Many people are confused about the difference between lactose intolerance and cow’s milk allergy. Misunderstood as same condition; the terms lactose intolerance and cow’s milk allergy are used interchangeably and incorrectly. Most likely due to the similarity of symptoms such as bloating, wind and diarrhoea; both being related to drinking milk and alleviated by avoiding it. When I say milk – I mean mammalian milks such as cow’s (including infant formula) goats, sheep and human milk. So, here is the main difference: Cow’s Milk Allergy is an immune system response to milk protein, which drives a spectrum of symptoms affecting the skin as well as the tummy. In the more severe IgE allergic reactions, the mouth, throat and breathing are affected. Lactose intolerance is not an allergy but a physical response due to lack of digestive enzyme lactase required to digest the milk sugar lactose. This blog will give an overview of symptoms, causes and dietary management of lactose intolerance providing further links on products and nutritional information.
Is a normal response to the presence of undigested lactose (milk sugar) in the large intestine. When lactose digestion fails in the small intestine the lactose sugar travels onto the large intestine where bacterial fermentation, responsible for the characteristic bloating, discomfort and wind, takes place. In the presence of large amounts of lactose, water and salts are drawn into the large bowel (by osmosis) causing increased water volume, urgency to go to the toilet and explosive stools. Lactose is found in milk and dairy products like soft cheese and yoghurts. Hard cheeses have naturally low levels of lactose, as do products like butter, margarine and double cream. Adults and older children with established lactose intolerance can typically eat these foods without any problem. Those small amounts of lactose provide food for the friendly lactobacillus bacteria which normal live in the large bowel.
What are the causes of lactose intolerance?
Lactose intolerance itself does not cause damage to the small intestine; rather it’s the result of tissue damage to the intestinal lining which affects lactase enzyme production. A temporary condition in infants and young children, it will resolve as the gut cells turnover and repair themselves. Lactase enzyme decreases progressively with age with around 70% of the world’s population with limited lactase activity. Persistent lactose intolerance is uncommon in infants and young children, due to their high milk intake, which maintains enzyme production. Teenagers however may not regain their lactase activity following small intestinal damage or serious infection. The most common causes of lactose intolerance include:
- Gastro-intestinal infection with characteristic diarrhoea and vomiting
- Allergic inflammation, especially with unresolved non-IgE Cow’s Milk Allergy
- Small bowel bacterial overgrowth eg. in older children, teens
Products and differences in dietary management
It’s important to understand that the nutritional composition of milk alternatives make them unsuitable as drinks for infants and toddlers, but can be a useful addition to solids, when a nutritious fluid is needed to blend or mix. When selecting a milk alternative, always choose one fortified with calcium. Lactose free milks and cheeses made from cow’s milk contain cow’s milk protein, making them unsuitable for those with cow’s milk allergy. Vegan cheeses, whilst lactose and cow’s milk protein free have poor nutritional value and are not fortified with any calcium. A low lactose diet to treat lactose intolerance is usually followed for between 2 and 6 weeks (depending on severity of symptoms) and a cow’s milk protein exclusion for CMA for at least 6 months. Use this guidance on reintroducing lactose back into the diet if you had lactose intolerance but do seek further guidance for Cow’s Milk Allergy in Infancy if feeding is difficult and you are unsure about next steps.
Following a 2 – 6 week low lactose diet to treat lactose intolerance, your child should now be well on their way to recovery from symptoms. Reintroducing lactose back into the diet in a controlled way is the next step. Starting with low lactose foods, then adding in medium and, once you’re satisfied all is being tolerated, finally adding in high lactose-containing foods. Use the guidance below on lactose content of dairy foods to assist you, taking about 2-4 weeks, gradually increasing, will do several things:
- stimulate production of lactase, the small intestinal digestive enzyme that digests lactose
- help establish and then increase the amount of dietary lactose that is tolerated
- assist in the build up and return of normal lactase production in the small intestine
Re-establishing tolerance to lactose
Re-establishing tolerance to lactose varies from child-to-child, depending on age, habitual diet and degree of severity. Because infants and young children are more dependent on a high milk diet, the lactase enzyme returns more readily and lactose intolerance is usually temporary. Resumption of a normal diet is somewhere between 2-6 weeks for most infants and children. Referred to as secondary lactose intolerance this is often the result of nasty gut bugs like rotavirus, or can be secondary to small intestinal damage caused by untreated cow’s milk protein allergy or coeliac disease. Individuals including older children and teens may develop primary lactose intolerance or a permanent reduction in lactase enzyme, more typically affecting non-caucasian children and those with a habitually low milk/no milk intake following a similar route via infection of small intestinal irritation. Amounts of 2 – 4g lactose per day are usually well tolerated despite the lack of lactase enzyme. Instead lactose is digested by the lactobacillus bacteria, naturally residing in the large intestine.
