In older children (> 5 years) and adults with lactose malabsorption, this situation may be a natural condition that is permanent and genetically determined (ie, lactase deficiency is primary and not the result of underlying injury to the intestinal mucosa). Caution should be used when the patient and their family originate from a population where lactase persistence is prevalent (ie, Whites from northern Europe). In these patients, a diagnosis of lactose malabsorption may need further investigation.
The treatment of lactose malabsorption in the absence of underlying disease consists of the following four general principles: (1) reduced dietary intake of lactose, (2) substitution of alternative nutrients to maintain energy and protein intake, (3) administration of enzyme substitute, and (4) maintenance of calcium intake.
Complete restriction of lactose for a limited time (1 to 2 weeks) is sometimes useful to ascertain the specificity of the diagnosis. After this period, these patients can experiment to find a level of lactose they can tolerate. In some patients, dairy products like aged cheeses (cheddar, Swiss, Parmesan or Romano), ice cream, or yogurt are more easily accepted without symptoms, especially if taken with other food. Most people can build up their level of tolerance by gradually introducing the lactose-containing foods. In general, many will be able to enjoy dairy products if they take them in small amounts or eat other kinds of food at the same time in order to delay gastric emptying. People who have a very low tolerance of lactose need to know that lactose is often added to prepared foods, even to products labeled "nondairy" (Table 62-2). People with severe lactose intolerance can be even affected by lactose used as a base for more than 20% of prescription drugs (ie, birth control pills) and about 6% of over-the-counter medicines (some tablets for stomach acid and gas) (National Digestive Diseases Information Clearinghouse, 2003).
TABLE 62-2. Hidden Lactose:Food Products That Contain Small Amounts of Lactose
Bread and other baked goods
Processed breakfast cereals
Instant potatoes, soups, and breakfast drinks
Candies and other snacks
Mixes for pancakes, biscuits, and cookies
Powdered meal-replacement supplements
"Nondairy" products, such as powdered coffee creamer, whipped toppings Prescription (> 20% lactose base or over-the-counter medications)
A concern for both growing children and adults with lactose intolerance is getting enough calcium in a diet that includes little or no milk. Patients with lactose restriction are at risk for osteoporosis, osteopenia, and fracture (Infante and Tormo, 2000). Age-dependent recommendations for required daily calcium intake is shown in Table 62-3. Many nondairy foods are high in calcium, such as green vegetables and fish with soft, edible bones (Table 624). In patients who need a complete restriction of lactose, calcium supplementation is often recommended. Absorption of calcium from the diet is promoted by vitamin D, which is adequately supplied in a balanced diet. Sources of vitamin D include eggs and liver; sunlight helps the body to naturally absorb or synthesize vitamin D.
For patients who react to very small amounts of lactose or have trouble limiting their lactose-containing foods, bacterial or yeast p-galactosidase enzymes are available without prescription. These enzyme preparations (eg, Lactaid) can be added to milk or cream (as liquid, 14 drops/quart), which is then refrigerated overnight. Lactose will be hydrolyzed, and the milk will taste sweeter. Enzyme tablets can be taken with lactose-containing foods.
Predigested dairy products such as Lactaid milk (completely lactose-free), or Dairy Ease milk (70% lactose reduced) are commercially available. Soy milk contains no lactose.
In conclusion, for patients with lactose intolerance, a carefully chosen and often self-guided diet is the key to reducing symptoms and protecting future health.
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