This site is intended only for the use of UK Healthcare Professionals

The prevalence of lactose intolerance in children with non-IgE-mediated gastrointestinal cows’ milk protein allergy (CMA)

Cows' Milk Allergy

31/03/2021

The prevalence of lactose intolerance in children with non-IgE-mediated gastrointestinal cows’ milk protein allergy (CMA)

Written as an E letter to the article: Differentiating milk allergy (IgE and non-IgE from lactose intolerance: understanding the underlying mechanisms and presentations.

Other Contributors:
Ana-Kristina Skrapac, Dietitian, Chelsea and Westminster
Claire De Koker, Research Dietitian, Stellenbosch University
Adriana Lozinsky, Gastro Research Fellow, Great Ormond Street
Heather Godwin, Research Nurse, Great Ormond Street
Kate Reeve, Paediatric Nurse, The Royal London
Helen Prunty, Chemical Pathologist, Great Ormond Street
Samantha Marshall, Dietitian, Hinchingbrooke NHS
Neil Shah, Consultant Gastro, Great Ormond Street Hospital

Study Rationale	Use of lactose containing formulas in non-IgE-mediated CMA remains highly debated because of concerns related to brush border damage in children with cows’ milk associated enteropathy¹ ESPGHAN guidelines have suggested that a hypoallergenic formula without lactose might be useful until normal absorptive function of the mucosa was regained² The prevalence of concomitant lactose intolerance in non-IgE mediated CMA has never been studied
Study Design	Multicentre prospective observational study
Subjects	Children <2 years of age (average age was 4.5 months) With gastrointestinal symptoms of suspected non-IgE-mediated CMA Not on a hypoallergenic formula at the time of diagnosis
Methods	Lactose loading dose (1g/kg) administered prior to commencing cows’ milk protein elimination diet Collected the first stool produced (frozen at -18°C) Stool chromatography performed at Great Ormond Street Hospital Symptom questionnaire before and after 4 weeks of cows’ milk elimination diet
Results	20 children were recruited and 8 stool samples were obtained within protocol specifications Lactose was not detected in any stool sample of children in this study

Discussion

Although numbers were small, this study suggests that lactose intolerance is not common in non-IgE-mediated CMA

It highlights that hypoallergenic formulas containing lactose, in the absence of breast milk, should be considered, especially as lactose has benefits including:

Increased palatability in hypoallergenic formulas^3,4
Increased mineral absorption of calcium and other minerals^5,6
Development and maintenance of a healthy gut mucosa and microbiome^2,7,8
Indirectly enhances the immune system⁹

Reflective Questions

What did you learn from the study?
How does this study compare with your current practice?
Will this alter your current practice?

Link to E letter

http://bjgp.org/content/66/649/e609/tab-e-letters

References: 1. Meyer R. The prevalence of lactose intolerance in children with non-IgE-mediated gastrointestinal cow’s milk protein allergy. Br J Gen Pract. 2016;66 (649) e-letter. 2.

Koletzko S, Niggemann B, Arato A, Dias JA, Heuschkel R, Husby S, et al. Diagnostic approach and management of cow’s-milk protein allergy in infants and children: ESPGHAN

GI Committee practical guidelines. J Pediatr Gastroenterol Nutr. 2012;55(2):221-9. 3. Niggemann B, et al (2008). Safety and efficacy of a new extensively hydrolysed

formula for infants with cow’s milk protein allergy. PAI.; 19: 348- 354. 7. 4. Rapp M, et al (2013). Characterization of an extensively hydrolysed whey infant formula with

a low bitterness. Clin Trans Allergy.; 3(suppl 3): 132. 8 5. Abrams SA, Griffin IJ & Davila PM (2002). Calcium and zinc absorption from lactose-containing and lactose-free

infant formulas. Am J Clin Nutr.; 76: 442-446. 6. Ziegler EE, Fomon SJ (1983). Lactose enhances mineral absorption in infancy. J Pediatr Gastroenterol Nutr.; 2: 288-294. 7.

Szilagyi A (2004). Redefining lactose as a conditional prebiotic. Can J Gastroenterol.; 18(3): 163-167. 8. Francavilla R, et al (2012). Effect of lactose on gut microbiota and

metabolome of infants with cow’s milk allergy. PAI.; 23: 420-427. 9. Waddell L. What do we know about lactose? Complete Nutrition Dec/Jan 2015; 15 (6): 73-78.

