mention this growing concern of mine, which is salicylate intolerances. I'm now...basically every week I'm seeing a new person who's diagnosed a child with salicylate and amine intolerance…
Andrew: Yep.
Alessandra: …and they're convinced that the child has, you know, these severe intolerances, so then they go on to highly restricted failsafe diet, and they feel that the digestive symptoms abate, and then the child also starts sleeping better. And so, I see children who've been on this diet where they're eating basically about 10 different foods for, talk about, between three and six months. And, it's a real concern for me, because that's where severe nutritional deficiencies occur.
Andrew: Yes.
Alessandra: And, in children, they cannot go really, really quickly.
Andrew: Yes, they do.
Alessandra: So, I would just like to really flag this, and again, say, just because...you know, a little child with the mother, and the mother has given a self-diagnosis, you don't necessarily have to accept that, and to question it, and dig a little bit deeper, because, you know, I really do not believe...actually I personally do not believe that salicylate intolerance is a thing.
Andrew: Right.
Alessandra: I think that it's masked by other things. I think that there are often just amine intolerances that are masking the salicylate. And, because they do the elimination combined, so they eliminate amines, then salicylates at the same time, then they feel that the salicylates are part of the issue.
But, generally speaking, it's more related to a dysbiotic picture, and where there are profound shift in microbiota. And, by removing even more sort of different kinds of prebiotic foods and foods that are high in polyphenols, which feed beneficial bacteria, then they end up stuck in the cycle where they're feeding more and more bacteria that produce things like amines, and so they become more and more convinced that, you know, the problem is actually the intolerance, whereas the problem is the gut in the first place.
Andrew: Yeah. You know what? Actually I have seen this or suspected this on a number of things where the new flavour of something comes in, and, you know, we intervene in a certain way and think that the changes that we see are, therefore, due to that intervention. But, what happens is, or what the real issue is that we're changing an overall thing, and so the changes are really due to that, but we think it's due to one thing. For instance, the French paradox I'm gonna talk about, you know, when they went high saturated fat but low heart disease, so therefore, high saturated fats. Good. Well, hang on, when you look at the French diet, they eat slowly without stress.
Alessandra: Absolutely.
Andrew: They eat a lot more vegetables. It's not just the saturated fats. So, there's all of these other things are much more attuned to the Mediterranean style eating rather than this saturated fat, that's the answer.
Alessandra: Absolutely, and lifestyle.
Andrew: And lifestyle.
Alessandra: Because they've got a much shorter working week, absolutely. I think stress is a huge component, but we tend to latch on to these…
Andrew: Yeah.
Alessandra: …sort of these results, and then make decisions as a result. And so, I think we've spoken before about, you know, how trendy it is now to have high-saturated fat everything, and, you know, I have experienced it firsthand personally, and also in clinic. I experimented with this years ago, and it was disastrous, absolutely disastrous. So, I think that a little bit of common sense in our approach probably wouldn't hurt.
Andrew: Yeah. You mentioned encopresis before. I just wanted to point out for our listeners that...so that's the soiling of underwear past toilet training, correct?
Alessandra: It is, yes. So, it’s involuntary soiling, yes.
Andrew: So, I've got to ask about psychological issues here, you know, a new sibling or some other, even a sinister, you know, sexually interfering with the child, or anything like that. Do you ever sort of have to, you know, be a little bit cautious in your questioning of the parents here to get to the real issue?
Alessandra: Yes, absolutely, and particularly because I'm not trained as a psychologist, so I have never been confronted with something like this in the sense where I thought that there was something untowards just because we saw the result, encopresis was the result. However...yeah, I would say, definitely as part of your case taking, you would be asking sensitive questions as, you know, "Are there any potential stressors in the home that you think could be contributing to this? Tell me a little bit about the family situations," those kinds of things.
And certainly, psychology and nervous system health are really intertwined with encopresis, and often, that is all that is required. But, from my point of view, I seem to see that encopresis children who have done all the testing, and nothing has worked.
Andrew: Right.
Alessandra: And really, I'm always surprised as to something as simple as a parasite test that has been missed by all the, you know, gastroenterologist, the children's hospitals, and no one has actually done a very simple parasite test.
