Lactose-free Formula Research Articles

A reduced-carbohydrate and lactose-free formulation for stabilization among hospitalized children with severe acute malnutrition: A double-blind, randomized controlled trial.

BackgroundChildren with medically complicated severe acute malnutrition (SAM) have high risk of inpatient mortality. Diarrhea, carbohydrate malabsorption, and refeeding syndrome may contribute to early mortality and delayed recovery. We tested the hypothesis that a lactose-free, low-carbohydrate F75 milk would serve to limit these risks, thereby reducing the number of days in the stabilization phase.Methods and findingsIn a multicenter double-blind trial, hospitalized severely malnourished children were randomized to receive standard formula (F75) or isocaloric modified F75 (mF75) without lactose and with reduced carbohydrate. The primary endpoint was time to stabilization, as defined by the World Health Organization (WHO), with intention-to-treat analysis. Secondary outcomes included in-hospital mortality, diarrhea, and biochemical features of malabsorption and refeeding syndrome. The trial was registered at clinicaltrials.gov (NCT02246296). Four hundred eighteen and 425 severely malnourished children were randomized to F75 and mF75, respectively, with 516 (61%) enrolled in Kenya and 327 (39%) in Malawi. Children with a median age of 16 months were enrolled between 4 December 2014 and 24 December 2015. One hundred ninety-four (46%) children assigned to F75 and 188 (44%) to mF75 had diarrhea at admission. Median time to stabilization was 3 days (IQR 2–5 days), which was similar between randomized groups (0.23 [95% CI −0.13 to 0.60], P = 0.59). There was no evidence of effect modification by diarrhea at admission, age, edema, or HIV status. Thirty-six and 39 children died before stabilization in the F75 and in mF75 arm, respectively (P = 0.84). Cumulative days with diarrhea (P = 0.27), enteral (P = 0.42) or intravenous fluids (P = 0.19), other serious adverse events before stabilization, and serum and stool biochemistry at day 3 did not differ between groups. The main limitation was that the primary outcome of clinical stabilization was based on WHO guidelines, comprising clinical evidence of recovery from acute illness as well as metabolic stabilization evidenced by recovery of appetite.ConclusionsEmpirically treating hospitalized severely malnourished children during the stabilization phase with lactose-free, reduced-carbohydrate milk formula did not improve clinical outcomes. The biochemical analyses suggest that the lactose-free formulae may still exceed a carbohydrate load threshold for intestinal absorption, which may limit their usefulness in the context of complicated SAM.Trial registrationClinicalTrials.gov NCT02246296.

Comparative effectiveness and safety of interventions for acute diarrhea and gastroenteritis in children: A systematic review and network meta-analysis.

BackgroundMany interventions have shown effectiveness in reducing the duration of acute diarrhea and gastroenteritis (ADG) in children. Yet, there is lack of comparative efficacy of interventions that seem to be better than placebo among which, the clinicians must choose. Our aim was to determine the comparative effectiveness and safety of the pharmacological and nutritional interventions for reducing the duration of ADG in children.MethodsData sources included Medline, Embase, CENTRAL, CINAHL, LILACS, and Global-Health up to May 2017. Eligible trials compared zinc (ZN), vitamin A, micronutrients (MN), probiotics, prebiotics, symbiotics, racecadotril, smectite(SM), loperamide, diluted milk, lactose-free formula(LCF), or their combinations, to placebo or standard treatment (STND), or among them. Two reviewers independently performed screening, review, study selection and extraction. The primary outcome was diarrhea duration. Secondary outcomes were stool frequency at day 2, diarrhea at day 3, vomiting and side effects. We performed a random effects Bayesian network meta-analysis to combine the direct and indirect evidence for each outcome. Mean differences and odds ratio with their credible intervals(CrI) were calculated. Coherence and transitivity assumptions were assessed. Meta-regression, subgroups and sensitivity analyses were conducted to explore the impact of effect modifiers. Summary under the cumulative curve (SUCRA) values with their CrI were calculated. We assessed the evidence quality and classified the best interventions using the Grading of Recommendations, Assessment, Development & Evaluation (GRADE) approach for each paired comparison.ResultsA total of 174 studies (32,430 children) proved eligible. Studies were conducted in 42 countries of which most were low-and middle-income countries (LMIC). Interventions were grouped in 27 categories. Most interventions were better than STND. Reduction of diarrhea varied from 12.5 to 51.1 hours. The combinations Saccharomyces boulardii (SB)+ZN, and SM+ZN were considered the best interventions (i.e., GRADE quality of evidence: moderate to high, substantial superiority to STND, reduction in duration of 35 to 40 hours, and large SUCRA values), while symbiotics (combination of probiotics+prebiotics), ZN, loperamide and combinations ZN+MN and ZN+LCF were considered inferior to the best and better than STND [Quality: moderate to high, superior to STND, and reduction of 17 to 25 hours]. In subgroups analyses, effect of ZN was higher in LMIC and was not present in high-income countries (HIC). Vitamin A, MN, prebiotics, kaolin-pectin, and diluted milk were similar to STND [Quality: moderate to high]. The remainder of the interventions had low to very-low evidence quality. Loperamide was the only intervention with more side effects than STND [Quality: moderate].Discussion/ConclusionMost interventions analyzed (except vitamin A, micronutrients, prebiotics, and kaolin-pectin) showed evidence of superiority to placebo in reducing the diarrhea. With moderate-to high-quality of evidence, SB+ZN and SM+ZN, demonstrated the best combination of evidence quality and magnitude of effect while symbiotics, loperamide and zinc proved being the best single interventions, and loperamide was the most unsafe. Nonetheless, the effect of zinc, SB+ZN and SM+ZN might only be applied to children in LMIC. Results suggest no further role for studies comparing interventions against no treatment or placebo, or studies testing loperamide, MN, kaolin-pectin, vitamin A, prebiotics and diluted milk.PROSPERO registrationCRD42015023778.

