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Sunday, June 03, 2007

American Academy of Pediatrics Recommendations

To get the consensus of what pediatricians think are the optimum policies for children with lactose intolerance, the Committee on Nutrition of the American Academy of Pediatrics (AAP) periodically issues a policy paper.

A couple of these policies were revised in 2006. They are much too long to repeat or even summarize here, but I can give you the links to the full documents and their concluding points.

Lactose Intolerance in Infants, Children, and Adolescents, by Melvin B. Heyman, MD, MPH for the Committee on Nutrition.

PEDIATRICS Vol. 118 No. 3 September 2006, pp. 1279-1286 (doi:10.1542/peds.2006-1721)

This policy is a revision of the policy posted on August 1, 1978.


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 of age, 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). 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 principle sources of protein and other nutrients that are essential for growth in children.

Optimizing Bone Health and Calcium Intakes of Infants, Children, and Adolescents, by Frank R. Greer, MD, Nancy F. Krebs, MD Committee on Nutrition

PEDIATRICS Vol. 117 No. 2 February 2006, pp. 578-585 (doi:10.1542/peds.2005-2822)

This policy is a revision of the policy posted on November 1, 1999.
Summary of Key Points

1) Pediatricians can actively promote bone health and support the goal of achieving adequate calcium intakes by children and adolescents by promoting the recommended adequate intakes of the Food and Nutrition Board of the NAS4 (Table 1). The prevention of future osteoporosis and the possibility of a decreased risk of fractures in childhood and adolescence should be discussed with patients and families as potential benefits for achieving these goals.

2) Physical activity, primarily weight-bearing exercise, is encouraged as part of an overall healthy bone program.

3) Currently, the average dietary intake of calcium by children and adolescents (Fig 1) is well below the recommended levels of adequate intake (Table 1). Information regarding calcium content of various foods should be given to patients and families for whom calcium intake seems inadequate. A registered dietitian may be consulted for a more thorough assessment of diet and to make the necessary recommendations to improve calcium.

4) Inadequate calcium intake by the child or adolescent is a family issue. Adequate intake of dietary calcium should be encouraged for all family members (Table 1).

5) In the office setting, calcium intake can be assessed periodically with a simple questionnaire. Suggested ages for screening are 2 to 3 years of age, after the transition from human milk or formula; 8 to 9 years of age during preadolescence; and again during adolescence, when the peak rate of bone mass accretion occurs. Targeted questions are suggested (see Table 3) to assess calcium intake, general diet, and lifestyle practices relevant to bone health.

6) The most common sources of calcium in the Western diet are milk and other dairy products. Whole milk is not recommended until after 12 months of age, although yogurt and cheese can be introduced after 6 months. Low-fat dairy products including skim milk and low-fat yogurts are good sources of calcium. Nondairy calcium-rich foods are the next preferred source, although the calcium in soy products has low bioavailability. Calcium supplements are another alternative source, but these products do not offer the benefits of other associated nutrients, and compliance may be a problem. Most people can achieve the recommended dietary intake of calcium by eating 3 age-appropriate servings of dairy products per day (4 servings per day for adolescents) or the equivalent.

7) The diet of all infants (including those who are breastfeeding), children, and adolescents should include the recommended adequate intakes of vitamin D (200 IU [5.0 µg] or 500 mL of vitamin D–fortified formula or milk per day) as well as fruits and vegetables that are sources of potassium and bicarbonate, which may improve calcium retention.

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