Other points worth noting about lactose intolerance and reintroduction
Special care with infants
Formula fed babies with lactose intolerance, need a lactose free formula. Lactose intolerance may also occur in breast-fed babies but is less common; only in very rare congenital primary lactase deficiency would there be a need to stop breast feeding and use a lactose free formula. What is important, is to correctly identify if cow’s milk allergy are the cause of the symptoms, to ensure that infants get the right dietary treatment. Products in the shops vary enormously in nutritional composition, and are not suitable to drink because of poor nutritional quality.
Lactose content of dairy foods
|Very Low Lactose
< 2g per portion
2-4g per portion
4-6g per portion
|The foods in this group contain very low amounts of lactose and are tolerated by most people with lactose intolerance. If consuming these foods does not give any symptoms, try medium lactose foods per portion.
||Continue to introduce lactose containing foods, including foods with medium lactose. If symptoms return, go back to the previous tolerated stage for 2 weeks and try again.
||In addition to very low and medium lactose content foods, continue to introduce lactose-containing foods, including one portion from the high lactose category.
|Most hard cheeses have very small amounts of lactose and are unusually well tolerated. Eg. cheddar, red leicester, caerphilly, stilton, parmasan
||Cheese spread, cottage cheese, soft cheeses eg. ricotta, marscapone, dolchelate
||Cheese spread, quark
|Yoghurts & fromage-frais 60g
|Greek yoghurt, Goat’s yogurt, all yoghurts and fromage-frais
||Yoghurts and fromage-frais, Low fat fruit yoghurts, Organic whole milk yoghurt
||Natural whole or fruit yoghurt, Low fat natural yoghurt, Diet/low calorie yoghurts
|Dairy desserts & creams 2oz
||4 – 6oz
|Half fat cream, Single, Double, Whipping, Clotted cream, UHT Spray Cream, Fresh Cheese Cake
||1 scoop ice cream, Frozen cheesecake, Trifle with cream, 1 chocolate mousse
||2 scoops ice cream, 10mls Angel Delight, 150g tinned rice pudding, 100mls Custard
|1 x small slice cake, 4 chocolate digestives, 1 chocolate coated biscuit eg. 2 finger kit-kat, 100g egg custard tart
||1 milk chocolate bar, 125mls whole milk, 70mls evaporated milk, 1 tblsp skimmed milk powder, 40mls condensed milk
Infants and children need good sources of calcium in their diets on a daily basis. Calcium absorption in the gut is variable and ranges from 25-50%, increasing when intake is low and reducing when intake is high. Plenty of foods rich in calcium are especially important throughout infancy to support the rapid bone growth and bone mineralisation that occurs at this time. The uptake of calcium by bones is then regulated by Vitamin D, with Vitamin D deficiency limiting bone mineralisation even in the presence of adequate calcium. Growth spurts during infancy and childhood, from a surge in growth hormone provides a boost to calcium absorption, which further strengthens bone mineralisation. Absorption of calcium from breast milk is very efficient at around 66% and from formula milk around 40%. For all infants and young children offer them calcium rich foods every day.
- Dairy products like milk, cheese and yoghurt are the UK’s best sources of calcium for infants and young children
- Calcium is also found in tinned fish, nut butters, tahini or sesame seed pulp, hummus, figs, dates, and green vegetables
- White wheat flour is fortified in the UK with 120mg Calcium per 100g
- Water in areas of hard water like Cambridge contains 120mg calcium per litre
- For all children with cow’s milk allergy, take care to offer calcium enriched products, checking sources of other valuable nutrients such as protein, iodine, Vitamin D as well as overall calories
- Prolonged poor calcium intake will lead to brittle bones that break more easily, both in childhood and in later adulthood
- Exercise and weight bearing activity will also strengthen bone
- Have a quick check on recommended intakes to check if your child is getting enough calcium
- Download the portions of calcium rich foods below
- Infants and young children need a Vitamin D supplement containing a minimum of 10ug daily until 5 years and thereafter for a minimum of the 6 Winter/Spring months to maintain good levels
- Daily calcium needs during infancy are 525mg
- 5-600mls formula provides the majority of calcium during infancy
- Breast fed infants depend on mum’s diet, and a calcium and vitamin D is advisable for mum
- Daily calcium needs during early years are 350-450mg; provided by 3-4 portions of calcium rich foods
- Daily calcium needs during primary school are 450-700mg; provided by 4-5 portions of calcium rich foods
- For all children with cow’s milk allergy, take care to offer calcium enriched products, checking sources of other valuable nutrients such as protein, iodine, Vitamin D as well as overall calories.