Knowledge and practice of pediatricians and nutritionists regarding treatment of cow’s milk protein allergy in infants

ABSTRACT Objective This study evaluated the knowledge and practices of pediatricians and nutritionists about cow’s milk protein allergy in infants, with an emphasis on issues related to the exclusion diet and nutritional status. Methods A cross-sectional, descriptive study was performed with a convenience sample of 204 pediatricians and 202 nutritionists randomly invited in scientific events in the city of São Paulo, from November 2014 to March 2016. Results Between 1.5% and 21.0% of respondents indicated inadequate products for the treatment of cow’s milk protein allergy, including goat’s milk, beverages or juices based on soy extract, lactose-free milk formula and partially hydrolyzed formula. The daily calcium recommendation for children between zero and 36 months of age was correctly indicated by 27.0% of pediatricians and 46.0% of nutritionists (p=0.001). Additionally, 96.1% of pediatricians and 82.7% of dietitians (p<0.001) provided guidance on about labels of industrialized products. Conclusion Pediatricians and nutritionists present gaps in knowledge about cow’s milk protein allergy treatment in infants and educational strategies that increase the knowledge of the professionals are important for the management of cow’s milk protein allergy.

Efficacy of low residue enteral formula versus clear liquid diet during bowel preparation for colonoscopy: a randomised controlled pilot trial

ObjectivesConventional bowel preparation for colonoscopy confines patient to clear liquid diet the day before and such non-nutritive dietary regimen often caused discomfort and hunger. The purpose of this study is to determine the feasibility of feeding patient with low-residue, lactose-free semi-elemental enteral formula (PEPTAMEN®) compare to conventional clear liquid diet during bowel preparation before colonoscopy. MethodsThis was a randomised, endoscopist-blinded study. Patients were randomised into two groups, those receiving oral PEPTAMEN® and mechanical bowel preparation (A) and those receiving clear liquid while undergoing mechanical bowel preparation (B). Documentation was made with regard to the type of bowel cleansing agents used, completeness of the colonoscopy, cleanliness quality score, and hunger score. ResultsA total of 97 patients were included in the study, A=48 and B=49. Eight patients, who were not compliant to the bowel-cleansing agent or had an incomplete colonoscopic examination, were excluded from the study. In terms of the overall cleanliness score, no statistical significant difference was seen (p=0.25) between the two groups, A (fair or poor 37.5%, good or excellent 62.5%) and B (fair or poor 49%, good or excellent 51%) whereas the hunger score showed a significant difference (p=0.016), A (no hunger 41.7%, slight hunger 12.5%, hungry 12.5%) and B (no hunger 24.5%, slight hunger 38.8%, hungry 36.7%). ConclusionsThese data suggest that the addition of oral PEPTAMEN® as part of the bowel preparation regimen did not significantly alter the luminal cleanliness score during colonoscopy while alleviating hunger.

