Updated: Jul 17
Lactose Intolerance, Cow's Milk Protein Allergy, Non-IGE mediated Cow's Milk Allergy (formally CMPI Intolerance); it can be a confusing space especially when it comes to babies and infants, which is why it is so important to use a qualified professional to assist in the assessment and management of any allergy or intolerance. Specifically this post is all about Lactose Intolerance, the types of lactose intolerance and what we commonly see in babies and children (i will discuss CMPA in a later post).
There are 4 main types of lactose intolerance:
Congenital lactase deficiency. This is an extremely rare genetic disorder where a baby is born without the lactase enzyme. It can be serious with malabsorption causing failure to thrive and dehyration. Management of this condition will be determined by a paediatrician.
Neonatal lactase deficiency. This can present in pre-terms <34 weeks and it typically resolves
Secondary lactose intolerance. This is usually a short term condition after infections like gastro/infectious diarrhoea or other underlying causes like unmanaged Coeliac disease which has caused inflammation of the small intestine. Treatment of the underlying condition is required and symptoms of lactose intolerance typically resolve. The average recovery time for the gut of a baby to heal after gastro is 4 weeks (breastfeeding will promote gut healing)
Primary Lactose Intolerance. This usually presents at an average 2-3 years of age if including all population groups but generally happens around 4-5 years of age as the lactase enzyme gradually starts to decrease (by this age a child is usually fully weaned). About 70% of people have this type of lactose intolerance and will usually tolerate varying amounts of lactose.
Lactose intolerance in babies:
Firstly it is not common for a baby under 12 months to have a lactose intolerance (sensitivity), unlesss as mentioned above they have a rare genetic disorder or neonatal lactase deficiency. This is becasue lactose is the main carbohydrate in breast milk and there is more of it in g/ml than compared to cows milk; breast milk contains 7.4g of lactose per 100ml and cow's milk contains 5g of lactose per 100ml. Due to this babies are primed to digest lactose, their small intestines are lined with the enzyme lactase (thank goodness otherwise they would not be able to digest breast milk). When lactose (C₁₂H₂₂O₁₁) is consumed it is broken down in the small intestine by the enzyme lactase, almost all infants have the enzyme lactase and can digest lactose from birth.
Lactose overload (not an intolerance, rememeber true lactose intolerance is vary rare) can sometimes be seen in infants < 3 months of age, usually a baby is unsettled and consuming large amounts of breastmilk, and their mothers have an oversupply. This can usually be easily fixed in a few days with an adjusted breastfeeding regime (see a lacatation consultant), continuing to breastfeed and breastmilk is still recommended as the best choice for your child.
Lactose Intolerance in Children:
In older children typically we see Primary Lactose Intolerance present around 2-5 years of age, although again this can be confused with cow's milk protein allergies and the symptoms may overlap. Common symptoms of lactose intolerance include bloating, diarrhoea, wind and pain after eating foods high in lactose. Lactose intolerance can be diagnosed with a breath test or a clinician led elimination protocol. It is treated by lowering the amount of lactose in the diet, however every child is different and children will tolerate different amounts of lactose; some children can tolerate a small amount, while others are very sensitive. Your child’s symptoms will help you decide how strict you need to be. To get a correct diagnosis use a trained paediatric Dietitian or Doctor/Paediatrician. Education on how to avoid lactose, food substitutes and any re-introduction of lactose should be completed by a Paediatric Dietitian.
Secondary Lactose Intolerance
Secondary lactose intolerance can occur in babies and children usually after a severe bout of gastro or infectious diarrhoea, it can also occur if there are undiagnosed conditions such as allergies or coeliac disease which cause inflammation in the intestine. This is because the enzyme lactase is procuded on the tips of the brush border of the intesttine (villi) so anything that damages the gut lining may cause secondary lactose intolerance. Secondary lactose intolerance is temporary, as long as the intestine can heal. Continuing to breastfeed in this situation is always recommended, and will not harm your baby as long as she is otherwise well and growing normally. Breastfeeding will aid in gut healing.
If a baby or toddler has had a severe bout of gastro or infectious diarrhoea and there is secondary lactose intolerance (discuss this with your health professional), it can be helpful to reduce FOOD DAIRY in the diet by switching to fermented dairy (eg kefir milk and yoghurt) and using lactose free milk (this should not replace breastmilk or infant formula in children <12 months of age) , whilst the gut heals for a short term eg 1-3 weeks. If they have prolonged symptoms of diarrhoea, this should be discussed with your healthcare provider.
A few points to remember:
A mother cannot reduce the amount of lactose in her breastmilk by eliminating cow's milk from her diet (nor does she need to, remember babies are primed to digest lactose)
Delaying the introduction of dairy foods in an infants diet when starting solids will not improve their tolerance to lactose or dairy. Dairy is an allergen and recommended to be introduced before 12 months of age.
Lactose intolerance is very different to cow's milk protein allergies (IGE and Non- IGE mediated) however the symptoms may overlap.
In almost all cases* of lactose intolerance, breast milk remains the best choice for your baby.