IMPORTANT NOTICE: Mothers should be encouraged to continue breastfeeding even when their infants have cows’ milk protein allergy. This usually requires qualified dietary counselling to completely exclude all sources of cows’ milk protein from the mothers’ diet. If a decision to use a special formula intended for infants is taken, it is important to give instructions on correct preparation methods, emphasising that unboiled water, unsterilised bottles or incorrect dilution can all lead to illness. Formula for special medical purposes intended for infants must be used under medical supervision.

Differentiating milk allergy (IgE and non-IgE from lactose intolerance: understanding the underlying mechanisms and presentations.

Other content you might be interested in

Cow’s Milk Allergy in Primary Care

This webinar, hosted by Dr. Helen Evans-Howells, focuses on recognising and managing cow’s milk protein allergy (CMPA) in primary care. It offers an overview of how to effectively work with patients who have CMPA in a community setting. Key learning points include the differences between allergies and intolerances, when to test for allergies and how to interpret results, and insights into the future of food allergies. The session concludes with an informative Q&A session.

SMA Althera and SMA Alfamino - Clinical Evidence Book

WHAT MAKES AN EFFECTIVE SPECIALIST CMA FORMULA? Very few eHFs and AAFs have been shown effective, both in terms of allergy and growth.6,7 At Nestlé Health Science, we set the highest standards for our CMA formulas, SMA® Althéra® and SMA® Alfamino®, ensuring both manufacturing excellence and robust clinical evidence to demonstrate: Proven hypoallergenicity According to guidelines, the gold standard is for hypoallergenic formulas to be tolerated by at least 90% of infants with proven CMA (with 95% confidence interval) in a clinical trial.1,3,6 Growth and development According to guidelines, the gold standard is for hypoallergenic formulas to demonstrate normal growth in a clinical trial, because whilst eHF and AAF nutritional profiles are governed by strict regulations,7,8 there are still significant compositional differences between brands.5 REFERENCES: 1. Luyt D et al. Clin Exp Allergy 2014; 44: 642–672. 2. Grimshaw K et al. Clin Transl Allergy 2016; 6: 1. 3. Koletzko S et al. JPGN 2012; 55(2): 221–229. 4. Muraro A et al. Allergy 2014; 69(5): 590–601. 5. Meyer R et al. EMJ Allergy and Immunol. 2017; 2(1): 46–51. 6. Chauveau, A. et al. Pediatr Allergy Immunol. 2016; 27(5): 541–543. 7. Commission Delegated regulation (EU) 2016/128. 8. Commission directive 1999/21/EC

Diagnosing and Managing Cows' Milk Allergy

The aim of this webinar is to aid primary care individuals in the diagnosis and management of cows' milk protein allergy. Evidence suggests that it can take an average of 10 weeks and 4 visits to a healthcare professional to get a diagnosis of cows' milk allergy (CMA).1

Could I recommend a carer adding anything to the formula to make it taste better?

Kate discusses how adding flavours isn’t recommended - she further discusses how formulas containing lactose can taste better and therefore may be tolerated better.

Are there any vitamins or minerals I should be prescribing?

Helen discusses the vitamins and minerals needed with both breastfed infants and formula fed infants both with or with cows’ milk allergy.

The dietary management of Cows' Milk Allergy in Primary Care

A webinar explaining the dietary management of Cows’ Milk Allergy in primary care.

Cows’ Milk Allergy Weaning Guide

The weaning guide contains recipes developed with leading dietitians from across the UK to help your patients' carers prepare milk-free recipes. The weaning guide can help give them confidence, that as their child grows, family meals can be adapted to make them suitable for CMA.

Allergy tests to diagnose cows’ milk protein allergy

Professor Antonella Muraro, Paediatric Allergist, discusses the tests available to help support diagnosing CMA in infants. Filmed 2017.

Weaning with cows’ milk allergy: what does this mean in practice?

Rachel DeBoer, specialist paediatric allergy dietitian, discusses the challenges faced when weaning (complementary feeding) infants with CMA. Filmed in May 2017.

Practical tips for managing feeding aversions in the allergic child

Food allergies can have an impact on eating habits and food intake. This includes CMA where feeding difficulties has been described as a possible feature. Dr Polly James, paediatric clinical psychologist, discusses practical tips for managing feeding aversions in the allergic child. Filmed in May 2017

The Benefits of Human Milk Oligosaccharides (HMO) on Immunity

Human milk contains bioactive components that confer protection on the newborn. These include complex carbohydrates called Human Milk Oligosaccharides (HMO). Research is revealing the full extent of the beneficial properties of HMOs.

Lactose Intolerance: Common Misunderstandings

Lactose intolerance is one of the more common forms of food intolerance and is often confused with cows' milk allergy. This video explains the differences in both symptoms, diagnosis and treatment. It also explains the different types of lactose intolerance.