Molecular and clinical characterization of citrin deficiency in a cohort of Chinese patients in Hong Kong

Background and objectives: This retrospective study analysed a case series of subjects with citrin deficiency, and aims to present the molecular and clinical characterization of this disease in the Hong Kong Chinese population for the first time. Patients and Methods: Data from medical records of eighteen patients with citrin deficiency (years 2006–2015) were retrieved. Demographic data, biochemical parameters, radiological results, genetic testing results, management, and clinical outcome were collected and analysed. Results: Eighteen patients with diagnosis of citrin deficiency were recruited. All 18 patients carried at least one common pathogenic variant c.852_855delTATG in SLC25A13. Prolonged jaundice (neonatal intrahepatic cholestasis caused by citrin deficiency, NICCD) was the most common presenting symptom, in conjunction with elevated plasma citrulline, threonine, alkaline phosphatase, and alpha-fetoprotein levels. The abnormal biochemical parameters including liver derangement returned to normal range in most of the cases by 6 months of age after the introduction of a lactose-free formula. There were a few cases with atypical presentations. Two subjects did not present with NICCD, and were subsequently diagnosed later in life after their siblings presented with symptoms of citrin deficiency at one month of age and subsequently received a molecular diagnosis. One patient with citrin deficiency also exhibited multiple liver hemangioendotheliomas, which subsided gradually after introduction of a lactose-free formula. Only one patient from this cohort was offered expanded metabolic screening at birth. She was not ascertained by conducted newborn screening and was diagnosed upon presentation with cholestatic jaundice by 1 month of age. Conclusion: This is the first report of the clinical and molecular characterization of a large cohort of patients with citrin deficiency in Hong Kong. The presentation of this cohort of patients expands the clinical phenotypic spectrum of NICCD. Benign liver tumors such as hemangioendotheliomas may be associated with citrin deficiency in addition to the well-known association with hepatocellular carcinoma. Citrin deficiency may manifest in later infancy period with an NICCD-like phenotype. Furthermore, this condition is not always ascertained by expanded newborn metabolic screening testing.

A milk formula containing maltodextrin, vs. lactose, as main carbohydrate source, improves cognitive performance of piglets in a spatial task

In recent years, lactose-free and low-lactose infant formulas have been increasingly used. The impact of using different carbohydrates than lactose on later cognition of formula-fed infants remains, however, unknown. We examined the effects of providing formulas containing either digestible maltodextrin or lactose as main carbohydrate source (28% of total nutrient composition) on cognitive performance of piglets. Piglets received the formulas from 1 to 9 weeks of age and, starting at 12 weeks, were individually tested in a spatial holeboard task (n = 8 pens/formula), in which they had to learn and memorize a configuration of baited buckets. After 28 acquisition trials, piglets were subjected to 16 reversal trials in which the location of the baited buckets was changed. Piglets fed the maltodextrin-based formula had higher reference memory (RM) scores than piglets fed the lactose-based formula towards the end of acquisition. During the switch of configuration, piglets offered the maltodextrin-based formula tended to have higher RM scores and make fewer RM errors than piglets offered the lactose-based formula. Working (short-term) memory was not affected by the formulas. Compared to lactose, the use of maltodextrin in milk formulas improved long-term spatial memory of piglets, even weeks after the end of the intervention.

Types of Special Infant Formulas Marketed in Korea and Their Indications.

Infant formula is classified into standard cow's milk-based and special formulas. This review aimed at summarizing the types of special milk formulas currently sold in Korea, and the appropriate indications for the use of these formulas; lactose free formula, soy-based formula, protein hydrolysate formula, amino acid-based formula, preterm formula, medium chain triglyceride formula, low-phosphorus formula, protein-energy-enriched formula, and formulas for inborn errors of metabolism.

