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Tag: lactose intolerance

good sources of calcium

what’s the difference between lactose intolerance and cow’s milk allergy?

26th November 2019 / / 1 Comment

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.

Lactose Intolerance
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.

alternative milks

reintroducing lactose back into the diet

30th October 2019 / / 0 Comments

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

 Medium Lactose

2-4g per portion

 High Lactose

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.
Cheese 1oz
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 125g Larger portion
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 Larger portion
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
Hidden milk
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

nutritional composition of milk alternatives

25th September 2019 / / 0 Comments

If you have a child who has lactose intolerance or cow’s milk allergy, chances are you need to think about the nutritional composition of milk alternatives. Cow’s milk and its products are good sources of calcium and trace elements like iodine in the UK diet.  As someone who takes nutrition seriously, a Paediatric Dietitian and mother of 3 growing teenagers, I would like to point out that the nutritional composition of milk alternatives available in our shops is shockingly poor.  It does not serve consumers well, has insufficient nutrition for infants, children or teens, and for those who depend on the nutrients milk would normally provide.  The missing nutrients and their physiological roles are as follows:

  • calcium – for growth and maintenance of strong bones, blood clotting
  • iodine – for neurological development during pregnancy, control of metabolism, thyroid function
  • Vitamin B2 – for healthy skin, eyes and nervous system, releasing energy from food
  • protein – for growth and repair of all body tissues, immune function
  • Vitamin B12 – assists in maturing red blood cells, absorption of iron
  • lactose – the milk sugar – food for the beneficial lactobacillus genus of bacteria, maintenance of a healthy intestinal microbiota

Exciting range of nut milks
I was quite excited to see such an explosion of nut milks now routinely available; and on researching this recently, felt somewhat aggrieved to see such poor nutritional composition.  Nuts are one of nature’s most incredibly nutritious foods – high in calories, protein, essential fats, minerals like zinc, calcium, iron and magnesium as well as B vitamins. They are also (currently) fairly conflict-free and sustainable. There are not many foods you can say that about! Unfortunately none – and yes I do actually mean NONE – of that goodness is retained in the resultant, washed out and expensive product marketed as milk.  Some have no calcium, no protein, no minerals no vitamins, and poor calories. Mil for mil they are 7 times the price.

Compare the nutritional composition of milk alternatives in the chart below, and take care to ensure that you choose ones with higher calories and protein for young children, ensuring they are fortified with calcium, and where possible Vitamin D and other vitamins.

Type of Milk Calories Protein Calcium Vitamin D Extras
Whole Cow’s Milk 69 3.3 120 Low Wide range of nutrients
Cow’s Milk formula 66 1.3 65 1.2 Full range of nutrients
Mature Breast Milk 67 1.3 35* Varies Wide range of nutrients
Goats Milk 70 2.8 120 Low Wide range of nutrients
Arla Lactose Free Milk 56 3.3 120 Low Wide range of nutrients
KoKo unsweetened 16 0.2 120 0.75 Nothing
Oatly Original 46 1.0 120 1.5 Vitamins
Innocent Hazelnut Milk 72 1.0 0 0 Nothing
Innocent Almond Milk 37 1.4 0 0 Nothing
Alpro Soya Original 42 3.3 120 0.75 Vitamins
Alpro Cashew Milk 23 0.5 120 0.75 Vitamins
Alpro Soya Growing-Up 1-3 64 2.5 120 1.5 Iodine, Vitamins
Rice Dream plus calcium 50 0.1 120 0.75 Not for <5years
  • absorption of calcium from breast milk is extremely efficient, but infants needs for calcium from 6-12 months through are high.  Check out  good sources of calcium if weaning your cow’s milk allergic infant.
diagnosis for cow's milk allergy

confirming a diagnosis of cow’s milk allergy

19th March 2018 / / 0 Comments

Confirming a diagnosis of Cow’s Milk Allergy is the 2nd in this 5-part blog series about Cow’s Milk Allergy in Infancy and is best read following identifying the symptoms of cow’s milk allergy.

Common symptoms of CMA eg. loose stools, pain/colic and reflux frequently occur in babies without CMA.  This makes the diagnosis a bit tricky.  CMA is more likely when there are at least two significant problems present which impact the baby’s wellbeing, growth or feeding.  In the absence of reliable tests, the following diagnostic pathway is used by GP’s, Paediatricians and Paediatric Dietitians in order to confirm (or exclude) a diagnosis of cow’s milk allergy.

