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AMERICAN ACADEMY OF PEDIATRICS
240 PEDIATRICS Vol. 62 No. 2 August 1978
Committee on Nutrition
The Practical Significance of Lactose Intolerance inChildren
Lactose intolerance has been reviewed in
published statements by the Protein AdvisoryGroup of the United Nations System,’ the Food
and Nutrition Board of the National Research
Council,2 and the American Academy of Pediat-
rics, Committee on Nutrition.’ Each of these
statements deals principally with the advisability
of encouraging population groups with a high
rate of lactose intolerance to consume nutritional-
ly beneficial quantities of milk. All three state-
ments conclude that it is inappropriate to discour-
age the use of milk on the basis of lactoseintolerance. Nevertheless, controversy over thepractical significance of the widespread preva-
lence4’5 of lactose intolerance has continued.
DEFINITIONS
Lactose intolerance is defined’ as a clinical
syndrome of abdominal pain, diarrhea, flatulence,and bloating after the ingestion of a standard
lactose tolerance test dose (2 gm of lactose perkilogram of body weight or 50 gm /sq m of body
surface area, maximum 50 gm in a 20% water
solution). If a maximum increase in blood glucose
level of less than 26 mg/dl is observed after alactose tolerance test dose, lactose malabsorption
is diagnosed.’ Lactose intolerance is classified as
primary, secondary, or congenital. Lactose intol-
erance is classified as primary when it is observed
with no history or signs of underlying intestinal
disease. If there is gastrointestinal disease, it isusually classified as secondary. Primary andsecondary lactose intolerance are not uncommon;
however, congenital lactose intolerance is rare.
This form is present at birth, the histologic
features of the gastrointestinal mucosa are
normal, and brush-border lactase activity is low
or completely absent.” � The three forms of
lactose intolerance must be considered separatelyto avoid confusion.
PRIMARY LACTOSE INTOLERANCE
Major areas of concern in reviewing the practi-
cal implications of primary lactose intolerance
are (1) the prevalence at specific ages in particu-
lar population groups, (2) the relationship
between primary lactose intolerance and intoler-ance to quantities of milk usually consumed, (3)response to hydrolyzed lactose milk, and (4) the
absorption of other nutrients in the presence of
amounts of lactose that surpass digestive capacitybut do not produce symptoms.
Studies on Lactose Intolerance
The widespread prevalence of lactose malab-
sorption and intolerance in children is well docu-mented in a review by Jones and Latham.4
Prevalence at specific ages in a particular popu-
lation group varies. In some groups, 90% preva-lence is observed by age 4 years; in others itremains much lower throughout life. Similar
information on children of American ethnic
groups has been published recently.5’7Paige and co-workers” studied 1 16 black chil-
dren 13 to 59 months old. Twenty-nine percent ofthese children had lactose malabsorption, and18% had signs of intolerance. Black children 4 to 9
years old were studied by Garza and Scrimshaw.9
They reported lactose intolerance in 1 1% of those
4 to 5 years old, 50% of those 6 to 7 years old, and
72% of those 8 to 9 years old. Paige and co-workers’#{176} studied another group of children 6 to
13 years old. Fifty-four percent had lactosemalabsorption and 65% had symptoms of intoler-
ance. Haverberg et al.” and Kwon et al.’2 studied
black patients 14 to 19 years old and reported
lactose malabsorption prevalence rates of 83%
and 81%, respectively.Studies of Mexican-American children have
also been reported. Woteki et at.” studied 282Mexican-American children who were 2 to 14years old. Eighteen percent of the 2- to 5-year-old
children were intolerant to lactose. This preva-
lence increased to 56% in the 10- to 14-year-old
children. Sowers and Winterfeldt” found a simi-lar prevalence (50%) in 9- to 21-year-old Mexican-
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AMERICAN ACADEMY OF PEDIATRICS 241
American children. In a study of 301 adolescents
and young adults’5 in rural Mexico, 222 of themwere classified as having lactose malabsorption,
but only 86 of these reported symptoms.American Indians have been studied by Casky
and co-workers.” Using hydrogen breath analysis,
lactose malabsorption was found in 20% of 3- to5-year-old children, in 10% of those 6 to 12 yearsold, and in 70% of those 13 to 19 years old.Newcomer et al.’7 reported a similar study inAmerican Indians in which 104 subjects 5 to 17
years old were studied. Lactose malabsorption
was diagnosed in 63% to 74% of the groups
stratified by age (5 to 6 years, 7 to 8 years, and soforth). Symptoms were reported in 76% of the
children with lactose malabsorption. Prevalence
of lactose intolerance at specific ages was not
reported.