Knowledge, attitudes, and practices of pediatricians on infantile colic in the Middle East and North Africa region

BackgroundRegional evidence-based guidelines for the prophylaxis and management of infantile colic are not available for the Middle East and North Africa (MENA) region. The Allied Against Infantile Functional GI Disorders (ACT) Working Group was created in January, 2015 to determine the knowledge gaps and the current management practices of infantile colic by physicians in the MENA region. The ACT group determined the need for a survey to address these questions. The objectives of the survey were to highlight current clinical practices on the management of infantile colic and to raise awareness on colic severity in the MENA region.MethodsThe ACT working group developed the survey which included respondent characteristics and closed questions on practice in colic prevention. The survey was subject to validation and ethics committee approval in all countries.ResultsA total of 1628 physicians (mostly pediatricians (75.4%), neonatologists (2.4%) and general practitioners (19.8%)) responded to the survey. The 5 most represented countries were KSA (27.9%), Kuwait (22.1%), Morocco (13.8%), Lebanon (10.6%), and Iraq (7.4%). Most of the respondents (77.8%) practiced in governmental settings. A majority of respondents (91.7%) reported that colic is diagnosed predominantly by clinical examination. Above 63%, of pediatricians surveyed, believed that the colic prevalence rate was >40%, which is greater than the 20% rate reported in worldwide surveys. Yet, most of the responding physicians (73%) prefer to simply reassure parents rather than prescribe a therapeutic agent. Most physicians were either neutral (58%) or did not endorse (18.4%) colic prophylaxis. Of those who prescribed formulae for non-breastfed children, a majority (64.3%) chose “Comfort” formulae over hydrolyzed or lactose-free formulae or formulae with probiotics.ConclusionsThe results of this survey suggest that a substantial proportion of responding physicians from the selected MENA countries do not advocate for prophylaxis of colic. The findings of this survey suggest that more educational efforts are required to increase awareness of the strong body of evidence supporting the efficacy of probiotics in the prevention and management of infantile colic.

Postprandial metabolic response of breast-fed infants and infants fed lactose-free vs regular infant formula: A randomized controlled trial

Lactose intolerance is a major concern driving the growth of lactose-free foods including lactose-free infant formula. It is unknown what the metabolic consequence is of consumption of a formula where lactose has been replaced with corn syrup solids (CSS). Here, a randomized double-blinded intervention study was conducted where exclusively formula-fed infants were fed formula containing either lactose or CSS-based infant formula and compared with an equal number of exclusively breast-fed infants. Plasma metabolites and insulin were measured at baseline, 15, 30, 60, 90 and 120 min after feeding. Differences in plasma metabolite profiles for formula-fed infants included a rapid increase in circulating amino acids, creatinine and urea compared with breast-fed infants. At 120 min post-feeding, insulin was significantly elevated in formula-fed compared with breast-fed infants. Infants fed lactose-based formula had the highest levels of glucose at 120 min, and leucine, isoleucine, valine and proline at 90 and 120 min, whereas infants fed CSS-based formula had the lowest levels of non-esterified fatty acids at all time points, and glucose at 120 min. Overall, these differences highlight that changes in infant formula composition impact infant metabolism, and show that metabolomics is a powerful tool to help with development of improved infant formulas.

Prevention and treatment of food allergy gastrointestinal manifestations in infants; allergy to cow's milk protein

Gastrointestinal manifestation (GM) of food allergy (FA) in infants are non-specific, e.g.: frequent throwing up, colic, abdominal pain, vomiting, food refusal, which significantly complicates the differential diagnosis and selection of treatment direction.Materials and methods. 311 infants with atopic dermatitis symptoms were examined. 43 % of children (n=134) (studied group hereinafter) aged to 6 months had durable, resistant to conventional therapy pathological manifestations from the gastrointestinal tract. Laboratory tests were carried out for all of the children: determination of total venous blood serum levels of immunoglobulin, specific immunoglobulin E to cow's milk fractions (boiled milk, α – Lactalbumin, β – Lactalbumin, casein), to soya and goat's milk, eosinophil cationic protein levels (ECP). Guided by the ESPGHAN algorithm, diagnostic elimination diet was suggested to all of the infants during 4 weeks with the following lactose cow's milk (0.33% fat) provocative test for mother, in case of breast-feeding, or return to lactose-free formula, characterized by lower hydrolysis degree, in the case of artificial feeding. In the case of clinical symptoms restoration, the elimination diet was extended for three months, and then, after three months, provocative re-test was suggested. Laboratory parameters were monitored regularly 4 weeks and 3 months later, the additional ECP determination in blood serum was carried out in infants having positive provocative test.Research results. Positive clinical dynamics of symptoms was observed during the first week of the treatment in 127 infants, and it significantly correlated with ECP level reduction in blood serum. 51 children on the 4th week of observation, and 4 children on the 3rd month of observation had positive provocative test. The tendency to general and specific IgE decrease in relation to cow's milk fractions was slower (15–20 % on the 3rd month of treatment) and did not correlated with clinical symptoms dynamics.Conclusion. In infants, stable GM can be connected with allergic pathology. Direct and indirect provocation tests can be used by pediatricians for the allergy to cow's milk proteins diagnosis. The use of hypoallergenic nutrition formulas as basic and dairy-free diet for mother can significantly decrease GM of FA. Eosinophil cationic protein is advisable to use for the severity of the allergic process estimation in infantsDuring the first week of the treatment, ECP level decreased and it correlates with clinical symptoms dynamics.The tendency to general and specific IgE decrease in relation to cow's milk fractions was slower (15–20 % on the 3rd month of treatment) and does not correlate with clinical symptoms dynamics

