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Lactose Intolerance in Children Care Pathway Overview

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Presentation

Lactose intolerance is a condition associated with lactase deficiency and malabsorption of dietary lactose resulting in gastrointestinal symptoms

  • Bloating
  • Flatulence
  • Abdominal pain
  • Diarrhoea
  • Vomiting

Symptoms occur within 2 hours of lactose ingestion and there is often a family history.

Types:

Absolute absence of lactase from birth.

  • Extremely rare
  • Presents with intractable diarrhoea when human milk or lactose containing formula introduced
  • Small intestine biopsy shows normal histology but low or completely absent lactase concentrations

  • Preterm infants less than 34 weeks gestation have relative lactase deficiency due to immature gastrointestinal tract
  • Do not typically present with clinical lactose intolerance

Relative or absolute absence of lactase

  • Most common cause of lactose malabsorption
  • Develops in childhood with age varying in difference racial groups
  • May develop later in life

  • Results from injury to small bowel mucosa
  • Usually occurs following an infectious gastrointestinal illness or other mucosal injury but may be present alongside newly or undiagnosed coeliac disease

Symptoms include abdominal bloating, increased (explosive) wind, loose green stools.

Lactose intolerance should be suspected in infants who have had any of the above symptoms that persist for more than 2 weeks.

Practice Point

Primary lactose intolerance is less common than secondary lactose intolerance and does not usually present until later childhood or adulthood.

Red Flags
Differential Diagnosis

  • Offer reassurance and advise parents and carers that in well infants, effortless regurgitation of feeds:
    • Is very common (it affects at least 40% of infants).
    • Usually begins before the infant is 8 weeks old.
    • May be frequent (5% of those affected have 6 or more episodes each day).
    • Usually becomes less frequent with time (it resolves in 90% of affected infants before they are 1 year of age).
    • Treatment or further investigation is not normally required.

Review infant or child if:

  • Regurgitation becomes persistently projectile — admission is required.
  • There is bile-stained vomiting or haematemesis — admission is required.
  • There are new concerns, such as signs of marked distress, feeding difficulties, or faltering growth — suggests a diagnosis of gastro-oesophageal reflux
  • There is persistent, frequent regurgitation beyond the first year of life

This is more common than Lactose Intolerance.

See Cow’s Milk Protein Allergy pathway

See GORD pathway

See Faltering Growth pathway
Initial Primary Care Assessment and Diagnosis

Breast milk is the ideal choice for most infants with lactose intolerance. Mothers should be encouraged and supported to continue breastfeeding:

  • If symptoms persist in  the exclusively breast-fed infant, a maternal "dairy-free" diet is indicated for a minimum trial of 2 weeks.
  • Breastfeeding mothers on a lactose free diet may require calcium supplementation. The Dietary Reference Values (DRVs) for calcium in breastfeeding women are 1250mg/d for 19-50 year olds and 1350mg/d for 15-18 year olds. If calcium intake will not be sufficient then recommend over the counter calcium supplements. Please also see The Association of UK Dietitians Calcium Fact Sheet.

Full history and examination to include family history.

General physical

  • check height and weight to assess growth and hydration status
  • check temperature, since fever may suggest infectious cause of secondary lactase deficiency

Abdomen

  • usually no physical exam findings but patients might have abdominal distention and/or excessive borborygmi ( bowel sounds)

  • strict lactose-free diet for 2 weeks with resolution of symptoms, followed by recurrence of symptoms upon reintroduction of dairy foods, should be used to diagnose lactose intolerance
  • consider stool studies in infants with diarrhoea, including faecal pH test
  • consider testing for intestinal etiologies of suspected secondary lactose intolerance including
    • stool exam for parasites
    • blood tests for coeliac disease or immunodeficiency (quantitative immunoglobulins)
    • intestinal biopsy for diagnosis of underlying mucosal pathology

Resolution of symptoms within 48 hours of withdrawal of lactose from the diet confirms diagnosis.
Initial Primary Care Management

Breast milk is the ideal choice for most infants with lactose intolerance. Mothers should be encouraged and supported to continue breastfeeding:

  • If symptoms persist in the exclusively breast-fed infant, a maternal "dairy-free" diet is indicated for a minimum trial of 2 weeks
  • Breastfeeding mothers on a lactose free diet may require calcium supplementation. The Dietary Reference Values (DRVs) for calcium in breastfeeding women are 1250mg/d for 19-50 year olds and 1350mg/d for 15-18 year olds. If calcium intake will not be sufficient then recommend over the counter calcium supplements. Please also see The Association of UK Dietitians Calcium Fact Sheet.

If mother needs additional support with breastfeeding please follow the Countywide Infant Feeding Pathway.

If breastfeeding is not continued then lactose free formulas are available to purchase over the counter.

Lactose free formula can be purchased at a similar price to standard formula and the GP should not routinely prescribe; advise to use lactose free formula with appropriate safety netting (advice on what to do if symptoms do not improve) may be all that is needed and parents should be asked to purchase the quanitity required.

Soya formula (Infasoy®, SMA Wysoy®) should not routinely be used for patients with secondary lactose intolerance. It should not be prescribed at all for those under 6 months due to high phyto-oestrogen content. It should only be advised in patients over 6 months who do not tolerate lactose-free cow's milk formula. Parents should be advised to purchase it as it is a similar cost to cow’s milk formula and readily available.

  • Review if child is more than 2 years old, the formula has been given for more than 1 year or greater amounts being given than expected
  • Advise 1-2 tins initially until compliance/tolerance established

  • Encourage breast feeding whenever possible
  • Do not suggest rice milk, goat, milk, sheep milk 
  • Do not use soya milk for secondary lactose intolerance
  • Avoid lactose free formula in secondary lactose intolerance if more than 1 years of age and previously tolerated cow’s milk as these are available over-the-counter eg. ‘Lactofree’ milk (www.lactofree.co.uk)
  • Secondary lactase deficiency - Treat with low lactose/lactose free formula for 4-8 weeks to allow symptoms to resolve.  Rarely symptoms may last up to 3 months
  • Lactase tablets/drops (Colief) taken with milk may reduce symptoms. This preparation is available to purchase over the counter from supermarkets and pharmacies
  • In infants who have been weaned, low lactose/lactose free formula should be used in conjunction with a milk free diet
  • Standard formula and/or milk products should then be slowly reintroduced to the diet
  • In children over 1 year who previously tolerated cow’s milk, do not prescribe low lactose/ lactose free formulae. Suggest use of lactose free full fat cow’s milk, yoghurt and other dairy products which can be purchased from supermarkets (Lactofree® brand)
  • In children under 1 year of age, low lactose/lactose free formula should not be prescribed for longer than 8 weeks without review and trial of discontinuation of treatment
  • Advise on adequate intake of Calcium and Vitamin D to maintain bone health while consuming lactose-restricted diet
When to Refer
  • If symptoms do not resolve when standard formula and/or milk products are reintroduced to the diet, refer to secondary or specialist care.
  • Refer to the Paediatric Dietician if the child is weaned and a milk free diet is required.
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