This is the current release of the guideline.

All clinical reports and policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

Lactose intolerance

Note: Cow milk-protein intolerance that can occur within the first 1 to 3 months of life is not the subject of this guideline.

Diagnosis
Evaluation
Management

Family Practice
Gastroenterology
Internal Medicine
Nutrition
Pediatrics

Advanced Practice Nurses
Dietitians
Nurses
Physician Assistants
Physicians

• To provide an updated review of lactose intolerance in infants, children, and adolescents
• To discuss differences between primary, secondary, congenital and developmental lactase deficiency that may result in lactose intolerance

Infant, children and adolescents with suspected lactose intolerance

Diagnosis

1. Clinical history
2. Symptom evaluation
3. Hydrogen breath testing
4. Dietary elimination and challenge
5. Stool examination, including fecal pH testing
6. Intestinal biopsy

Note: The lactose-tolerance test was considered but not recommended. The lactose breath test is being considered as a test to augment the hydrogen breath test but is still primarily an investigational tool.

Management

1. Dietary restriction
   • Avoidance of milk and other dairy products
   • Lactose free, lactose reduced milk
   • Lactose free formulas
2. Oral lactase-replacement therapy
3. Calcium supplementation

• Symptom relief
• Calcium intake
• Bone mineralization
• Differential diagnosis

Searches of Electronic Databases

Not stated

Not stated

Not stated

Not applicable

Review

Not stated

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Peer Review

Not stated

Summary

Lactose intolerance has been recognized for many years as a common problem in many children and most adults throughout the world. Although rarely life-threatening, the symptoms of lactose intolerance can lead to significant discomfort, disrupted quality of life, and loss of school attendance, leisure and sports activities, and work time, all at a cost to individuals, families, and society. Treatment is relatively simple and aimed at reducing or eliminating the inciting substance, lactose, by eliminating it from the diet or by "predigesting" it with supplemental lactase-enzyme replacement. Calcium must be provided by alternate nondairy sources or as a dietary supplement to individuals who avoid milk intake.

Conclusions

1. Lactose intolerance is a common cause of abdominal pain in older children and teenagers.
2. Lactose intolerance attributable to primary lactase deficiency is uncommon before 2 to 3 years of age in all populations; when lactose malabsorption becomes apparent before 2 to 3 years, other etiologies must be sought.
3. Evaluation for lactose intolerance can be achieved relatively easily by dietary elimination and challenge. More-formal testing is usually noninvasive, typically with fecal pH in the presence of watery diarrhea and hydrogen breath testing.
4. If lactose-free diets are used for treatment of lactose intolerance, the diets should include a good source of calcium and/or calcium supplementation to meet daily recommended intake levels.
5. Treatment of lactose intolerance by elimination of milk and other dairy products is not usually necessary given newer approaches to lactose intolerance, including the use of partially digested products (such as yogurts, cheeses, products containing Lactobacillus acidophilus, and pretreated milks (Medow et al., 1990; Saunders & Klaenhammer, 2001). Evidence that avoidance of dairy products may lead to inadequate calcium intake and consequent suboptimal bone mineralization makes these important as alternatives to milk. Dairy products remain principal sources of protein and other nutrients that are essential for growth in children.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

Appropriate diagnosis and treatment of patients with lactose intolerance

Not stated

An implementation strategy was not provided.

Living with Illness
Staying Healthy

Effectiveness

Not applicable: The guideline was not adapted from another source.

2006 Sep

American Academy of Pediatrics - Medical Specialty Society

American Academy of Pediatrics

Committee on Nutrition

Primary Author: Melvin B. Heyman, MD, MPH

Committee on Nutrition, 2005 to 2006: Frank R. Greer, MD, Chairperson; Jatinder J.S. Bhatia, MD; Stephen R. Daniels, MD, PhD; Melvin B. Heyman, MD; Marcie B. Schneider, MD; Dan W. Thomas, MD; Robert D. Baker, Jr, MD, PhD

Liaisons: Sue Ann Anderson, PhD, RD, Food and Drug Administration; Donna Blum-Kemelor, MS, RD, US Department of Agriculture; Margaret P. Boland, MD, Canadian Paediatric Society; Laurence Grummer-Strawn, PhD, Centers for Disease Control and Prevention; Capt Van S. Hubbard, MD, PhD, National Institutes of Health; Benson M. Silverman, MD, Food and Drug Administration

Staff: Raymond J. Koteras, MHA

Not stated

This is the current release of the guideline.

All clinical reports and policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

None available

None available

This NGC summary was completed by ECRI on December 7, 2006. The information was verified by the guideline developer on December 22, 2006.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the Permissions Editor, American Academy of Pediatrics (AAP), 141 Northwest Point Blvd, Elk Grove Village, IL 60007.