Prevalence of lactose malabsorption in whitechildren tends to be much lower than in these
other groups. Persons classified as white in this
country tend to be heterogeneous; therefore, dataare difficult to compare with studies published in
countries with more homogeneous populations.Data presented by Woteki et al.’3 and Garza and
Scrimshaw9 are representative. Lactose intoler-ance is rarely observed in 2- to 6-year-old chil-
dren, and increases to about 30% among adoles-
cents. Lebenthal et al.’8 have reported lactaselevels from 172 of 1,077 biopsy specimens. Thegroups studied were white and were healthy
siblings and parents of patients with cystic fibro-sis, children with failure to thrive without diar-rhea, and patients with “irritable colon syn-
drome.” No low lactase activity was encounteredin children less than 5 years old.
Comparable data on the prevalence of lactoseintolerance in American children from other
ethnic backgrounds who were expected to have a
high prevalence of lactose intolerance (e.g.,
Chinese, Japanese, and Greek) are not available.Assessing the relationship between lactose and
milk consumption is also important in determin-mg the practical significance of lactose intoler-ance in children. Comparison of the standard
lactose tolerance test dose with quantities of milk
normally consumed shows that the test dose isrepresentative of the amount of milk consumed
by young infants but not of that consumed byweaned children. The 200 to 250 ml of milk
usually consumed at one sitting by the latter
children contains 12 gm of lactose. This issubstantially less than the 2 gm/kg usuallyprovided in the lactose tolerance test.
Paige et al.’9 reported that lactose intolerancein elementary school children adversely in-
fluenced their acceptance of moderate amounts
of milk. Milk’s significant role in publicly spon-
sored, supplemental feeding programs led Paige
and other investigators to study lactose intoler-ance further. Paige et al.5 found no differences in
milk consumption between lactose-tolerant and
lactose-intolerant black children 13 to 59 months
old. Garza and Scrimshaw9 found no differences
in milk consumption between lactose-tolerant
and lactose-intolerant black children 6 to 7 and 8
to 9 years old, although the 8- to 9-year-old black
children consumed less milk regardless of lactose
tolerance status than a comparable group ofwhite children. Woteki et al.” reported no differ-
ence in milk consumption by the lactose-tolerant
and lactose-intolerant Mexican-American chil-
dren they studied. In a study in rural Mexico,’5
conflicting results were obtained and do not helpto determine whether lactose malabsorption
interferes with milk consumption.
Stephenson and Latham2 studied slightly older
children with lactose malabsorption; no differ-
ence in milk consumption was observed betweenthe lactose-tolerant and lactose-intolerant sub-
jects in this study. In Newcomer and co-workers’study’7 of American Indians, two thirds of the 156subjects studied were less than 18 years old, andthose with lactose malabsorption had mean daily
lactose intakes of 19 gm compared to 25 gm in
those with lactose absorption. Woteki et al.”
reported no differences in milk intakes betweenthose with lactose absorption and malabsorption,but children classified as Anglo-American drank
more milk than the Mexican-American children.