Availability of zinc from infant formula by in vitro methods (solubility and dialyzability) and size-exclusion chromatography coupled to inductively coupled plasma-mass spectrometry.

Zinc bioaccessibility from infant formula was estimated by in vitro methods (solubility and dialyzability) and size-exclusion chromatography (SEC) coupled to inductively coupled plasma-mass spectrometry (ICP-MS). Infant formula samples were first characterized in terms of Zn bound to lipids and proteins and Zn distribution in the aqueous soluble protein fraction. We found that Zn is not incorporated into the lipid fraction of the samples, being mainly associated with the protein fraction (around 100%). Fractionation of Zn-containing proteins in the soluble protein fraction was achieved by SEC-ICP-MS after performing protein extraction with a solution of 100mM (pH 6.8) Tris-HCl. The percentages of zinc in the soluble protein fraction in the soy-based and lactose-free infant formula were very low, around 7 and 24%, respectively, whereas the content of Zn in the soluble protein fraction of milk-based formula was around 90%. By SEC-ICP-MS, we found that Zn is associated with low-molecular weight compounds (around 10kDa) in all the infant formulas tested. The percentages of Zn estimated in the in vitro gastrointestinal digests of the infant formula ranged from 30 to 70% and from 1 to 10% for solubility and dialyzability assays, respectively. The dialyzability test resulted in lower than expected scores, as SEC-ICP-MS analysis of the gastrointestinal extracts revealed that Zn is bound to biomolecules with a molecular weight ranging from 1 to 7kDa, which suggests that dialysis data should be interpreted with caution. Speciation studies are a valuable tool for establishing availability of nutrients and for validating data from dialyzable in vitro methods.

Double blind clinical trial on a lactose-free and a lactose-containing formula in the treatment of acute diarrhea in children

Background Lactose intolerance is a common complication ofdiarrhea in young children particularly that due to rotaviral infec-tion. A meta-analysis study evaluated the use of undiluted lactosecontaining formula or cow’s milk during an episode of diarrhea. Itwas concluded that routine dilution of milk and the use of lactose-free milk formula are not necessary.Objective To evaluate the effect of lactose free formula comparedwith lactose-containing milk formula during acute diarrheal episodein outpatient setting.Methods A total of 56 children with acute diarrhea with mild-mod-erate or no dehydration attending to the outpatient clinic were ran-domly assigned to receive a lactose-free formula (Nestle Nan ® freelactose) or lactose-containing milk formula (Nestle Nan 2 ® formula)after initial rehydration. Comparisons of stool frequency, durationof diarrhea and treatment failure rates were noted. Treatment fail-ure was defined as clinical requirement for intravenous infusionafter rehydration or prolonged diarrhea (>7 days).Results The duration of diarrhea was similar between the twogroups (P=0.195) in spite of two children who received lactosefree formula did not resolve from diarrhea within 7 days of treat-ment. The median of stool frequency was indifferent in the twogroups (P=0.199) in rotavirus gastroenteritis; there were no differ-ences in the duration of diarrhea or the stool frequency.Conclusion Children without dehydration or with mild dehydra-tion tolerated to lactose-containing formula as well as lactose-freeformula for the treatment of acute diarrhea

The Level of Knowledge of Dietitians About Dietary Management of Children with Food Allergy

