Lactose Intolerance – Your Baby and Lactose

Lactose Intolerance and the Breastfed Baby by Joy Anderson BSc, Dip.Ed., Grad.Dip.Med.Tech., IBCLC, ABA Breastfeeding Counsellor

Lactose is the sugar in all mammalian milks. It is produced in the breast and is independent of the mother’s consumption of lactose. It is present in a constant concentration in breastmilk. Foremilk, the milk the baby gets when he first starts to feed, does not contain more lactose than hindmilk, but it does contain less fat. Lactase is the enzyme that is required to digest lactose. Lactose intolerance arises when a person does not produce this enzyme (or does not produce enough) and is therefore unable to digest lactose.

The symptoms of lactose intolerance are liquid, frothy stools, and an irritable baby who may pass wind often. If a baby is lactose intolerant, the medical tests, ‘hydrogen breath test’ and tests for ‘reducing sugars’ in the stools would be expected to be positive. However these are positive in most normal babies under three months too so their use in diagnosing lactose intolerance is open to question.

There are some common fallacies about lactose intolerance that you may hear in the community:

1. Lactose in the breastmilk will be reduced if the mother stops eating dairy products.

2. Lactose intolerance in other family members (adults) means baby is more likely to be lactose intolerant.

3. If a mother is lactose intolerant then her baby will be as well.

4. A baby with symptoms of lactose intolerance should immediately be taken off the breast and fed on soy-based infant formula, or other special lactose-free formula.

5. Lactose intolerance is the same as intolerance or allergy to cows’ milk protein.

Read on to see what is wrong with these ideas!

Lactose Intolerance in Babies

Primary (or true) lactose intolerance is an extremely rare genetic condition and is incompatible with normal life without medical intervention. A truly lactose intolerant baby would fail to thrive from birth (ie not even start to gain weight), and show obvious symptoms of mal-absorption and dehydration – a medical emergency case needing a special diet from soon after birth.

Anything that damages the gut lining, even subtly, can cause secondary lactose intolerance. The enzyme lactase is produced in the very tips of folds of the intestine, and anything that causes damage to the gut may wipe off these tips and reduce the enzyme production, for example:

• gastroenteritis
• food intolerance or allergy (In breastfed babies, this can come from food proteins, such as cows’ milk, soy or egg, in the mother’s milk originating in her diet, as well as from food the baby has eaten.)
• coeliac disease (intolerance to the gluten in wheat products)
• following bowel surgery

Note that cows’ milk protein allergy (or intolerance) is often confused with lactose intolerance, and they are thought by many people to be the same thing. This confusion probably arises because cows’ milk protein and lactose are both in the same food, i.e. dairy products. Also contributing to this confusion is the fact that allergy or intolerance to this protein can be a cause of secondary lactose intolerance, so they may be present together.

Secondary lactose intolerance is a temporary state as long as the gut damage can heal. When the cause of the damage to the gut is removed, for example the food to which a baby is allergic is taken out of the diet, the gut will heal even if the baby is still fed breastmilk. If your doctor does diagnose ‘lactose intolerance’ you need to know that this is not harmful to your baby as long as she is otherwise well and growing normally.

Occasionally it is considered preferable to reduce the immediate symptoms, by reducing the amount of lactose in the diet for a time, particularly if the baby has been losing weight. In this case, it may be suggested that the mother alternate breastfeeding and feeding the baby with a lactose-free artificial baby milk.

Sensitivity of the baby to foreign protein (cow or soy) should be considered before introduction to artificial baby milk, as types other than the truly hypoallergenic ones may make the problem worse. Although commonly advised, there is no good evidence to support taking the baby off the breast altogether. In the case of a baby recovering from severe gastroenteritis, average recovery time for the gut is four weeks, but may be up to eight weeks for a young baby under three months. For older babies, over about 18 months, recovery may be as rapid as one week.

When even partially taking the baby off the breast temporarily is being considered, thought should also be given to other aspects of the breastfeeding relationship. These include:

• How will alternative feeding methods affect this baby? Could it result in breast refusal later?
• How easily will the mother be able to express her milk to maintain her supply?

A mother needs to be aware of exactly what is happening, and understand that this episode need not undermine her confidence in breastfeeding. Her breastmilk is still the normal and proper food for her baby in the long term.

You may have heard about giving ‘Lactaid’ drops to babies who have symptoms of lactose intolerance. There is no proof that these are of any value used this way. These drops do contain the enzyme, lactase, but need to be put into expressed breastmilk and left overnight for the enzyme to digest the lactose in the milk. In practice they are rarely useful for babies.

Adult Lactose Intolerance

The lactase enzyme levels normally change over the course of a life span. They rise rapidly in the first week after birth and fall sharply in later childhood, starting to fall from about three to five years of age. The low levels of the enzyme present in the first week of life are matched by low levels of lactose in colostrum. Cows’ milk is commonly consumed by adults in some populations, but these consist of people of mostly northern European descent. In about 70% of the people of the world, and about 10% of Australians, levels of this enzyme fall so low in adulthood that these people are lactose intolerant.