In contrast, Paige et al.2 ‘ reported that 50% of 6-
to 12-year-old children with lactose malabsorp-
tion consumed less than one-half pint of milk
offered in school feeding programs. They found
that children with lactose malabsorption whowere classified as milk-drinkers had higher
increases in blood glucose level than those classi-fled as non-milk-drinkers. Lebenthal et al.18 havealso reported greater milk consumption (> 960
mi/day) in individuals with high intestinal lactase
levels and their families than in patients and
families with low lactase levels (< 250 mi/day).The question of tolerance to various lactose
intake levels in intolerant subjects and those with
lactose malabsorption has also been examined.Garza and Scrimshaw9 report that, despite thesignificant prevalence of lactose intolerance they
observed in 4- to 9-year-old black children, no
child was intolerant to 240 ml of milk. In contrast,
Mitchell et al.,22 who studied 11- to 18-year-old
black adolescents, found that 21% had symptoms
after consuming 240 ml of milk. In double-blindstudies, Haverberg et al.” and Kwon et al.’2report, respectively, that 28% and 9% of adoles-
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242 LACTOSE INTOLERANCE
cents with lactose malabsorption had symptoms
after drinking 240 ml of milk, as did 16% and 19%
of those with lactose absorption. In a slightly
older age group studied by Stephenson andLatham,2#{176} all those with lactose malabsorption
could tolerate 240 ml of whole milk without anyor only mild symptoms. In studies of nativeAmerican Indians, Newcomer et al.2’ report thatall of the subjects they studied who had malab-
sorption (6 to 62 years old) tolerated amounts oflactose equivalent to 240 to 300 ml of milk taken
with a meal with no intestinal symptoms attribut-
able to lactose. In contrast, lower tolerance levels
are reported in older adults by Bayless et al.24 and
in Peruvian children by Paige et al.25 Studies from
other countries have reported a lack of symptoms
in lactose-intolerant children comparable to those
reported here.2’27
A possible solution for circumventing intoler-ance to normal intakes of milk is to hydrolyze the
lactose. Although studies such as those of Jones et
al.2” report that lactose hydrolysis substantially
increases milk tolerance in adults, other studies
cast doubt on the efficacy of lactose hydrolysis in
children. Paige and co-workers29 tested whole
milk, 50% hydrolyzed lactose milk, and 90% hy-drolyzed lactose milk in 22 black 13- to 19-
year-old subjects with lactose malabsorption.
Three of these teenagers reported symptoms to
untreated whole milk and to 90% hydrolyzedlactose milk. None reported symptoms to 50%hydrolyzed lactose milk. Similarly, Kwon et al.’2reported that 28 of 45 teenagers with lactosemalabsorption did not experience symptoms to
240 ml of whole milk or lactose-free milk. Ten of
the others had inconsistent symptoms; some hadsymptoms to lactose-free milk only, some to both
lactose-free milk and whole milk, and others to240 ml but not 480 ml of whole milk. Seven
subjects had consistent symptoms, but none hadsymptoms to 240 ml of milk, with or withoutlactose.
Milk in the Diet
The importance of milk in the American diet
rests on its high nutrient content. The U.S.Department of Agriculture30 estimates that dairy
products, excluding butter, contribute only 11%
of the available food energy; however, they
provide 75% of the calcium, 39% of the riboflavin,
35% of the phosphorus, 22% of the magnesium,
20% of the vitamin B,2, and substantial propor-
tions of other nutrients. The question of the
bioavailability of these nutrients in the presenceof lactose malabsorption without symptoms ofintolerance is, therefore, important. Unfortunate-
ly, little data are available. Significant malabsorp-
tion is unlikely if there are no symptoms; howev-
er, the chronic effects of subtle differences in
bioavailability of various nutrients might besignificant, especially under conditions of margi-nal intakes. There are substantial data on the
“malabsorption of lactose,” but there are no
studies estimating metabolizable energy inlactose-containing diets of children with lactose
malabsorption. Less increase in blood glucose
levels has been demonstrated2’ in those withlactose malabsorption than in those with lactose
absorption after milk ingestion. The possibilitythat slower but sustained digestion of lactose is
responsible for these smaller increases remains
unknown.
A metabolic study in which milk provided alldietary protein was designed by Calloway andChenoweth” and was conducted in lactose-toler-
ant and -intolerant adults. After adjustments formetabolizable energy were made, no effect onnitrogen balance was demonstrated. Unpublished
results from this study indicate that calcium,phosphorus, and magnesium absorption also were
not influenced by the presence of lactose.Leichter and Tolensky,’2 in a study �n weaned
rats that were fed lactose-containing diets,
obtained suggestive evidence that lactose mayreduce protein and fat absorption in animals with
low lactase activity. Bowie” reported the effectsof lactose-induced diarrhea on nitrogen and fatabsorption. Nitrogen absorption was depressed in
those with lactose malabsorption who were fedmilk compared to a disaccharide-free diet, but
nitrogen retentions were similar with both diets.No differences in fat absorption were noticed. In
a separate study by Bowie et al.,’4 absorption was
studied by using xylose. No difference in xyloseexcretion was observed when malnourished,
lactose-intolerant subjects were fed whole milk or
a disaccharide-free formula. A recent study’5
conducted in 2- to 8-month-old infants comparedcalcium and magnesium absorption when un-treated milk, Iflilk treated with lactase tenminutes before feeding, and a lactose-free milkwere fed. Calcium and magnesium absorption
was best (72% and 81%, respectively) with
lactase-treated milk and poorest (calcium 37%
and magnesium 39%) with lactose-free milk. The
infants were presumably lactose tolerant.