  1. An allergy focused clinical history including questions about family and individual atopy (eczema, asthma, hayfever), infants feeding and growth history, signs and symptoms focused on the gut, skin and respiratory systems, details of previous management.
  2. If the history is suggestive of Cow’s Milk Allergy, determination of whether symptoms are likely to be IgE (immediate) or non-IgE (delayed) and referral for allergy tests if IgE suspected.  The severity and timing of reactions being important. A 2-4 week trial of a strict cow’s milk exclusion diet with suitable formula, or maternal avoidance if breast feeding, with advice on supplementation of 1000mg Calcium + 10ug Vitamin D.
  3. Resolution of symptoms during the exclusion followed by obvious and confirmed relapse on re-introduction (formula or maternal consumption if breast-feeding) confirms the diagnosis.
  4. A diagnosis can only be made following a planned reintroduction of cow’s milk, which has resulted in the relapse of symptoms, mostly commonly in in 4 out of 5 infants following this diagnostic pathway.

Confirming a diagnosis of cow’s milk allergy in a timely manners and ensuring the most appropriate treatment and support is important for a variety of reasons.  For non-IgE CMA (delayed reactions) – gut symptoms resolve, pooh habits improve, tummy’s are more comfortable, eczema improves, feed volumes increase, infants are happier feeding, positive associations with feeding are made.  All of which support growth & feeding development, which in turn makes the next steps in feeding ie. weaning to solids, run much more smoothly.  Sleep is improved for all and parents anxiety is reduced – mostly!  So, just a few things then! Timely treatment also reduces risks to the baby of developing other food allergies, which are related to the presence of atopic conditions such as infant eczema.

Non-IgE Cow’s Milk Allergy is the first and most common food allergy to develop, affecting around 5% of infants in the UK, both in exclusively breast-fed and bottle-fed babies, and usually treated by the GP.  A diagnosis can be made anytime during the first year, and will depend on the severity of symptoms, other co-exisiting conditions eg. eczema and feeding or growth related difficulties.

Next Treatment options for Cow’s Milk Allergy

 

cow's milk allergy in infancy

identifying the symptoms of cow’s milk allergy

7th March 2018 / / 2 Comments

Identifying the symptoms of Cow’s Milk Allergy is the 1st part in this 5-part blog series about Cow’s Milk Allergy in Infancy.

Cow’s Milk Allergy (CMA) is an immune reaction to the proteins found in cow’s milk affecting 1 in 20 infants in the UK.  There are two distinct types of cow’s milk allergy: IgE reactions with immediate onset of symptoms and non IgE reactions with delayed onset.  In both types, symptoms range from mild-moderate to severe and persisting with potentially life-threatening reactions such as anaphylaxis. The following table will help you in identifying the symptoms of Cow’s Milk Allergy.

Delayed Onset Symptoms

Non-IgE Cow’s Milk Allergy

2 – 72 hours after milk intake

 Immediate Onset Reactions

IgE Cow’s Milk Allergy

Minutes after milk intake
Affecting formula-fed, exclusively breast fed infants or at the onset of mixed feeding/solids Affecting formula-fed infants or at the onset of mixed feeding
Gastrointestinal symptoms may be mild-moderate or severe and persisting
colic, reflux, loose, frequent stools, soft stool constipation, painful wind,  blood or mucous in nappy, food refusal, feeding aversion, poor growth vomiting, diarrhoea, colic
Skin symptoms can be mild-moderate or severe and persisting
itchy, raised red rash, atopic eczema intense itching, erythema (raised red rash), urticaria (flushing, spreading rash), flare up of atopic eczema, angioedema (facial swelling)
Respiratory symptoms are confined to IgE reactions
acute rhinitis (hayfever), conjunctivitis (swelling in and around the eyes) ANAPHYLAXIS

This blog series will focus on non-IgE CMA with delayed onset, which although less severe can be more complex and difficult to diagnose.  This is due to a number of issues: the similarity to other common conditions during infancy such as colic, reflux or loose stools and also the symptoms being mistakenly treated as lactose intolerance. Again this is due to the similarity in gut symptoms such as colic, bloating, discomfort and diarrhoea.  Unlike IgE CMA, there is no diagnostic allergy test for non IgE CMA and because reactions are delayed up to 72 hours after intake, cause and effect is not quite so clear. Lactose intolerance does not involve immune reactions, but results from lack of the digestive enzyme lactase, with malabsorption of the “milk sugar” lactose  causing discomfort and diarrhoea. A lactose free formula (which normally contains cow’ s milk protein) will resolve lactose intolerance but not Cow’s Milk Allergy,

Non IgE Cow’s Milk Allergy in infancy responds extremely well to prompt dietary treatment, with the majority of infants outgrowing their allergy within 6-12 months.  Delays in diagnosis and treatment lead to symptoms becoming severe and persistent, with feeding difficulties and growth faltering more evident.  Identifying the symptoms of Cow’s Milk Allergy early and discussing an allergy focused history with a trained GP or Paediatric Dietitian will assist making a diagnosis and accessing prompt appropriate treatment.

Next Confirming a diagnosis of Cow’s Milk Allergy.

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