Andrew: Wow.
Alessandra: And these children actually have a parasite.
Andrew: Yeah.
Alessandra: They’re soiling themselves for a reason. It's not really encopresis..
Andrew: Yeah, yeah.
Alessandra: It’s actually an infection. So, yeah, it always amazes me when I see that.
Andrew: Look, you know, this is one of my basis. The medical...I'm gonna say industry, profession, is taught common things happen commonly. The problem is that you tend to...many practitioners, and not just medical practitioners would tend to, therefore, always or, you know, for the vast majority of times, look for the common thing, rather than always suspecting that, you know, my answer to that is, common things do happen commonly, but sinister things will kill you before the common things.
So, my issue is, if I can't see it, if I don't know what's going on inside that gut, I want some test to reassure me that I'm not doing applicative-type treatment where something horrendous is going on, that will affect that family and that child forevermore, you know. That's where my sort of...call it paranoia, sort of steps in. And, that's why I really like what you do, that you cover your bases before progressing.
But then, can I ask, with regards to treatment, when do you tend to revisit treatment, particularly with kids who can go off the boil and come back on again quite quickly? And then, how do you tease apart a...let's call it a placebo response, let's call it a subjective, "Ah, they're listening to me. They're doing something, whereas before nobody has listened to me, so I'm happy.” There might be less stress, and so the child feels less stressed and gets better vs. a parasitic-type issue that's, you know, a demonstrated pathology that's getting objective response. How do you tease that apart?
Alessandra: Well, firstly I agree with you, you need both, and I've actually got a little anecdote for you to illustrate my point.
Andrew: Yeah.
Alessandra: I was recently speaking to the mum of a little client, a six-year-old little girl who I've been seeing for recurring worms and constipation, and I tend to follow up my clients on a weekly or, you know, every 10 days. So, I'll send them an email to see how they're progressing and if they have any questions. And so, I remember checking in with this lady. I think it was about three weeks into the treatment, and the mum was adamant that there was no change.
Andrew: Yep.
Alessandra: And so, I took that on-board, and I thought, "Okay, well, we might have to revisit the treatment, and I'll have to reassessment." But, then I thought, "Well, hang on. She's six. She's six and a half. She actually nearly seven." So, I thought, "Let's actually ask the daughter." So, I emailed her back and I said, "You actually asked her?" And, it turns out, in fact, she started emptying her bowel much more regularly. She hadn't had an itchy bottom, you know, for a couple of weeks.
Andrew: Yep.
Alessandra: So, I think it's important to do both. In terms of revisiting testing, I tend only to do that in terms of parasitic infections, and when there have been gross nutritional deficiency. Otherwise I base my treatment review on the clinical presentation, how the symptoms are progressing.
Andrew: Yep.
Alessandra: As to whether, you know, how much of it is placebo, how much of it is actually biochemical, I don't know, and really, at the end of the day, I'm not really sure that I care that much, because what I want to see is results…
Andrew: Yeah.
Alessandra: …whichever way they come. And, I think that's part of the beauty of being complementary practitioner, that placebo effect probably plays a big part, because we counsel the clients during the consultation, you know, the little patient might be sitting on the floor listening to what's being said about them while they're doing some drawing. And so, it is part of that holistic, you know, "We're here for you. We're listening." And so, as you pointed out, it could be that stress response just gets abated by noticing that someone's paying attention.
Andrew: Yeah. I think the big thing there is longevity of results, you know?
Alessandra: Yes.
Andrew: Like, I've been to medical practice, I've been to physios, and you feel great after the physio appointment because they're supporting, you know, the movement of the spine, things like that. "Wow! That feels so good." Three hours later...you know? And yet, conversely to that, I've had other patients...and I'm gonna speak from a personal point of view, my wife, who has visited an extremely caring practitioner, physio, and she is getting long-term results in-between visits. So, there's two sides of that "placebo coin.”
Alessandra: Yes.
Andrew: Is it necessarily bad? You know, if you wanna sell a drug, yes. But, if you wanna get people better...I think the big issue is longevity of results.