A balanced plate, palate and healthy eating for school children means eating a wide range of foods from all of the food groups as shown in the Eatwell Guide. Children from age 5 until 11, learn about healthy eating at school as well as at home. What and how they eat at school is an important part of their learning. As children grow, their needs for key nutrients change, although calcium and iron continue to be a priority for maintaining growth and development. A healthy weight can be achieved by getting the balance between energy intake from food and spending energy in physical activity. 3 top priorities and 15 top tips for a balanced plate for primary school children:
Don’t skip breakfast
- Eating breakfast improves concentration and behaviour during the school day
- Start the day with a wholegrain breakfast cereal or toast with milk or natural yoghurt plus fruits or a small glass of fruit juice. A boiled or poached egg with toast is a good alternative
- Breakfast in associated with maintaining a healthy weight and not with weight loss and helps to avoiding snacking on high sugar and fat snacks like crisps, biscuits and confectionery
- Breakfast clubs at school can provide a healthy breakfast
Eat three meals a day; breakfast, lunch and dinner
- A routine of three meals per day help provide the energy and nutrient needed
- Make sure each meal includes at least one portion of fruit, vegetables or salad
- Include starchy foods such as pasta, rice, wholegrain bread or potatoes with their skins
- Choose a protein foods rich in the minerals iron and zinc eg. meat, chicken, fish, eggs, beans, nuts
- Include at least 3 portions of dairy foods or alternatives as a source calcium
- Snack sensibly and limit sugars
- Sugar contains “empty” calories and causes dental decay. Added sugar is found in many foods like soft drinks, breakfast cereals and snacks but also occur naturally in fruit juice, smoothies and honey.
Avoid sweets and sweetened fizzy drinks
- Swap any soft drinks for water
- Choose lower sugar varieties of milk drinks and smoothies
- Change to no added sugar cereals containing more whole-grains
- Offer fruit as a snack after school when kids are hungry or a more substantial snack if doing extra sports or the evening meal is a long way off
Need further advice? Contact Carine to make an appointment.
Helping kids get 5 a day, whatever their age, need not be a big stress. Try also to remember that although it’s a parents remit to provide a balanced diet; including 5 a day, it’s a child choice to eat it. Never force; always reinforce – the positive. Positive associations really help kids to develop good relationships with food. I’ll never forget when my 6-year-old daughter, after much persuasion, got two rabbits. They munched and munched – very cute – but it really helped her to nibble and munch her way through lots of green beans! Keep it fun; keep it light.
- Always have some fruit or dried fruit with breakfast cereals
- With cooked breakfasts try mushrooms, tomatoes or baked beans
- Always offer/have at least one vegetable and one fruit at the midday and evening meals
- Crunchy raw vegetables like carrot sticks or cucumber slices are popular in lunch boxes and with cold meals
- Stir fried vegetables are usually more popular than boiled vegetables. Try courgette, peppers, aubergine, cabbage, cavolo nero, cauliflower and broccoli
- For simple puddings, serve fruit with yogurt, fromage frais, custard or ice cream
- Younger children often eat more fruit when it is cut up for them
- Choose cooked puddings containing fruit, eg fruit crumbles, tarts and soufflés
- If serving cake or biscuits always serve them with some pieces of fruit
Food additives can exacerbate atopic asthma in sensitive children. Here is a list of the worst offenders.
|Orange food colouring
||Soft drinks, sweets, jams, snack foods, packaged soups, tinned fish
|Yellow food colouring
||Soft drinks, Baked goods, sweets, snack foods, ice-cream
|Red food colouring
||Meat, sausages, marinades, fruit drinks, jam, jelly, sauces, sweets
||Soft drinks, dried fruits, beef burgers, sausages
||Soft drinks especially orange, salad dressings, pickles, fruit based sauces, naturally found un cinnamon, cloves, cranberries, prunes
||Ready meals, soups, sauces, meat products, dried pasta and noddle snacks, Chinese food
10 tips to help children maintain a healthy weight
- Avoid sweets, crisps and all fizzy drinks
- Choose snacks lower in added fats and sugars
- Get more active as a family, walking more, playing outside games
- Reduce time spent in slouchy activities such as TV or computer games
- Help young children to get enough sleep – set a sensible bedtime and stick with it
- Eat breakfast – you are less likely to overeat later in the day when overcome with hunger
- Don’t add junk to packed lunches
- Structure main meals for children; this helps them eat well and snack less
- Avoid daily puddings, choosing fruit or yoghurt as a rule – you can always have pudding or cake at the weekend!
- Help kids get their 5-a-day
Getting your kids involved with their food really helps develop healthy eating in the early years. Whatever works is good – fun food play, stirring the big cooking pot, baking something nice or planting some seeds and growing your own. It also means eating a wide range of foods from all 5 food groups. From age 1 – 4 little ones need to grow their experience with all types of food; they are already familiar with milk, so even although its a good source of calcium, do be careful not to rely on it too much. Milk drinking can displace eating other foods and also limit the practice of eating that helps to extend their overall range of foods. Nutrient needs in the early years are around 4-5 times higher for most nutrients, and yet their tummies are still so small.