Objective: The aim of this study was to evaluate the knowledge of dietitians and dietetic students about food allergy in order to develop suggestions for educational activities. Materials and Methods: Dietitians and dietetics students were surveyed via a questionnaire aimed to document their knowledge about food allergy management. Results: Of the 150 questionnaires distributed, 122 valid questionnaires were returned. The response rate was 81.3%. Of all the respondents, 51.4% were working in a hospital. About sixty percent of respondents rated themselves ‘moderate’ for identifying some clinical manifestations of FA, developing elimination diets, providing avoidance education, managing the dietary needs of children with cows’ milk allergy (CMA). Only 72.1% of respondents answered the questions about foods that can cause anaphylaxis correctly. About forty percent of respondents did not recognize that food allergens could be transmitted by means of tools used for service such as knives and spoons and thought that smoke of the cooking food does not cause allergy. About sixty percent of respondents also thought that touching the food never causes allergic reactions. Of all the respondents, only about 18.9% suggested amino acid based formulas for children with CMA, 23% suggested fully hydrolized formulas and 39.3% thought that lactose free formulas can be given to patients with CMA. Conclusion: This study revealed that there are some gaps in the knowledge of dietitians about food allergy. Dietitians should be given training on this subject and there should be a re-evaluation of health policies with a wider global perspective.

Lactose Intolerance in Children with IgE-Dependent Allergy to Milk Proteins.

The aim of this study was to assess the frequency of the occurrence of lactose intolerance in children with an IgE-dependent allergy to cow's milk. The study group consisted of 48 children diagnosed with IgE-dependent allergy to cow's milk proteins (group I). The control group (group II) included 40 children, in a similar age range and with normal architecture of the mucosa of the small intestine, with excluded food allergy. All patients underwent gastroduodenoscopy with biopsy, in which the activity of lactase was determined. The average activities of lactase in the group of patients with allergy were lower than in group II and amounted to 5.6 and 8.64 U/1 g. Lactase deficiency was observed in 6/48 patients in the group of patients with allergy. In group II, lactase deficiency was observed in 20%, which corresponds to the frequency of lactase intolerance in Poland. Lower activity of lactase was statistically significantly more common in older children. A reduced activity of lactase was more frequent in children with atrophy of the intestinal villi; however, that difference was not statistically significant. Lactose intolerance was less frequent in children with a diagnosed IgE-dependent milk proteins allergy. Due to the positive role of lactose in the diet, it seems that including a lactose-free formula in patients with diagnosed IgE-dependent allergy to milk is not necessary.

The effect of lactose-free formula feeds on growth responses among severely malnourished HIV-infected children in Durban, South Africa

Background. The co-occurrence of HIV infection and severe malnutrition contributes to high rates of morbidity and mortality among children in resource-limited settings. Lactose-free, ready-to-use therapeutic feeds (RUTFs) may be most appropriate in this population because of underlying mucosal damage secondary to inflammation and infection. Objectives. To describe the effect of lactose-free RUTFs on the growth parameters of severely malnourished HIV-infected children in Durban, South Africa (SA). Methods. This was a prospective, observational study of nutritional recovery in HIV-infected, severely malnourished children, aged 6 months to 5 years, who received lactose-free RUTFs following admission to King Edward VIII Hospital in Durban, SA. The primary outcome was nutritional recovery, defined as 15% weight gain from enrolment to end of study. Secondary outcomes included z -scores for weight-for-height, weight-for-age, height-for-age, triceps skinfold thickness (SFT) and subscapular SFT calculated at baseline and 7, 14, 30 and 45 days after admission. Univariate analysis was done to compare outcomes among antiretroviral therapy (ART)-naive and ART-experienced children; the effect of ART on nutritional recovery was evaluated in a logistic regression model. Results. A significant improvement in most nutritional parameters was found at 45 days; 59% of children attained nutritional recovery. There was no significant difference in the proportion of children reaching recovery based on ART status at admission ( p =0.08). Conclusion. Lactose-free formula feeds may be an effective strategy for nutritional rehabilitation of severely malnourished and HIV-infected children in resource-limited settings. It remains to be determined how ART initiation affects nutritional recovery in these children.