Alessandra: Yeah. And, look, I think that some...I'm not sure how much an exclusive placebo effect would last in terms of longevity, particularly when we're looking at, you know, a dysbiotic picture. So, we know that the longevity of the results will also come after the treatment has ended, the active treatment in terms of the parents or, you know, the clients being able to sustain the dietary change, the lifestyle changes, the mindset changes that we recommend as complementary practitioners, and so self-care is really high on my agenda, and I generally now only work with people on, you know, a four-to-five month program…
Andrew: Yep.
Alessandra: …because I have found that, in order to cultivate that new mindset of self-care, it really takes a bit of time, and working on educating them on actual information as opposed to finding information on blogs written by people…
Andrew: Yes.
Alessandra: …who have no clinical experience, no qualification. I find that, you know, with this kind of therapy, you get really, really great results that stick, so generally they don't come back to see me.
Andrew: So, prevention of reinfection. I know we've discussed this before in a previous podcast that I did with you on Blasto, but with regards to that prevention of reinfection, you know, when you're looking at the environmental aspects, I remember somebody talking to me about Northern Rivers, you know, Blastocystis was rife throughout the Northern Rivers because people…
Alessandra: Yep.
Andrew: …commonly, not always, but more commonly than other areas relied on rainwater thinking that it was a healthy option, but yet it was unfiltered. So, I was like, “Eeek!”
Alessandra: That’s right. Yeah.
Andrew: What do you think of...? What sort of things do you go through here?"
Alessandra: That is definitely a big, big flag. I always ask people if they...part of my initial questionnaire: do they drink tap water? And if so, what kind of filtration system they have. Traveling measures, you know, when did they last travel abroad, or, you know, are they active bush walkers? Do they drink from rivers? So, those kind of questions are really important. But, from a more urban point of view, also simple things such as, you know, "Is your child attending daycare?"
Andrew: Yeah.
Alessandra: To me, straight away, you know, suspecting possible co-infections, you know, worms, that's really important, and assessing also, not just from an infection point of view, but if they’re at daycare, are they being fed the food by the daycare? You know, what's the food like there? So, those questions are also important.
And, even in terms of personal hygiene, you know, when you're doing the physical examination, which, I think, I didn't answer your question earlier about the kind of examinations that I undertake. I was going on about the medical history, but I certainly do do a physical examination, and particularly for digestive issues in children where, as you correctly said, they cannot describe what's going on in their tummies, I think that doing an abdominal examination, especially concentrating on observation and palpation is important…
Andrew: Yeah.
Alessandra: because, with palpation, you will be able to sense and see the guarding…
Andrew: Yep.
Alessandra: …if there is an area that has some inflammation or infection, or something else. And then, looking even at the fingernails, you know. Are the fingernails nice and trim? Are they clean? Also looking at the tongue, that's a really, really big part of the examination, for me.
So, going back to the environmental assessment, the other thing that's important, that kind of falls a little bit outside of the environment, but who else also might be harbouring an infection or parasite in the family?
Andrew: Right.
Alessandra: Do you test everyone else in the family? Do you know who the carriers are?
Andrew: Right.
Alessandra: So, those things are important because often there are reinfections, and it's important to know that it is very common for families to carry parasites.
Andrew: Yep.
Alessandra: And it doesn't necessarily mean that the parasite needs to be eradicated. That's not the aim, for me, of the treatment. But, if the child is more susceptible to actually developing digestive symptoms as a result, and they've had severe diarrhoea as a result of constipation, then knowing that there are carriers in the family is really important.
Andrew: You know, this is one of the things I love about you, Alessandra, is you've gotten away from that kill-kill mentality, "quick, you know, hit it with a hammer" sort of thing, and you're saying, “Whoa, back here. Let's look at why they reacted. Why have they got an issue where somebody else hasn't?" Because, for instance, Blasto is this sort of facultative, it’s not an obligate pathogen, it's a facultative pathogen which will, you know, take advantage of a poor terrain and say, "I'll have a piece of that, thanks." I don't know why these pathogens are always English, but anyway...
