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Got Milk Anyway?
New Guidelines: Kids Who Are Lactose-Intolerant Should Be Offered Smaller Amounts of Dairy Foods to Boost Calcium Intake

By Elizabeth Agnvall
Special to The Washington Post
Tuesday, September 19, 2006

The American Academy of Pediatrics (AAP) has new advice for parents of lactose-intolerant children: Give milk a chance.

New guidelines from the academy recommend that children with lactose intolerance try not only milk but other dairy products such as cheese and yogurt. The guidelines, which pediatricians and pediatric gastroenterologists often consult when deciding how to treat children and advise parents, appear in the September issue of the journal Pediatrics.

While the guidelines' authors received no dairy industry funding, the AAP has received dairy industry support for calcium and nutrition education programs.

"We felt we needed more emphasis on the fact that you could tolerate some lactose even if you are lactose-intolerant," said Melvin Heyman, a pediatric gastroenterologist at University of California, San Francisco, and lead author of the new guidelines. He points out that tolerance varies considerably among individuals.

Particularly worrisome, Heyman said, is the increasing evidence that children and adolescents, especially those who are lactose-intolerant, are not getting enough calcium. Insufficient calcium during the formative years can lead to poor bone development, elevated fracture potential and perhaps an increased risk of osteoporosis later in life.

When children are lactose-intolerant, their digestive systems are not able to break down lactose, a sugar found in milk and other dairy products. Symptoms can include nausea, cramps, gas and diarrhea.

Between 30 million and 50 million Americans are lactose-intolerant, according to the National Digestive Diseases Information Clearinghouse. The condition is uncommon in people of northern European descent, but as many as 20 percent of Hispanics, 60 to 80 percent of blacks and Ashkenazi Jews and 90 percent of Asians and American Indians have it. The problem is more common in adults and teens than in children, though symptoms may begin as early as age 2.

According to the report, complete avoidance of dairy products is not necessary for many lactose-intolerant children. Heyman recommends that children diagnosed with lactose intolerance try small amounts of dairy to see how much they can tolerate without triggering symptoms. Some can drink one to two glasses of milk each day without developing symptoms. Others can tolerate aged cheeses and yogurt more easily than other dairy products.

There is a debate among researchers about whether children's bodies absorb calcium better from dairy products than from supplements or fortified foods. Heyman said it's best for kids to get calcium from dairy, but if they can't tolerate such foods, they need to get it from other sources.

The report points out that lactose-free and lactose-reduced milks are widely available, although they are more expensive than regular milk. It also notes that milks made of rice, soy or other proteins are generally free of lactose, "although the nutrient content of most of these milks is not equivalent to cow milk."

But Nancy Chapman, executive director of the Soy Foods Association of North America, disagrees. Soy milk, she said, is fortified with calcium, giving children as much calcium as regular milk, if not more. She also pointed out that soy milk has no cholesterol, is low in saturated fat and contains the essential fatty acids children need for growth and development.

None of the authors of the AAP guidelines received dairy industry funding. But over the past three years, the AAP has received $100,000 from the National Dairy Council to support the industry group's "3-A-Day of Dairy for Stronger Bones" campaign and a new calcium information brochure. One of the authors of the guidelines, Jatinder J.S. Bhatia, is an unpaid AAP representative on the 3-A-Day advisory panel.

Intolerance or Not?

The new guidelines -- which update a set of standards adopted in 1978 -- explain proper diagnosis of lactose intolerance in children. John Latimer, chief of the division of pediatric gastroenterology and nutrition at Georgetown University Hospital, said these could be useful to many pediatricians.

Often, he said, when a child is sent to him with a suspected diagnosis of lactose intolerance, the problem is actually something else -- a milk allergy, for example.

Latimer said it's important that parents realize infants are rarely lactose-intolerant; usually, the body slows or stops making lactase, the enzyme that breaks down lactose, as the child grows into an adult. "It's likely that symptoms are going to develop slowly over the years," he said.

Many parents giving lactose-free formula to their infants mistakenly think a gassy or cranky baby has lactose intolerance, he said. "I think that in the majority of those infants the lactose restriction is unnecessary and is likely leading to less than optimal calcium absorption," Latimer said.

He said that there is some evidence that lactose aids in calcium absorption and that infants may not absorb calcium as well from formulas that are lactose-free as they do from milk or regular formula.

I Scream, Etc.

Elizabeth Rose, a public relations consultant who lives in the District, said she started to notice a pattern of discomfort when her daughter Diana Jerome was 4 or 5 and began attending birthday parties. After a feast of chocolate milk, pizza and ice cream, "she would just be doubled up on the floor in pain," Rose said.

Rose said her daughter usually had no negative reactions to just one slice of pizza or a couple of sips of milk, but add the ice cream and Diana would come down with stomachache and painful gas. The problem wasn't severe, Rose said, but she did work with some other parents at Georgetown Day School to add Lactaid milk to the lunch menu.

Rose said her daughter, now 12, sets her own limits. She drinks Lactaid skim milk and eats some cheese and a little ice cream, but not on the same day. This is precisely what the new guidelines suggest.

Paul Weiner, a pediatrician with the Pediatric Care Center in Bethesda, said most parents of his patients are already doing just that. He counsels parents of kids who have chronic stomachaches with loose stools and gassiness to avoid dairy for two weeks to see if symptoms go away. If they do, he recommends reintroducing dairy slowly.

"I'll tell them to give smaller amounts, try things like cheese and yogurt," Weiner said.

Although there is a definitive breath hydrogen test for lactose intolerance, Weiner said it's not easy to give because the patient must first drink a liquid with high levels of lactose and then have his breath measured over a two- to three-hour period. Usually a gastroenterologist, not a pediatrician, administers the test.

Pediatricians in his practice already recommend some dairy for lactose-intolerant kids. He said calcium-fortified orange juice is also good, although doctors are trying to steer kids away from sugar-heavy juices. The antacid Tums has a lot of calcium, though some children resist taking the tablets.

The truth is, he said, regardless of guidelines and pediatricians' advice, most parents are pretty savvy about what makes their children hurt.

"Most of the parents have figured it out," Weiner said. ยท

Elizabeth Agnvall last wrote for the Health section about teenagers' future expectations. Comments:health@washpost.com.

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