Lactose intolerance among pediatrics: systematic review

Objectives The aim of the study was to perform systematic review to summarize the investigation and management of lactose intolerance among children. Data sources Medline, articles in Medscape, AAFP, and PubMed were searched. The search was performed on 1 April 2014 and included all articles with no language restrictions. Study selection The initial search presented 320 articles. The number of studies that met the inclusion criteria was 15. The articles included lactose intolerance and health common clinical presentation, investigation to confirm the diagnosis, dietary modification and its impact on bone health, supplementation using different formula, and manifestation of lactose intolerance. Data extraction Data from each eligible study were independently abstracted in duplicate using a data collection form to capture information on study characteristics, interventions, and quantitative results reported for each outcome of interest. Data synthesis There was heterogeneity in the collected data. It was not possible to perform meta-analysis. Significant data were collected. Thus, a structured review was performed. Conclusion Five articles were review articles and one systematic review summarized the clinical presentation, investigation, and management. Two studies showed the effect of lactose intolerance on bone and serum calcium and zinc as lactose intolerance prevents the achievement of an adequate peak bone mass; calcium absorption was significantly greater from the lactose-containing formula than from the lactose-free formula, whereas zinc absorption showed no difference. Six studies showed the relationship between ingested formula and clinical manifestation and relationship with methane production, which recommended the supplementation using small frequent doses or gradual increasing dose to produce adaptation. One study showed that the LCT(T/C-13910) polymorphism was associated with subjective milk intolerance and reduced bone mineral density (BMD) that may predispose to bone fractures.

Selective IgA deficiency associated with allergy to cow's milk protein, case report

Event Abstract Back to Event Selective IgA deficiency associated with allergy to cow's milk protein, case report Catalina M. Gómez Henao1*, Cristina I. Herrera Morales1, Ana M. Celis Henao1 and Carlos F. Chinchilla Mejía1 1 Universidad de Antioquia, Colombia Background: IgA is the most abundant immunoglobulin in the human; it is found in tissues and in secretions especially from the gastrointestinal tract reflecting its role in mucosal immunity and the development of tolerance. Selective IgA deficiency (<10mg/dl) is the most common primary immunodeficiency, most patients with IgA deficiency are asymptomatic so its clinical significance is unknown, although it has been associated with increased incidence of some autoimmune and allergic diseases, being food allergy and asthma most frequently related. The protein allergy to cow's milk is one of the most prevalent and important food allergies in childhood. In patients with allergy to proteins in cow's milk have been shown a decrease in the production of TGF-β, one of the main cytokines that stimulate the production of IgA by B cells, a mechanism that could also be explaining the relationship between allergy to the protein in cow's milk with selective IgA deficiency. Objective: To report a case of protein allergy to cow's milk in the presence of IgA deficiency. Methods: Case Report Results: Patient 5 years of age, female, personal history of recurrent infections, rhinitis and Asthma, with colic pain since three years of age that is increased with cow milk intake, tolerate forms extensively cooked. Treatments: Salmeterol/Fluticasone 25-125 every 12 hours. Montelukast 4 mg daily, 100mg daily Mometasone Furoate. Paraclinical: IgA: 0.4 (20-358), IgG: 999, IgM 132.4, specific IgE for casein 4.5 IU/ml (class 3), Alpha-lactalbumin 2.98 (Class 2) Whole cow's milk 2.82 (Class 2), beta-lactoglobulin 0 (Class 0), dog dander 2.2 (Class 2). Prick test negative, albumin 4.8. Avoidance of cow's milk is recommended. During follow-up the patient gradually decreases levels of specific IgE to cow's milk protein, Tolerating lactose-free formulas to 7 years, with a slight increase in levels of IgA (13.9mg/dl). Conclusion: This case illustrates a clear association between selective IgA deficiency and food allergy which has been previously described in the literature, specifically in our patient allergic to cow's milk protein.

Congenital sucrase-isomaltase deficiency: an under-diagnosed disease in Chinese children

BackgroundCongenital sucrase-isomaltase deficiency (CSID) is a rare genetic disorder. The prevalence of CSID in Chinese population is unknown and no single case has been reported.MethodsSucrose tolerance tests were performed in three children suspected of CSID. Glucose tolerance tests were performed to exclude glucose malabsorption. Blood glucose was measured at fasting and at 30 min, 60 min, 120 min, and 180 min of the study. Gastrointestinal symptoms were recorded up to 4 hours after the study.ResultsFrom December 2008 to June 2011, three children, ranging from 16 to 19 months old, were referred to our tertiary children’s hospital due to chronic watery diarrhea and failure to thrive. Laboratory investigations including complete blood counts, ESR, CRP, and serum immunoglobulins were normal. Routine stool culture for bacteria and exam for parasites were negative. Upper endoscopy, colonoscopy and histology were unremarkable. All children failed lactose-free and amino acid-based formulas. All three children had flat sucrose tolerance tests and began to have watery stool 2–4 hours after feeding sucrose test solution. The glucose tolerance tests were normal and no children developed watery stools up to 4 hours after feeding glucose test solution.ConclusionsThis is the first case series of CSID in Chinese children. The diagnosis of CSID can be made based on clinical suspicion and sucrose tolerance test. CSID is probably an under-diagnosed or misdiagnosed disease in Chinese children and should be considered in children with chronic watery diarrhea.