Couple of things I have to broach with you, though, you mentioned the six-month sort of program. Motivation, very commonly, tapers off. How do you broach that motivation factor over that elongated period to make sure that they're on the straight and narrow, making sure that they're doing the good things, you know, cooking the good food, feeding the good food to their children, avoiding the bad stuff? What do you do?
Alessandra: I watch them like a hawk.
Andrew: Right.
Alessandra: I specifically call them. So, you know, I'll send out an email, weekly to see where they're at..
Andrew: Yep.
Alessandra: …of previous interventions. Have they implemented the changes? If they say no, and it's, you know, no to a lot of the questions I'm answering, then I go, "Right, I'm calling in five minutes," or, "Let's organise our five-minute catch up, and just to help them identify basically, you know, is there any self-sabotaging going on, or is it really a time issue? Do they need a little bit of coaching in terms of time management and getting their life organised? Is there any help I can help them bring in, in the home to give them that support?"
Andrew: Wow!
Alessandra: But, I have to say...can I tell you something, though? I actually screen...I screen my clients before they come on-board.
Andrew: Yeah, you've said this before.
Alessandra: Because, I'm not a psychologist. So, if there is someone where I identify, where there are really, you know, severe mindset issues in terms of, you know, "I'm not worth it," or, "I'm not gonna be able to get better, I've always been unwell," then I don't feel like that I'm best qualified to help them, so I try to refer them to the GP to get mental healthcare plans in place first, and get them to overcome those psychological barriers. And then, once they're ready, great, we can fly, and as long as there's commitment, that's fine. So basically, yeah. It's a matter of breaking down, chunking out the steps, and the aims and goals, so, you know, if someone is coming to you with a standard Australian diet, and they're eating, you know, white bread, and junk food, and everything is pre-prepared, they're just eating a bit of iceberg lettuce once a week, you really cannot possibly expect them to be 100% compliant…
Andrew: No.
Alessandra: …if you put them on to 100% whole food diet. So, I came to introduce things first. So, are they not drinking water? "Let's put in the water, let's bring in some extra veggie sticks a day. Let's have an apple a day," so, all the things that they can add so they don't feel like they're giving up their lifestyles, and then bit by bit, bit by bit, we make the changes.
Andrew: You know, I held you in high esteem before, Alessandra, but I gotta say I tip my hat to you, because it's very rare that I will meet a practitioner that would say, "You know what? You need somebody else's help first before, you know, you're going to have the success with my program. I'm not gonna even touch you." And, you know, you’re not rejecting them. You're saying, "There are other people who can better help you prepare for when you might be ready to undergo this program, because it involves change." And, I really applaud you for that. That's very rare and very well done. Good on you.
Alessandra: Thank you. Thank you very much. That means a lot coming from you. Thank you.
Andrew: My honour. I gotta say, I love this job. I do. I just get to meet the best minds, it's awesome.
I have to ask, though, the bad question that we never like to ask: What happens when things simply don't work, and you are confounded? And, I'd like to raise a thing here that was told me by Dr. David Jaa. Hi, David. And, he said, "When things go bad, that's okay. I know enough, y ou know, I'm confident in my education to say, 'All right, let's change.'" When things go well, he said, "That's great. I just get a bigger self-esteem." He said, "It's when things don't change..." He said, "When things don't change, I'm dead in the water. I got nothing. I got no signpost." He said, "That's the most frustrating thing to me." What do you do to reassess? What sort of things do you do to look at...maybe even find out if there's compliance issues and they might be not telling you the truth?
Alessandra: Absolutely, especially with children. Look, for me, I am...I'll come clean now, I am incredibly competitive. You know, when we go to naturopathic college, and even subsequent years with continuing professional development, you're always told, "Don't take it personally," but I take it personally. I invest a lot of my time, you know, research into these cases. And, when there is...you know, luckily it doesn't happen all that often, but it does happen when people that just don't buy it, at all. I do take it personally, and I do not take no for an answer.