The tendency to adult lactose intolerance is genetically determined. Some races, such as Asian, African, Australian Aboriginal and Hispanic populations have a greater tendency to adult lactose intolerance. Caucasians are more likely to be able to consume milk as adults because they tend to continue to produce the lactase enzyme throughout life. Even so, the levels do fall with age and people who have been able to drink milk as adults may find they become lactose intolerant when elderly. An adult who has very low levels of the enzyme can usually tolerate some lactose because normal bacteria living in the gut provide a limited capacity to handle it. However, the person may find it tends to give them loose stools and ‘wind’.

All human races’ babies can tolerate lactose. In fact human milk has a very high concentration of lactose compared to cows’ milk and that of other mammals. This is thought to be related to a human baby’s rapid brain growth in infancy, compared to other mammals. Removing lactose from any baby’s diet for more than a short period should not be done lightly, and only under medical supervision.

Lactose overload

Lactose overload can mimic lactose intolerance, and is frequently mistaken for it. An overload is commonly seen in babies consuming large amounts of breastmilk, ie in mothers with an oversupply. This may result in symptoms such as an unsettled baby with adequate to large weight gains, more than ten wet and many dirty nappies in 24 hours. Baby is usually less than three months old. Ironically, a mother may perceive that she has a low supply because her baby always seems to be hungry. The nappy count can be the biggest clue to what’s happening. What comes out the bottom must have gone in the top!

There is a vicious cycle here – a large-volume, low-fat feed goes through the baby so quickly that not all the lactose is digested. (More fat would help slow it down.) The lactose reaching the lower bowel draws extra water into the bowel, and is fermented by the bacteria there producing gas and acid stools. The latter often causes a nappy rash. Gas and fluid build-up causes tummy pain and the baby ‘acts hungry’ (wants to suck, is unsettled, draws up his legs, screams). Sucking is the best comfort he knows, and helps move the gas along the bowel. This tends to ease the pain temporarily, and may result in the wind and stool being passed. Since the baby indicates that he wants to suck at the breast, his mother, logically, feeds him again. Sometimes it is the only way to comfort him. Unfortunately this provides another large feed on top of the other one, which hurries the system further, and results in more gas and fluid accumulation. The milk seems to almost literally ‘go in one end and out the other’.

Many mothers whose babies have had this problem have found it helpful to temporarily change from an on-demand breastfeeding routine. They aim to slow the rate at which milk goes through baby, so they feed one breast per feed, or set aside say a three-hour period (adjust this according to the severity of the oversupply) and every time baby wants to feed during this period, they use the same breast. Then they use the other breast for the next three hours, etc. This way, each time baby returns to the already used breast, he gets a lower-volume, higher-fat feed that helps slow the system down. When the baby’s symptoms are relieved, the mother is able to go back to a normal according-to-need breastfeeding routine.

Where the problem is severe and/or long-lasting, it might be worth trying to determine why there is an oversupply of breastmilk.

• Is the mother timing feeds and switching sides after a set number of minutes?
• Has something caused the baby to be unusually unsettled that has resulted in frequent comfort sucking and an oversupply?
• Is secondary lactose intolerance adding to the overload situation?
• Sometimes a mother is worried about having a low supply and overcompensates and overstimulates her supply.
• Perhaps the baby has been unwell, or is suffering discomfort from a difficult birth, and sought comfort in frequent feeds.
• Some mothers just have a tendency to oversupply – there is a normal variation in this as in everything else about our bodies. In days gone by, these may have been the mothers who could have made a living as wet nurses!

Specific ways to help with each of these is beyond the scope of this article. However, individual situations can be discussed with an Australian Breastfeeding Association counsellor, an International Board Certified Lactation Consultant (IBCLC) or other health professional. The ABA’s booklet ‘Too Much’ has tips for helping oversupply problems and Why Is My Baby Crying? which has lots of suggestions for soothing unsettled babies.

In conclusion, there are several types of lactose intolerance, as explained above, but it is very rare for a baby to have to stop breastfeeding because of this condition. Except for the extremely rare primary type, there is always a cause behind lactose intolerance in babies. Getting to the cause and fixing that is the key to resolving the baby’s symptoms of lactose intolerance.

References:

Brodribb W (ed), 2nd ed. Breastfeeding Management in Australia, Merrily Merrily Enterprises Pty Ltd 1997.
Lawlor-Smith C & Lawlor-Smith L, 1998, Lactose intolerance, Breastfeeding Review 6(1): 29-30
Leeson R, 1995, Lactose intolerance: What does it mean? ALCA News 6(1): 24-25, 27.
Minchin M, Food for Thought, Alma Publications 1986.
Rings EHHM et al, 1994, Lactose intolerance and lactase deficiency in children, Current Opinion in Pediatrics 6: 562-567.
Woolridge M, Fisher C 1988, Colic, ‘overfeeding’ and symptoms of lactose malabsorption in the breast-fed baby: a possible artifact of feed management? Lancet (ii): 382-384.

Minor revision August 2006

This article was reproduced from the Australian Breastfeeding Association.