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    Lactose intolerance: Diagnosis and diet strategies

    Is it lactose intolerance or a milk allergy? Here’s how to diagnose the clinical spectrum of lactose problems and manage diet to relieve symptoms and ensure good nutrition.

     

    Management

    The pediatrician has several means with which to manage lactose intolerance in pediatric patients.

    Dietary restriction

    For most patients with lactose intolerance, avoiding milk and dairy products results in improvement of symptoms. However, this is generally not necessary or advised. Most patients with lactose intolerance are able to tolerate 1 to 2 cups of milk or the equivalent per day without significant symptoms. Routine consumption of lactose over the entire day may be better tolerated than intermittent, daily bolusing of lactose. Patients may slowly increase intake after a period of restriction to determine each individual’s threshold for symptoms.8,14,15 Children intolerant of milk may tolerate milk chocolate and also yogurt, which often results in fewer symptoms because of its semisolid state. Aged cheeses also tend to produce fewer symptoms because of lower lactose content.2

    The pediatrician wants patients to maintain calcium and vitamin D intake as much as possible. It is important for parents and caregivers to be educated that ingestion of lactose does not lead to damage of the gastrointestinal tract even if the child develops symptoms.

    Enzyme replacement

    If a child ingests more than 2 cups of milk per day or its equivalent, a child or adolescent may take one of the commercially available lactase enzyme preparations that are available as liquid or sprinkles. According to its website, Lactaid may be taken daily by children aged 4 years and older (bit.ly/Lactaid-FAQs).

    Lactose-free formulas

    Lactose-free formulas, although commercially available in the United States, are generally not needed because enough enzyme activity remains to preserve digestion and absorption. Lactose-free formulas have not demonstrated an outcome advantage in terms of growth, development, or behavioral issues such as colic.2 If needed, lactose-free or reduced milk is available for children aged older than 1 year, and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) will provide vouchers when needed.

    Maintaining calcium and vitamin D intake

    The pediatrician should warn parents against total lactose-free diets because this practice is associated with lower calcium absorption and potential problems with bone mineralization.

    Next: Small-for-tddler is unable to walk

    The pediatrician should encourage intake of calcium-rich foods and consider calcium supplementation (liquid calcium gluconate for younger children and calcium carbonate for older children are readily available) if this is not possible. Vitamin D status should be monitored and intake replaced when appropriate as well. Dietary consultation may greatly assist the pediatrician and the family in identifying and monitoring both calcium and vitamin D intake.

    Conclusion

    Lactose intolerance is a common problem in pediatric practice. The pediatrician needs to be aware of practical strategies for diagnosis and management as well as when further workup needs to be done, in addition to preventing deficiency of calcium and vitamin D.

    REFERENCES

    1. Di Stefano M, Veneto G, Malservisi S, Strocchi A, Corazza GR. Lactose malabsorption and intolerance in the elderly. Scand J Gastroenterol. 2001;36(12):1274-1278.

    2. Heyman MB, Committee on Nutrition. Lactose intolerance in infants, children, and adolescents. Pediatrics. 2006;118(3):1279-1286.

    3. Hertzler SR, Savaiano DA. Colonic adaptation to daily lactose feeding in lactose maldigesters reduces lactose intolerance. Am J Clin Nutr. 1996;64(2):232-236.

    4. Suchy FJ, Brannon PM, Carpenter TO, et al. NIH consensus development conference statement: lactose intolerance and health. NIH Consens State Sci Statements. 2010;27(2):1-27.

    5. Gijsbers CF, Kneepkens CM, Büller HA. Lactose and fructose malabsorption in children with recurrent abdominal pain: results of double-blinded testing. Acta Paediatr. 2012;101(9):e411-e415.

    6. Lomer MC, Parkes GC, Sanderson JD. Review article: lactose intolerance in clinical practice—myths and realities. Aliment Pharmacol Ther. 2008;27(2):93-103.

    7. Berni Canani R, Pezzella V, Amoroso A, Cozzolino T, Di Scala C, Passariello A. Diagnosing and treating intolerance to carbohydrates in children. Nutrients. 2016;8(3):157.

    8. Suarez FL, Savaiano DA, Levitt MD. A comparison of symptoms after the consumption of milk or lactose-hydrolyzed milk by people with self-reported severe lactose intolerance. N Engl J Med. 1995;333(1):1-4.

    9. Serra J, Azpiroz F, Malagelada JR. Intestinal gas dynamics and tolerance in humans. Gastroenterology. 1998;115(3):542-550.

    10. Glatstein M, Reif S, Scolnik D, et al. Lactose breath test in children: relationship between symptoms during the test and test results. Am J Ther. August 17, 2016. Epub ahead of print.

    11. Gasbarrini A, Corazza GR, Gasbarrini G, et al; 1st Rome H2-Breath Testing Consensus Conference Working Group. Methodology and indications of H2-breath testing in gastrointestinal diseases: the Rome Consensus Conference. Aliment Pharmacol Ther. 2009;29 suppl 1:1-49.

    12. Eisenmann A, Amann A, Said M, Datta B. Implementation and interpretation of hydrogen breath tests. J Breath Res. 2008;2(4);046002.

    13. Newcomer AD, McGill DB, Thomas PJ, Hofmann AF. Prospective comparison of indirect methods for detecting lactase deficiency. N Engl J Med. 1975;293(24):1232-1236.

    14. Suarez FL, Savaiano D, Arbisi P, Levitt MD. Tolerance to the daily ingestion of two cups of milk by individuals claiming lactose intolerance. Am J Clin Nutr. 1997;65(5):1502-1506.

    15. Montalto M, Curigliano V, Santoro L, et al. Management and treatment of lactose malabsorption. World J Gastroenterol. 2006;12(2):187-191.

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