Summary
Lactose intolerance is observed in black andMexican-American children by age 3 years, and itprobably occurs in other non-northern European
ethnic groups at a similar age. However, intoler-
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AMERICAN ACADEMY OF PEDIATRICS 243
ance to the consumption of 250 ml of milk
apparently is rarely seen in preadolescents.
Current research on the response of adolescentsto hydrolyzed lactose milk suggests that the
symptoms observed in lactose-intolerant subjects
after milk ingestion may be unrelated to lactoseor may be mild enough to be of little practical
significance. The effects of undigested lactose onnutrient absorption has received little attention,
but preliminary data suggest that this is not a
problem, except perhaps when overall intakes aremarginally adequate.
SECONDARY LACTOSE INTOLERANCE
The predominant view at present is thatprimary lactose intolerance is genetically prede-
termined. The following observations supportthis view: its prevalence among apparentlyhealthy populations, its absence among specificgroups,36’8 the inevitable decrease with age inlactase activity in most mammalian species,39 andthe apparently noninducible nature of the
enzyme in humans.2’4#{176} However, the environ-
ment’s role in accelerating the age of lactoseintolerance, determining the severity of its
expression, and increasing the prevalence within
population groups has not been assessed. Fewstudies have been directed at a basic understand-
ing of the physiology of the intestinal mucosal
cells as it relates to lactose intolerance and
malabsorption. Yet the importance of the envi-
ronment is repeatedly demonstrated by the
apparently transient decrease in lactase activity
and intolerance to lactose commonly associated
with gastrointestinal disease or significant malnu-
trition. This condition is classified as secondarylactose intolerance. Areas of concern in assessing
its practical implications are (1) its significance in
the treatment of malnutrition, which is common
to gastrointestinal disease; and (2) the “reversibil-
ity” of this condition and its effects on the
expression of a presumably, genetically deter-mined decrease in lactase.
Lactose intolerance in malnutrition has beenwell described344�4’; however, the relevance ofthis intolerance to milk feeding is controversial.
Reddy and Pershad,2 in a study evaluating amilk-based diet in refeeding programs, conclude
that this is a self-limiting problem and of littlepractical importance. An ongoing evaluation” of
a supplemental milk feeding program serving32,000 rural Haitians and an accompanying
program refeeding the severest cases of malnutri-tion (301 subjects) make the same conclusions. Afavorable outcome was reported for 93% of thesubjects in a refeeding program. Milk intolerance
could not be excluded as a possible cause offailure in only 1% of the subjects. In a studyreported by Prinsloo et al.,42 children refed on
cow’s milk did not have more diarrhea than those
fed formulas with glucose, sucrose, or D-maltose,although lactic acid excretion was high in chil-
dren fed cow’s milk.
In the study by Bowie” referred to earlier,
lactose-induced diarrhea had no effect on nitro-gen retention or fat absorption. He concludedthat, as long as milk is the most widely available
and cheapest source of good protein, it should be
used. However, he does caution that childrenwith severe diarrhea will require a lactose-free
formula for a variable period of time. Mason etal.44 reported similar tolerances.
Mitchell et al.45 reported results of blind-
controlled feeding trials evaluating prehydro-lyzed lactose milk and a reconstituted whole milk.
Thirty-five slightly undernourished Australianaboriginal infants were studied. No complicationswere seen in children fed either milk, but five of
those fed whole milk failed to gain weightcompared to only one in the hydrolyzed lactosemilk group. Children fed the hydrolyzed lactosemilk had a mean 70% larger weight gain than
those fed the whole milk. Children with diarrheaor weights less than 90% of expected weight for
age who were fed hydrolyzed lactose milk hadstatistically significant higher weight gains than
comparable groups of children fed whole milk.
