Chapter 2 Index

A. Evaluation by system:

1. General

2. HEENT

3. Cardiopulmonary

4. GI
--Colic: A Parent’s (and Pediatrician’s) Nightmare

Milk Intolerance vs. Milk Allergy

Introduction: One of the most commonly diagnosed conditions in infants is milk intolerance.

Milk Intolerance includes lactose intolerance, and milk protein allergy.

I.  Lactose Intolerance: Positive family history common. Major differences in different ethnic groups: almost 100% in Southeast Asia.

If parents say that they themselves have never "liked" milk, then it is likely that they are milk intolerant. Can have a complete intolerance in which case symptoms will be induced by any lactose containing food (such as yogurt, ice cream, cheese), or incomplete, in which case just switching milks will be enough to control symptoms.

Milks that contain lactose: 1. Breast Milk; 2. Enfamil, Similac, Gerber, Carnation

Milks that do not contain lactose: 1. Lacto-free; 2. Prosobee, Isomil; 3. Nutramigen, Pregestimil, Alimentum

Symptoms of lactose intolerance in infants and children:

1. Irritability: from gas pains; can start in infancy but more likely to show up in older children.
2. Bloating and distension
3. Diarrhea and increased spitting up
4. Sleeplessness: more related to milk protein allergy.
5. In older children: recurrent abdominal pain
6. In adults, relationship with irritable bowel syndrome and with osteoporosis (dec intake)

Diagnosis of lactose intolerance: usually trial and error, but can be diagnosed by the breath hydrogen test.  Usually available only after consultation with gastroenterologist. This test is based on higher amounts of hydrogen in the breath due to activity of enteric bacteria producing it in those with lactose intolerance. Normal children absorb the sugar in the small int.

II.  Milk Protein Allergy: Often associated with SOY allergy. An IgE mechanism for some children (those better off with soy than predigested formulas), but not demonstrated in most.  No precise mechanism of immunological rxn described.

Symptoms: In infants, symptoms can be restricted to those of lactose intolerance, but can also include the following:

1. Severe abdominal cramps: may show up only as a sleep disturbance.
2. Bloody diarrhea: can be microscopic or gross blood.
3. Vomiting severely.
4. Enteropathies: varying combinations of malabsorption, steatorrhea, and hypoalbuminemia.
5. Heiner’s Syndrome: pulmonary hemosiderosis with pulmonary infiltrates.

Diagnosis: Elimination, re-introduction with return of symptoms.  Skin testing: IgE: not always helpful.  RAST tests: for soy unreliable.  No advantage over skin testing.

Treatment: Because of high correlation with soy allergies, it makes sense to switch children from whatever formula they are on to a predigested formula rather than a soy: Pregestimil, Nutramigen or Alimentum. If this not tolerated, then consider goat’s milk - but must supplement folic acid because of megaloblastic anemia.  Should boil goat’s milk first because of brucellosis.

Recommendation: Do not get in the habit of switching formulas around because of parental concern over gas pains.

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Department of Pediatrics  |  Medical College of Georgia
Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004