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Ask Dr. Sue
LACTOSE INTOLERANCE
Dear Dr. Sue,
My daughter is lactose intolerant, just like her father
and his mother. I’m concerned about getting enough
calcium into her once she’s no longer on formula.
(My husband won’t drink soy milk, so I’m thinking she
won’t either.) I’m assuming she’ll be lactose
intolerant for life. She drinks soy formula now and is
doing much better.
Dear Mother,
I seriously doubt that your daughter is lactose
intolerant, and you’ll see why in a moment. It
sounds like your baby had some sort of reaction when she
drank one of the cow’s milk formulas, and she was
switched to a soy formula and the symptoms resolved.
Or she may have even had symptoms with breastfeeding and
improved when you stopped breastfeeding and changed to a
soy formula.
There are several types of reactions that
babies can have to milk. First of all, symptoms of
fussiness and discomfort in breastfed infants can be due
to improper breastfeeding technique. If babies do
not fully empty one breast during each feeding, they
will receive too much lower fat foremilk and not enough
higher fat hindmilk. This low fat milk causes the
stomach to empty very quickly so that a large amount of
lactose is dumped into the intestines at one time.
Even though these infants produce a normal amount of the
enzyme that breaks down lactose, this huge burden of
lactose can cause green, watery, loose stools and a lot
of discomfort. When they are encouraged to fully
empty one breast they receive more calories and more
fat, and lactose is delivered to their intestines more
gradually, which often solves the problem.
Some babies, whether breast or bottle fed, are cow’s
milk intolerant. This has nothing to do with
lactose (milk sugar), but is thought to be a reaction to
milk protein. Cow’s milk protein in the mother’s
diet does end up in breast milk in sufficient amounts to
cause symptoms in an intolerant baby. Babies being
fed regular formulas, which are made from cow’s milk,
are receiving large amounts of cow’s milk protein.
It is believed that about 2 to 7% of infants have this
problem, which unlike lactose intolerance tends to go
away. (Many babies outgrow cow’s milk intolerance
by the age of six months, even more by a year of age,
and nearly all by the time they are two.) Many,
but not all, babies that are intolerant to cow’s milk
are also intolerant to soy - approximately 20 to 30%.
This means, though, that the majority of babies with
this problem do just fine when there is no longer any
cow’s milk protein in their mother’s milk, or, in the
case of formula fed infants, when they are switched to a
soy formula. For those who react to soy, other,
more specialized (and more expensive) formulas are
available.
Actual allergy to cow’s milk protein is less common than
cow’s milk intolerance. About 2% of all infants
are truly cow’s milk allergic. When a food allergy
occurs, the immune system is turned on against something
that it considers an invader. The immune reaction
can involve the whole body (including the heart, the
lungs or the skin), or it can be localized to the
stomach and/or the intestines. The three most
common foods that cause allergies are cow’s milk
protein, soy protein and egg white. Nearly 50 % of
babies that are truly allergic to cow’s milk protein are
also allergic to soy. (Remember, these foods can
pass into the baby through breastmilk.) Symptoms
of food allergy can include vomiting, fussiness,
unwillingness to eat or the opposite - what seems like
ravenous hunger. Babies who are milk allergic may
pass blood in their stools, which are often quite
watery. Occasionally milk allergic babies can have
problems with wheezing, a constant stuffy nose or
difficult to treat eczema. Quite rarely, milk
protein allergy can even lead to anaphylaxis, the
overwhelming allergic response that can lead to shock
and death. Even true milk allergy is usually
outgrown between 6 months of age and entry into school.
(Fewer than 0.1% of school age children are allergic to
milk.)
So far it sounds as if your daughter could fall into
either one of the above categories, though
statistically, she is more likely to be milk intolerant
than milk allergic. Your family history may be
helpful here; if others in the family have had hives or
other clearly allergic symptoms brought on by a food,
then food allergy would be a strong possibility.
Now let’s look at the likelihood of true lactose
intolerance. Lactose intolerance occurs because an
individual does not make enough of the enzyme lactase,
which is necessary to break down the milk sugar,
lactose. Thankfully, lactose intolerance is quite
rare in children under two or three years of age.
If it was not rare, the human race would have been in
trouble before commercially prepared formulas were
available, since breastmilk contains lactose, and babies
who are lactose intolerant usually lose weight and do
very poorly. (The American Academy of Pediatrics
states that infants with congenital lactase deficiency
would not have been expected to survive before the 20th
century.) In those rare cases in which a healthy
full-term baby is born with lactose intolerance, it is
obvious that something is wrong within a few days after
birth (as soon as the mother’s milk begins coming in, or
as soon as he is fed cow’s milk formula).
There are three situations in which
lactose intolerance is not rare, though. First,
premature infants usually do not make enough lactase
until at least 34 weeks gestational age, and sometimes
until they get close to their original due date.
These babies frequently require supplementation of
lactase, or feeds that have a lower lactose content.
Second, after a bout of severe diarrhea it is not
uncommon for temporary lactase deficiency to occur, due
to injury of the lining of the intestine where lactase
is found. This is usually a relatively mild
problem, and natural healing takes place fairly quickly,
with only a few extra days of loose stools and crampy
stomach pain to hint at the problem.
Third, lactose intolerance is quite common in children
over age three. About 80% of all non-Caucasian
people world-wide are lactose intolerant after that age,
as well as about 15% of U.S. Caucasians. These
people all made a normal amount of lactase as infants,
but make less and less of this enzyme as they get older.
Most of these people will not even develop symptoms
until late adolescence or adulthood, even though they
are deficient in lactase at a much younger age.
Lactose intolerance usually causes abdominal distension,
gas, abdominal cramping, and diarrhea. These symptoms
usually occur within about 30 minutes of consumption of
milk or other dairy products.
You should discuss this matter again with your
pediatrician, and together decide whether, at what age
and how to reintroduce cow’s milk protein to your
daughter’s diet. Chances are great that she will
outgrow this problem!
References:
1. Heyman, Melvin B., MD, MPH for the Committee on
Nutrition. Lactose Intolerance in Infants, Children and
Adolescents. Pediatrics Vol. 118 No. 3, Sept. 2006, pp.
1279-1286.
2. Vonlanthen, Maryelle, MD. Lactose Intolerance,
Diarrhea, and Allergy. From Breastfeeding Abstracts,
November 1998, Volume 18, Number 2, pp. 11-12.
 
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