So, what I do is, first of all, as you said, I check for compliance always. Luckily, as part of these programs that I run now, that's kind of, you know, I assess that on a weekly basis, so I know generally they are compliant. However, sometimes they are non-compliant through no fault of their own, in the sense that they have perhaps misread my instructions, or I didn't make it clear enough, so they might not be taking the correct dosage.
Andrew: Yep.
Alessandra: That’s the first thing.
Andrew: Yep.
Alessandra: Once I've assessed that, then I actually...I basically sit down of an evening, and I take everything out. I reassess all the tests. I'll go back to the initial questionnaire and I get my mind map software out, and I just basically reassess the whole case, and put it through a fine comb and see whether I've missed any differential diagnoses at the beginning, or if there are some differential diagnosis that I haven't yet explored with testing.
So, sometimes when the case is really complex, you cannot test for every single possible option. So then, that's another avenue. If then I find that that's not the case, and I'm still convinced that I was on the mark with the original diagnosis, then I review my treatment, and particularly the dosage.
Andrew: Yep.
Alessandra: And, this is something that, I think, comes with experience, and in the early days, I never used to do. I used to kind of stick to dosage by what, you know, would say on the bottle, if you like. And, I think, once you have that confidence, sometimes just increasing the dosage or the frequency of the dosage, that might be all it takes. The other thing it could be that, again, something that comes with experience, is that perhaps they need a little bit longer on this treatment.
Andrew: Right.
Alessandra: And finally, if that doesn't work, then I've got my two other options, which is I actually pay for a mentor.
Andrew: Yep.
Alessandra: So, I have two or three mentors in Australia that I sync with on a regular basis, even with cases that, it's not they're not budging at all, but perhaps they're not moving as fast as I'd like. And, the other thing is also to have good GPs on board that you can actually call up and say, "Could I ask a few questions? What do you think of this?" So, I think that, generally speaking, it's rare that I find someone just I cannot help, at all, after having done all these steps.
Andrew: So, my next question is regarding treatment. You've got several herbs which you've got to be more cautious with in kids, for instance, those containing thujone, those herbs containing thujone. Are there any treatments that you particularly avoid in children because of potential toxicity, not that I've seen any on the Database of Adverse Events Notification, DAEN, for the TGA, but are there certain herbs that you avoid? Are there certain herbs that you really like to use in kids, that have really good effect?
Alessandra: Yes, and yes. Again, it depends on what particular condition we're talking about. But, generally speaking, I find that herbs that I would certainly avoid in children would be things like coptis, for example, and herbs that are particularly non-selective in terms of their antimicrobial actions. So, I am not a huge fan for gastrointestinal conditions in children of hydrastis, and I tend...with children, I tend to work more in terms of introducing things rather than killing. So, I work a lot with prebiotics, different types of prebiotics. I work with individual nutrients, so, you know, things like zinc, for example, or you know, low-dose vitamin A, and I will do that through functional foods as well, or functional supplements like cod liver oil.
Herb-wise, I really like sort of fairly low-dose in my treatment, and I tend to concentrate on those herbs that actually have more selective actions in the gut, so like unica, and also anti-inflammatory actions, so like chamomile.
Andrew: Okay. So, with regards to functional foods, for instance, things like fructooligosaccharides, or inulin, you know, as an industry, it's just
“Inulin, there you go, see you later." That's what it is. But, there's different-sized molecules, there's different types of these fibres. Do you find that different foods, for instance, work differently, or that you choose different supplements because of a different molecule length?
Alessandra: Yes, absolutely. And, look, I've had the great fortune of having Jason Hawrelak, a good naturopathic, as my mentor now, for best part of a year and a half now. So, my approach is heavily influenced by his research, and I have to say that the application of different foods and different probiotic fibres in terms of modulating specific bacteria works…
Andrew: Yep.
Alessandra: …really, really well for me. And, the way I do that is generally by doing a comprehensive stool analysis based on, you know, PCR technology. So, you can really gauge...have a good idea as to what kind of modulation you're looking for. And so, generally speaking, I see a lot of bacteria that really thrive on protein and fat, and not so much of the bacteria that just really love...you know, love fibre, love coloured fruit and veg, and, you know, prebiotic fibres, even in terms of foods, in terms of eating lentils and beans, and that is right across the board. So, 9 times out of 10, that is the kind of dysbiotic picture I see.
