March 5, 2014 LACTOSE INTOLERANCE IN INFANTS AND CHILDREN(DR.

RAMOLETE)

NORMAL DIGESTION AND ABSORPTION OF LACTOSE Prevalence of Lactose malabsorption in the Philippines
 Increasing prevalence with age
o <12 months old- 19%
o >12 months old- 23%
o >3-4 years old- 68%
o 9-10 years old- 86%

*Milk allergy- more on infants

*Lactose intolerance- more in school children
*in Filipino children- high prevalence

Lactose Intolerance and Genetics

 60% chance of inheritance if one parent is lactose intolerant
 99-100% chance if both parents are lactose intolerant

Lactase Development in the Gut Lactose Intolerance vs. Milk Protein Allergy
 Lactase Lactose Milk-protein
o 40% of infants with significant levels at 34 weeks AOG Intolerance Allergy
o Preterms have diminished levels at birth Non-immunologic reaction +
o Inducible only during the premature neonatal period
More common in older children and +
o Activity is genetically programmed to decline at age 2
adults
years
Can cause severe morbidity +
GI manifestations (abdominal pain, + +
Lactose Intolerance vsMalabsorption
colic, diarrhea)
Skin and respiratory involvement +

Types of Lactase Deficiency

 Primary delayed-onset or adult type
 Secondary lactase deficiency
 Congenital lactase deficiency
 Transient lactase deficiency in the newborn

a. Primary delayed-onset or adult type

 Most common in the general population
**Lactose malabsorption can lead to lactose intolerance.  Autosomal recessive
 Lactase activity declines between 2 and 20 years of age

b. Secondary lactase deficiency

MECHANISM OF DIARRHEA AND GAS PRODUCTION IN LACTOSE
 Most common in children
INTOLERANCE
 Due to intestinal mucosal injury
 Can appear at any age
 Children <2 years more susceptible
o High sensitivity of the gut to infectious agents
o Smaller intestinal surface area
o Reliance on milk-based products

c. Congenital lactase deficiency

 Complete absence of lactase
 Can be fatal if not recognized
 Extremely rare autosomal recessive disorder

d. Transient lactase deficiency in the newborn

 Developmental condition
Consequences of persistent malabsorption  Newborns have a relatively lower level of intestinal lactase
 Common in premature infants
Increased lactose malabsorption

Increased SCFA production Signs and Symptoms of Lactose Intolerance in Infants and Children
Decreased SCFA reabsorption  Osmotic diarrhea
o More common in infants
 Nausea
Inadequate colonic salvage
 Non-specific abdominal pain and cramps
Osmotic Diarrhea  Bloating/colic or gas
Decreased Stool pH o More common in older children
 March 5, 2014 LACTOSE INTOLERANCE IN INFANTS AND CHILDREN(DR. RAMOLETE)

 Borborygmi Mom pregnancy diet No (peanut?) No (peanut?)

o “hunger pains” Exclusive BF 6 months 4-6 months
Mom lactation diet No peanuts (CM, Eggs, No
Fish)
Soy No No
HF instead of CM eHF (consider pHF) Decreased allergenicity
Delayed solids 6 mos- low 4-6 mos
allergenicity
12 mos- CM
24 mos- egg
36 mos- pn/ nut/ fish

