Lactose intolerance and gastrointestinal cow’s milk allergy in infants and children – common misconceptions revisited

Abstract

Lactose is the main carbohydrate in human and mammalian milk. Lactose requires enzymatic hydrolysis by lactase into D-glucose and D-galactose before it can be absorbed. Term infants express sufficient lactase to digest about one liter of breast milk daily. Physiological lactose malabsorption in infancy confers beneficial prebiotic effects, including the establishment of Bifidobacterium-rich fecal microbiota. In many populations, lactase levels decline after weaning (lactase non-persistence; LNP). LNP affects about 70% of the world’s population and is the physiological basis for primary lactose intolerance (LI). Persistence of lactase beyond infancy is linked to several single nucleotide polymorphisms in the lactase gene promoter region on chromosome 2. Primary LI generally does not manifest clinically before 5 years of age. LI in young children is typically caused by underlying gut conditions, such as viral gastroenteritis, giardiasis, cow’s milk enteropathy, celiac disease or Crohn’s disease. Therefore, LI in childhood is mostly transient and improves with resolution of the underlying pathology. There is ongoing confusion between LI and cow’s milk allergy (CMA) which still leads to misdiagnosis and inappropriate dietary management. In addition, perceived LI may cause unnecessary milk restriction and adverse nutritional outcomes. The treatment of LI involves the reduction, but not complete elimination, of lactose-containing foods. By contrast, breastfed infants with suspected CMA should undergo a trial of a strict cow’s milk protein-free maternal elimination diet. If the infant is not breastfed, an extensively hydrolyzed or amino acid-based formula and strict cow’s milk avoidance are the standard treatment for CMA. The majority of infants with CMA can tolerate lactose, except when an enteropathy with secondary lactase deficiency is present.

‘No nuts please’: Food allergen management in takeaways

“…Although there is limited survey among food services regarding the differences between milk allergy and lactose intolerance, there are evidence suggesting general confusion between cow's milk allergy and lactose intolerance (Heine et al, 2017). There are some individuals with lactose intolerance who may be able to tolerate a small amount of milk products but those with cow's milk allergy may experience severe allergic reactions.…”

Knowledge of Lactose Intolerance among Clinicians

“…Reports have highlighted the problems associated with differentiating between LI and CMPA and the potential for Article Table 1 misdiagnosis. 20 Crucially, one question relating to the HBT was answered incorrectly by more than 80% of the participants. This highlights acceptable knowledge of general issues, but not the diagnostic aspects, of lactose intolerance among doctors.…”

Food Allergy Prevention and Treatment by Targeted Nutrition

“…Contrary to common perception, lactose is tolerated well by most infants with CMA [125]. The only exception are infants with cow's milk protein-induced enteropathy and secondary lactase deficiency due to villous damage (Table 2).…”