Andrew: Right.
Alessandra: I think we just have way too much availability of meat, these days, and I'm not really convinced, looking at the assessment I'm doing, that that's how we're supposed to be eating. So, my selection of these fibres is really based on this. So, what does the stats tell us? Are the symptoms correlating this microbial picture that I'm looking at, so on this piece of paper? And then, how do we modulate, and how do we select...you know, which fibre do I select for that? And, the great thing about these fibres is that compliance with kids is fabulous because they taste like sugar, so they can be eating off the spoon, they can be incorporated in juices, smoothies, and it's a lot easier to give them that than you know, herbs , although I do use some terrible tasting herbs as well, but not for everybody.
Andrew: I'll get to the terrible-tasting herbs, because that's a definite trick that one. But, I was really interested I read a paper, and forgive me if this is wrong, but I get the feeling it was either from Fred, I think, it's Backhead that you would pronounce his last name, Fred Backhead, or Martin Blaser, but what I was looking at was the microbiota over the life, i.e. as we grow, and at different phases of growth, i.e. when you're sort of infants and the teenage years, these Propionibacteria tended to be higher in amounts. So, I wonder if it's sort of this...you know, we know about the maternal microbiota will sort of tend towards the carbohydrate harvesting, and I wonder if there's a function in some of this modulation of the protein harvesting bacteria…dare I say that word, over a lifestyle, you know, with regard to periods of growth, muscle growth in particular. You ever seen this, or...?
Alessandra: I think that's a really interesting question. I know what you're talking about, and I think that I read about this. I think Martin actually talked about it in listing microbe.
Andrew: Yeah.
Alessandra: I haven't thought of it in that way, and it's certainly an interesting point of view, perhaps because my population sample is a little bit skewed in the sense that I only ever see people who have got symptoms.
Andrew: Yeah.
Alessandra: So, for me, the correlation to me, is, well...
Andrew: Get rid of the symptoms, yeah.
Alessandra: It gets rid of symptoms, also. The correlation is just, you know...I've seen this kind of dysbiotic picture, not just in infants or children who are in that sort of anabolic state. So, I'm not sure, and it doesn't seem there's gonna be evidence here as to what that means.
Andrew: Yeah.
Alessandra: The way I interpreted it is more in terms of the current lifestyle practices that we all have, we generally have a loss of diversity over the course of a lifetime, and, if you like, it's survival of the fittest, and so, the fittest will be the ones that gets fed the foods that they thrive on on a more regular basis.
Andrew: Yep.
Alessandra: And so, perhaps that's more of the case. I'm not so sure.
Andrew: Can I ask you then, I guess...yes, sometimes I've heard practitioners say, you know, "There's too many lactobacilli," and so, therefore, the initial reaction for that would be, "Lactobacilli are, therefore, bad." And, my concern is, "Well, hang on. Shouldn't you be looking at why there's too many lactobacilli?" Do you ever see this sort of reaction going on?
Alessandra: I get it all the time. There is lactobacillus overgrowth, and there's streptococcus overgrowth. So, let's take, you know, a course of antibiotics. I don't know where that came from. I really don't know. My husband does a lot of work at SAMHRI, South Australian Medical Health Research Institute, and there's some really hot sciences there in terms of microbiome research.
Andrew: Cool.
Alessandra: And, I've actually gotten to ask this question specifically, because I used to get this all the time, and their response was, you know, the same as mine, is, you know, "We don't know where that comes from. It is not really accurate. There is no such thing as lactobacillus overgrowth, and you need to look at the kind of testing that you build results."
Andrew: Yeah.
Alessandra: So, I think, again, be judicious as to who is saying that, and how they are testing specifically for that. And, when you think about it, you know, lactobacillus really does not make up a huge percentage of the bacterial population. So, we're kind of like this...
Andrew: No, E. coli.
Alessandra: It's just this idea there's like, these huge amounts bifido and lactobacillus, and it's like...well, there's so many more, and they play a significant role in terms of health states, and we've got the research for it. So, I never...you know, if I see that, I go, "No, don't worry about...I'm happy you've got a lot of lactobacillus. Let's leave it there…
Andrew: Yep.