Natural History of Food (CM) Allergy

perianal rash  IgE mediated CMA often persists to school age and is a risk factor
for other atopy;
Diagnostic tests for lactose intolerance  Non- IgE mediated CMA, by contrast, is a benign infantile
condition
 Indirect
o Breath hydrogen test
o Lactose challenge Natural History of Food Allergy
o Stool test - Dependent on food and immunopathogenesis
 Reducing sugars(Clinitest tablet) - PREVIOUS STUDIES: 85% Cow’s milk, egg. Wheat, soy allergy remit
 pH (litmus paper) by 3 years
 Direct - RECENT STUDIES: Prospective study from 6 mos – 8 yrs
o colonoscopy
o Median age for tolerance:
o Intestinal mucosal biopsy
 Cow’s milk: 7 yrs 11 mos
 Egg allergy: 6 yrs 6 mos
 Wheat: 7 yrs 2 mos
Treatment of Lactose Deficiency
 Involves one or more of the following approaches:
o Lactose-free diet Risk Factors
o Reduced lactose intake  Allergy in the family is the Most Important Risk Factor for the
 Colonic adaptation to daily lactose feeding Development of Atopic Diseases
o Appropriate choice of dairy food o Both parents atopic with same manifestations: 50-80%
o Delayed gastric emptying time o Both parents atopic: 40-60%
o Probiotics o Either parent atopic: 20%-40%
o Lactase substitutes (B-D-galactosidase) o Neither parent atopic: 5-15%
o One sibling atopic: 25-35%
COW’S MILK ALLERGY
Breastfeeding
PRIMARY PREVENTION  Longer breastfeeding duration (7-9 mos.) was associated with a
lower risk of recurrent wheeze in infants of mothers
o With no allergy or asthma (p=0.02)
U.S. and European Dietary Recommendation for Primary Prevention
o With allergy but no asthma (p= 0.02)
PARAMETERS AAP 2008 ESPACT/ESPGHAN o And with asthma (p= 0.06)
1999: ESPGHAN 2008  Longer breastfeeding (7-9 mos) may reflect protection against
High risk infants Parent or sibling with Parent or sibling respiratory infections
documented allergic affected (1999)  At 7 yrs participants who had been exclusively breastfed and had
disease a history maternal atopy were less likely to have asthma.
Mom Pregnancy Diet Lack of evidence -  OR 0.8 95% Cl, 0.6-1.0), but by 14 yrs. And above, the risk
Exclusive BF Evidence for 3-4 mos 4-6 mos reversed.
(waiting 4-6 mos tied
to introducing solids) Long Term Risk of Food Allergy
Mom Lactation Diet Some evidence of -
 Children who begin with 1 food allergy, specially if it is an IgE-
reduced atopic
mediated allergy, have a very high chance of developing
dermatitis
additional food allergies as well as inhalant allergies.
Soy No No
HF instead of CM HF Decreased allergenicity
(1999)
Delayed Solids Evidence to wait 4-6 Not before 17 wks and
mos; lack of no later than 26ks; no Long Term Risk of Cow Milk Allergy
convincing evidence convincing evidence  Food hypersensitivities, like CMA, particularly due to IgE-
for avoiding specific for delaying mediated reactions are predisposed to develop respiratory
allergenic foods potentially allergenic allergies later in life
foods such as fish, egg o Skin sensitivity to hen’s egg, cow milk, or both in the
(2008) first 5 years of life was predictive of asthma. (odds
ratio: 10.7, 95% confidence interval: 2.1- 55.1; P= .001,
U.S. and European Dietary Recommendation for Primary Prevention sensitivity: 57%, specificity: 89%)
PARAMETERS AAP 2000 ESPACT/ESPGHAN  Allergic sensitization (positive tests) or clinical reactions to foods
1999 in infancy predict the later development of respiratory allergies
High risk infants Biparental, parents, sib Affected parents, sib and asthma.
 March 5, 2014 LACTOSE INTOLERANCE IN INFANTS AND CHILDREN(DR. RAMOLETE)

 Preventive measures may improve symptoms of food allergy, but Most Common Allergenic Foods
the long term prognosis is challenging, since asthma prevalence  Peanuts*
may increase up to 54% in subsequent years.  Eggs
 Milk
Can we prevent the allergic reaction  Wheat
 May depend on the status of sensitization:  Seafood
o Food hypersensitivity at young ages, even though  Fish
transient:  Chocolates
 Increases risk for BA, eczema and AR at 8
yrs. When to reintroduce food
 Seafood- 2 years
 Peanuts and eggs- 3 years old
SECONDARY PREVENTION  Foods with increased histamine
o Chocolates
“Allergic March” o Strawberries
 Natural history of atopy dictates: o Tomatoes
o Atopic sensitization to foods precedes food allergy and
aeroallergen sensitization.
o Food allergy, food and inhalant sensitization precedes
allergic rhinitis and asthma
o AD and infectious asthma precedes atopic asthma
o Infectious asthma precedes atopic asthma
o Nasal eosinophilic and basophilic cell infiltrations
precede AR

MUST KNOW TABLE!!!****

Milk Allergy Lactose Intolerance
Prevalence Low High
Epidemiology Infancy Late childhood
Mechanism Immunology Enzyme lack
Offending agent Bovine protein Bovine, human milk
Manifestation All systemic GIT
(*borborygmi, abdominal
distention, diarrhea,
vomiting)
Risk High Low
Diagnosis Skin test, RAST Screening pH reducing subs
challenge (*pH lower)
Treatment Avoidance Enzyme replacement
Prognosis Outgrow 30%-2yrs Permanent
60%-4yrs
80%-6yrs
Prophylaxis Breastfeeding specific None
formula

Type Source Method Example

Soya bean Soy protein Processed Isomil, Prosobee
Evaporated milk Bovine Heat Carnation
Casein Bovine Partially ProgestemilNutrami
hydrolysate hydrolysed gen
Whey Bovine Partially NAN HA
hydrolysate hydrolysed
Elemental diet Modified Synthesized Pregon
CHONs of amino acids
animals

Allergens
 Milk
o Casein
o Caseinate
o Whey
 Egg
o Ovalbumin
o Ovamucous
 Corn