Infant Colic and Functional Gastrointestinal Disorders

B y the time their child is 4 months old, up to 20% of parents have reported colicky symptoms in their infants. Is infant colic a disorder? Is it related to the intestine, as the term colic implies? Is any treatment other than reassurance of families regarding the transient nature of these symptoms indicated? In short, are we stepping in an evidence-based arena or are we dealing with ‘‘gut feelings’’? This supplement on infant crying, colic, and gastrointestinal (GI) disturbances in early childhood provides theoretical and clinical observations on this and other intriguing functional GI topics. The supplement provides the scientific and clinical evidence that should guide current clinical practice and serve future studies that will enable better understanding and appropriate management by physicians and families alike. Burns and Thapar review the embryonic and postnatal events related to the enteric nervous system (ENS), which is the regulator of gut secretion, blood flow, sensation, and coordinated motility (1). They provide evidence that a significant amount of modification of the ENS occurs not only during the fetal period but also postnatally; thus the ENS can be altered in a number of ways: stress, infections, and changes in nutrition. Indrio et al focus on the non-nutritive pathophysiology of colic, looking at the relation of colic to gastroesophageal reflux (GER), GI motility disorders, the role of gut hormones, and intestinal microflora (2). Their review raises the old debate of whether colic is a functional disorder (eg, troubling GER or ‘‘immature’’ motility) or should be regarded as a normal developmental occurrence. The authors correctly conclude that ‘‘little evidence supports a substantial role of GER or GERD in the majority of infants with colic,’’ and observations for the role of hormones such as ghrelin and motilin as well as the positive effect shown for probiotic supplementation should be studied further. Indrio and colleagues also elaborate on the role of probiotics in the management of infant colic and provide recent and exciting data on the clinical benefit of the administration of probiotics in treating functional disorders and organic diseases (3). This review explores the hypothesis that there is a window of time when the gut microbiota may affect the structure and the function of the brain. The review by Di Lorenzo on early life events brings us elegantly to the ‘‘vulnerable child,’’ summarizing what is known about factors that predispose an infant to become colicky (4). Much of the available data refers to the possible link among infectious, inflammatory, and psychological noxious events that may cause changes in enteric nerve reactivity, as well as immune responses or alterations in intestinal microbiota composition that can then lead to functional GI disorders later in life. For example, there is evidence that early pain experiences are associated with altered pain responses later in infancy. Although the genetic background cannot be changed and the stressful events may be unavoidable, identifying the child at risk may provide an opportunity for interventions that will attenuate or prevent later functional disorders. Ha-Vinh Leuchter et al discuss the possibility that the peak shape of the crying behavior found in colicky as opposed to noncolicky babies, the circadian rhythm of the crying, and the observation that these babies are not soothed by ordinary sensory stimulation reflect a difference in central nervous system functioning (eg, differences in circadian rhythm maturation, different response to stimuli) rather than GI dysfunction (5). Heine summarizes available data on the relation between cow’s-milk allergy and infant colic (6). He notes that in breast-fed infants, elimination of cow’s milk and other food proteins from the maternal diet was associated with a greater reduction in crying or fussiness duration, and that the treatment of formula-fed infants with extensively hydrolysed formula was associated with reduced crying in several clinical trials. The use of lactose-free formulae provides inconsistent results, however. A limited trial of an Infant Crying, Colic, and Gastrointestinal Discomfort in Early Childhood: A Review of the Evidence and Most Plausible Mechanisms

Citrin deficiency in a Romanian child living in Spain highlights the worldwide distribution of this defect and illustrates the value of nutritional therapy

We report citrin deficiency in a neonatal non-East-Asian patient, the ninth Caucasian reported with this disease. The association of intrahepatic cholestasis, galactosuria, very high alpha-fetoprotein and increased plasma and urine citrulline, tyrosine, methionine and threonine levels suggested citrin deficiency. Identification of a protein-truncating mutation (c.1078C>T; p.Arg360*) in the SLC25A13 gene confirmed the diagnosis. An immediate response to a high-protein, lactose-free, low-carbohydrate formula was observed. Our report illustrates the need for awareness on citrin deficiency in Western countries.