Alessandra: …and let's not worry about it."
Andrew: Let's not kill it, yeah.
Alessandra: Let's not kill it.
Andrew: Where can people learn what you learn? Do you teach...do you mentor anybody else now? Have you written books? And, if not, when?
Alessandra: No. Thank you. My book is, I've got the date now, it’s coming out, mid-April, but it is not a book that's related to this, so I don't think that would be of use. I would say I stopped mentoring in the last six months just because I couldn't fit it in into my schedule anymore.
Andrew: Yeah.
Alessandra: But, I would say mentoring is definitely great, so just try and find someone who is, you know, happy to do that, and just also keep going on to PubMed/MEDLINE, and keep reading the research, and experiment with these prebiotic fibres because that's the great thing about these, is that there are no side effects…
Andrew: Yep.
Alessandra: …other than, you know, if someone's got IBS and they're fructose intolerance, perhaps things like FOS might not work very well for them.
Andrew: Yeah, yeah.
Alessandra: But, generally speaking, they're pretty safe, they're food, so you can't really go wrong.
Andrew: So, last question: Five favourite foods.
Alessandra: These have to be healthy foods?
Andrew: No, they have to get an effect, in kids.
Alessandra: Okay. Sorry, you know, I was about to go off on a tangent. My favourite foods...that's a great question. Okay, favourite food would be chickpeas…
Andrew: Yep.
Alessandra: …because everybody loves them...
Andrew: Oh, yeah.
Alessandra: ...and they're very well tolerated. Artichoke. They are a little bit of an unsung hero, and I really like them. And, the great thing about artichokes is that they can be an easy addition, you know, you can even buy them in glass jars, so they're really great. Other foods that I love are coloured grain. That's a really great way to increase, you know, the nutritional content and the polyphenol content of the foods, and how we feed beneficial bacteria. So, that's a neat trick that I learned from Jason Hawrelak.
Andrew: Coloured grains.
Alessandra: Coloured grains. So, you know, generally speaking, we tend to counsel our clients to eat whole grain…
Andrew: Yep.
Alessandra: …and so just go the extra step and say "whole coloured grain." You know, I love tri-colour quinoa.
Andrew: Red rice, yeah.
Alessandra: It's widely available. You can buy Australian-based quinoa as well.
Andrew: Ah, good.
Alessandra: Rices are really well-tolerated for most people with digestive issues. And so, if you've got someone who's really not tolerating grain very well, but rice is okay, then rather than just give them brown rice, you can get them to rotate their red rice, black rice, wild rice. They can be incorporated in breakfast, but that's probably quite a few foods in there that I've mentioned.
Andrew: Well done.
Alessandra: And, the other thing that I love, probably my last one...again, a neat trick is to cook and cool potatoes, great addition for kids' lunches, and you're actually changing the composition of the starch.
Andrew: Yes.
Alessandra: So, that looks really lovely. So, you could do, you know, stew veggie sticks with some hummus and cold potato as a lunch...microbiota friendly lunch for kids.
Andrew: Yeah, and that changes it into a resistant starch which is gonna feed, not specifically, but certainly going to help along your bifidobacterium or the bacteria in your lower bowel, yeah?
Alessandra: That's right.
Andrew: Alessandra, I could talk to you for hours. There's so much that we could cover, and there's so many different tangents, but, you know, time permitting, I guess, we have to cut it here. But, would you join us for FX Medicine at other times, because I gotta say, I just I love the way that you think outside of a box, and certainly outside of commercial boxes that we're taught, you know, and that practitioners grab so eagerly onto, and you go that extra step. To me, it's all for the patient, and I really, really applaud you for that. You really...you know, I doff my hat to you. It's very well done.
Alessandra: Thank you. I would love that. I really enjoyed this conversation. So, absolutely, any time.
Andrew: Excellent. Thanks so much. This is FX Medicine, and I'm Andrew Whitfield-Cook.
Other podcasts with Alessandra include:
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