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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.

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