The effects of previous malnutrition orgastrointestinal disease on the prevalence ofprimary lactose intolerance is difficult to evaluate
because few studies have attempted to quantitate
the severity of observed intolerance or malabsorp-tion. Paige and co-workers25 report no differences
in prevalence between previously malnourished
children and their siblings who had no history ofsignificant malnutrition, although tolerance levelsin both groups appear lower than observed inchildren in this country. Woteki et al.” found theprevalence of lactose intolerance of Mexican-Americans similar to that reported by Sowers andWinterfeldt’4 from rural Mexico. Stoopler et al.27restudied children with lactose malabsorptionseven months after an initial evaluation and found
that 21% had normal lactose tolerance curves onretesting. In Britain, no correlation was found
among continuing lactose intolerance, maximalincrease in blood glucose level after a standardlactose test dose, intestinal lactase levels, andsmall intestinal morphology on reevaluation46 of30 children 2 to 38 months old with a previous
diagnosis of presumably secondary lactose intoler-
ance.
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244 LACTOSE INTOLERANCE
Summary
Individuals using milk-based diets in refeedingprograms occasionally report initial problems
with diarrhea aggravated or precipitated bylactose. In this early phase, a hydrolyzed lactose
or lactose-free milk may be optimal. Apparently,
however, whole milk is successfully used forrefeeding, unless there is severe diarrhea. This
suggests that the milder cases seen out of the
hospital may present less significant problems.
The report by Mitchell et al.,45 however, suggeststhat the effect of lactose may be more subtle.
Although unavailable lactose may not presentmajor problems to fat and nitrogen absorption,
the decrease in metabolizable energy may be
enough to decrease the rate of weight gain,lengthen hospital stays, and therefore decrease
the effectiveness of lactose in refeeding programs,
unless compensated for in the total diet. Compar-
able studies should be repeated in hospital andsupplementary feeding programs to determinewhether or not potential effects on nutrient
bioavailability are as significant as this study
suggests.
CONGENITAL LACTOSE INTOLERANCE
The extremely low or absent activity of brush-border lactase67 in congenital lactose intolerance
can be life-threatening because of the accom-panying severe diarrhea and dehydration when
lactose is fed. The condition is rare, but it is not
unusual for secondary lactose intolerance to be
misdiagnosed during the newborn period as
congenital lactose intolerance. A definite diagno-
sis requires intestinal biospy for histology and
enzyme assay. Nonetheless, it is imperative that a
lactose-free formula be provided as soon as thediagnosis is suspected because of the seriousness
of the condition.
RECOMMENDATIONS ANDCONCLUSIONS
The Committee’s position remains unchanged.On the basis of present evidence it would beinappropriate to discourage supplemental milk
feeding programs targeted at children on the basis
of primary lactose intolerance. The Committee
continues to encourage the development of nutri-
tious and acceptable supplementary foods inareas with inefficient and uneconomical milkproduction. The use of milk should not be dis-couraged in the refeeding of malnourished chil-
dren-except if they have severe diarrhea-as long
as milk continues to provide the best and cheapest
source of high-quality protein. However, the
Committee cautions that some of these childrenwill require lactose-free diets if recovery is to be
achieved with minimal complications. It alsourges that studies such as those of Mitchell et a!.’5be continued in inpatient and outpatient facilities
for reasons outlined here; that more attention begiven to studies of environmental effects onenterocyte function, thereby increasing our
understanding of the development of low lactaselevels; and that efforts to provide effective, low-cost, supplemental foods to children be continuedas part of comprehensive health planning for
decreasing morbidity in children.
COMMITTEE ON NUTRITION
Lewis A. Barness, M.D., Chairman; Alvin M. Mauer,M.D., Vice-Chairman; Arnold S. Anderson, M.D.; Peter R.Dallman, M.D.; Gilbert B. Forbes, M.D.; Buford L. Nichols,Jr., M.D.; Claude Roy, M.D.; Nathan J. Smith, M.D.; W.Allan Walker, M.D.; Myron Winick, M.D.
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1978;62;240Pediatrics The Practical Significance of Lactose Intolerance in Children
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