Learning about food happens at home with family – but also within their friends at play group and nursery. Young children need plenty of calories and nutrients, but their tummies are still small! With three meals a day plus 2 – 3 planned snacks, especially when you want to choose the best options for your child, it needs to be organised! Check out this fantastic resource on healthy snacks from First Steps Nutrition. For healthy eating in the early years, salt, sugar, fats and fibre recommendations are quite different.
- Offer fruits and vegetables every day; 5 child size portions (fits in their hand) is about right.
- This will help them develop preference for low sugar options, and educate their palate
- Develops that pincer grasp with berry fruits, grapes, segments of citrus
- Separate colourful hand-size veggies on their plate and encourage self feeding
- Cut up into bite-size chunks or sticks to makes it easier to eat
- Fruit juice is OK in moderation, but acid can affect teeth; once a day is recommeded
- See this eye opening report on fruit snacks for children if you dare!!
- Include a range of healthy fats, oils and foods containing fat for healthy brain and nervous system.
- Little ones needs about half their calories from fats, rather than the 1/3 that adults need
- Fats provide fat soluble vitamins A, D and E to help protect the body
- Fats are tasty, make you feel full and are a good source of the calories they need
- Try avocado, olives, cheese chunks, smoked salmon, nut butters, fish sticks, full fat hummus
- Get the balance right with fibre – Think Goldilocks! – not too much not too little, but just right!
- Some high fibre foods help children to develop good toilet habits and avoid constipation
- Provide some lower fibre carbs too – they don’t have to be very processed
- Great source of B vitamins for making energy easy and economical to buy
- Try oats, vary your grains, nuts and seed products, choose breakfast cereals wisely!!
You know what to do about salt and sugar! Aim not to develop a preference for salty and very sweet foods. It matters now and it matters later …
Nutrient needs in the early years are 4 – 5 times greater than for an adult. Some nutritional knowledge is therefore essential in selecting a nutritious diet for your youngster. Eating a range of foods from the main food groups, with three meals a day plus 2 – 3 planned snacks means that food is never far from a mum’s mind! In a recent survey from the Infant & Toddler Forum, 73% of mums felt that their toddler wasn’t eating enough, yet childhood obesity is increasing. Think quality NOT quantity.
Essential fats for brain growth and development
Young children need a range of healthy fats and oils for developing tissues in the brain and nervous system. Fats provide a concentrated source of energy, to help get enough calories into smaller tummies. Whole milk (4%) and dairy products should be used unless excessive weight gain is a problem. They contain more vitamins A and D needed for developing bones, muscles and the immune system. The body cannot made it’s own essential fats so depend on a dietary supply. Choose oily fish every week, nut butters, avocados, seeds and whole-grains cereals to provide those essential fats.
Getting the balance right with fibre
Too much fibre for young children can fill them up, reduce absorption of important nutrients like iron and zinc and reduce their appetite. On the other hand fibrous foods are less processed and contain their own essential nutrients; feed the good bacteria in our lower gut to maintain good gut health. Think Goldilocks! – not too much not too little, but just right! Include small portions of pulses, beans, nuts and seeds regularly.
Swap the sugars
Sugar contains “empty” calories and causes tooth decay. Simply avoid it where possible.
Should I use salt?
Too much added salt is not suitable for young children. Most dietary salt is found in pre-packed foods, convenience foods and savoury snacks like crisps. Home cooked food is naturally lower in salt, so helps to keep salt intake lower.
Need further advice? Contact Carine to make an appointment.
How confident do you feel about portion sizes for your toddler? In a recent survey from the Infant & Toddler Form, 73% of mums felt that they their toddlers were not eating enough. Toddlers appetites vary depending on how they feel, what’s on offer, how tired they are Some days there is no feeding them. Fussy eating and food refusal during the toddler years is a great cause for concern with parents, but it is a normal part of childhood development. Toddlers can be be tricky feeders at mealtimes, with food refusal gaining attention and often resulting in a battle of wills. Use this portion size guide to help guide you.
Can giving toddlers large portions cause excess weight gain and obesity?
Large portion sizes for toddler meals are linked to obesity development says another recent survey. There is however no single cause for obesity, just as there is no single correct portion size for toddler. Meal times are good opportunities to eat nutritious food, and portion sizes of nutritious food should not be limited. Foods high in fats and sugars, deep fried and battered should be kept to a minimum, as these are very high in calories and do contribute to obesity if eaten regularly. But, it’s often the food eaten outside of mealtimes that is high in calories with low nutritional value. For all you worried mum’s out there, its good to know that nutrient deficiencies are rare in the UK, and children who are eating a variety of foods from the 5 food groups will not need a vitamin supplement.
Need further advice? Contact Carine to book an appointment.