Guidance For The Clinician In Rendering Pediatric Care

CLINICAL REPORT

Lactose Intolerance in Infants, Children, and Adolescents
Melvin B. Heyman, MD, MPH, for the Committee on Nutrition

Guidance for the Clinician in Rendering Pediatric Care

ABSTRACT The American Academy of Pediatrics Committee on Nutrition presents an updated review of lactose intolerance in infants, children, and adolescents. Differences between primary, secondary,congenital, and developmental lactase deficiency that may result in lactose intolerance are discussed. Children with suspected lactose intolerance can be assessed clinically by dietary lactose elimination or by tests including noninvasive hydrogen breath testing or invasive intestinal biopsy determination of lactase (and other disaccharidase) concentrations. Treatment consists of use of lactase-treateddairy products or oral lactase supplementation, limitation of lactose-containing foods, or dairy elimination. The American Academy of Pediatrics supports use of dairy foods as an important source of calcium for bone mineral health and of other nutrients that facilitate growth in children and adolescents. If dairy products are eliminated, other dietary sources of calcium or calcium supplements needto be provided.

INTRODUCTION
SIGNIFICANT CHANGES IN our knowledge and approach toward lactose intolerance

have occurred over the past quarter century, since the first statement on lactose intolerance was published by the American Academy of Pediatrics Committee on Nutrition.1 Lactose ingestion in certain susceptible individuals can cause abdominal symptoms that are variable and can betreated with dietary restriction or enzyme replacement, depending on the amount of lactose consumed and the degree of lactase deficiency. Pediatricians and other pediatric care providers should maintain awareness of the benefits and controversies related to the consumption of dietary milk products and milk-based infant formula. The lactose content of milk often influences, correctly or not, the ultimatedecision about the use or continuation of milk in the diet. Milk and dairy-product avoidance has a negative effect on calcium and vitamin D intake in infants, children, and adolescents. Other nutrients such as protein make dairy products an important source of nutrition for growing children. This revised statement will update the initial statement of 1978 while incorporating changes from the 1990supplement2 and current state-of-theart relating to lactose intolerance. Recommendations regarding dietary calcium have been updated recently.3 Lactose, a disaccharide that comprises the monosaccharides glucose and galactose, is the primary carbohydrate found exclusively in mammalian milk. Absorption of lactose requires lactase activity in the small intestinal brush border to split the bond linkingthe 2 monosaccharides. A -galactosidase termed “lactase-phlorizin hydrolase” (lactase) accounts for most of the lactase activity in the intestinal

www.pediatrics.org/cgi/doi/10.1542/ peds.2006-1721 doi:10.1542/peds.2006-1721 All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.Key Words abdominal pain, breath tests, calcium, dietary, dairy products, diarrhea, flatulence, lactase, malabsorption, pediatric
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2006 by the American Academy of Pediatrics

PEDIATRICS Volume 118, Number 3, September 2006

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mucosa.4 Lactase is found in the small intestine and localized to the tips of the villi,a factor of clinical importance when considering the effect of diarrheal illness on the ability to tolerate milk. Milk intolerance may be attributed to either the lactose or the protein content. Lactose intolerance can occur among infants and young children with acute diarrheal disease, although the clinical significance of this is limited except in more severely affected children. Symptoms of...