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what’s the difference between lactose intolerance and cow’s milk allergy?

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Many people are confused about the difference between lactose intolerance and cow’s milk allergy. Misunderstood as same condition; the terms lactose intolerance and cow’s milk allergy are used interchangeably and incorrectly.  Most likely due to the similarity of symptoms such as bloating, wind and diarrhoea;  both being related to drinking milk and alleviated by avoiding it. When I say milk – I mean mammalian milks such as cow’s (including infant formula) goats, sheep and human milk.  So, here is the main difference:  Cow’s Milk Allergy is an immune system response to milk protein, which drives a spectrum of symptoms affecting the skin as well as the tummy.  In the more severe IgE allergic reactions, the mouth, throat and breathing are affected. Lactose intolerance is not an allergy but a physical response due to lack of digestive enzyme lactase required to digest the milk sugar lactose. This blog will give an overview of symptoms, causes and dietary management of lactose intolerance providing further links on products and nutritional information.

Lactose Intolerance
Is a normal response to the presence of undigested lactose (milk sugar) in the large intestine. When lactose digestion fails in the small intestine the lactose sugar travels onto the large intestine where bacterial fermentation, responsible for the characteristic bloating, discomfort and wind, takes place. In the presence of large amounts of lactose, water and salts are drawn into the large bowel (by osmosis) causing increased water volume, urgency to go to the toilet and explosive stools. Lactose is found in milk and dairy products like soft cheese and yoghurts.  Hard cheeses have naturally low levels of lactose, as do products like butter, margarine and double cream.  Adults and older children with established lactose intolerance can typically eat these foods without any problem. Those small amounts of lactose provide food for the friendly lactobacillus bacteria which normal live in the large bowel.

What are the causes of lactose intolerance?
Lactose intolerance itself does not cause damage to the small intestine; rather it’s the result of tissue damage to the intestinal lining which affects lactase enzyme production.  A temporary condition in infants and young children, it will resolve as the gut cells turnover and repair themselves. Lactase enzyme decreases progressively with age with around 70% of the world’s population with limited lactase activity.  Persistent lactose intolerance is uncommon in infants and young children, due to their high milk intake, which maintains enzyme production. Teenagers however may not regain their lactase activity following small intestinal damage or serious infection.  The most common causes of lactose intolerance include:

  • Gastro-intestinal infection with characteristic diarrhoea and vomiting
  • Allergic inflammation, especially with unresolved non-IgE Cow’s Milk Allergy
  • Small bowel bacterial overgrowth eg. in older children, teens

Products and differences in dietary management 
It’s important to understand that the nutritional composition of milk alternatives make them unsuitable as drinks for infants and toddlers, but can be a useful addition to solids, when a nutritious fluid is needed to blend or mix.  When selecting a milk alternative, always choose one fortified with calcium. Lactose free milks and cheeses made from cow’s milk contain cow’s milk protein, making them unsuitable for those with cow’s milk allergy.  Vegan cheeses, whilst lactose and cow’s milk protein free have poor nutritional value and are not fortified with any calcium.  A low lactose diet to treat lactose intolerance is usually followed for between 2 and 6 weeks (depending on severity of symptoms) and a cow’s milk protein exclusion for CMA for at least 6 months. Use this guidance on reintroducing lactose back into the diet  if you had lactose intolerance but do seek further guidance for Cow’s Milk Allergy in Infancy if feeding is difficult and you are unsure about next steps.

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reintroducing lactose back into the diet

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Following a 2 – 6 week low lactose diet to treat lactose intolerance, your child should now be well on their way to recovery from symptoms.  Reintroducing lactose back into the diet in a controlled way is the next step. Starting with low lactose foods, then adding in medium and, once you’re satisfied all is being tolerated, finally adding in high lactose-containing foods. Use the guidance below on lactose content of dairy foods to assist you, taking about 2-4 weeks, gradually increasing, will do several things:

  • stimulate production of lactase, the small intestinal digestive enzyme that digests lactose
  • help establish and then increase the amount of dietary lactose that is tolerated
  • assist in the build up and return of normal lactase production in the small intestine

Re-establishing tolerance to lactose
Re-establishing tolerance to lactose varies from child-to-child, depending on age, habitual diet and degree of severity. Because infants and young children are more dependent on a high milk diet, the lactase enzyme returns more readily and lactose intolerance is usually temporary.  Resumption of a normal diet is somewhere between 2-6 weeks for most infants and children. Referred to as secondary lactose intolerance this is often the result of nasty gut bugs like rotavirus, or can be secondary to small intestinal damage caused by untreated cow’s milk protein allergy or coeliac disease. Individuals including older children and teens may develop primary lactose intolerance or a permanent reduction in lactase enzyme, more typically affecting non-caucasian children and those with a habitually low milk/no milk intake following a similar route via infection of small intestinal irritation.  Amounts of 2 – 4g lactose per day are usually well tolerated despite the lack of lactase enzyme.  Instead lactose is digested by the lactobacillus bacteria, naturally residing in the large intestine.

Other points worth noting about lactose intolerance and reintroduction

Special care with infants
Formula fed babies with lactose intolerance, need a lactose free formula. Lactose intolerance may also occur in breast-fed babies but is less common; only in very rare congenital primary lactase deficiency would there be a need to stop breast feeding and use a lactose free formula. What is important, is to correctly identify if cow’s milk allergy are the cause of the symptoms, to ensure that infants get the right dietary treatment. Products in the shops vary enormously in nutritional composition, and are not suitable to drink because of poor nutritional quality.

Lactose content of dairy foods

Very Low Lactose

< 2g per portion

 Medium Lactose

2-4g per portion

 High Lactose

4-6g per portion
The foods in this group contain very low amounts of lactose and are tolerated by most people with lactose intolerance.  If consuming these foods does not give any symptoms, try medium lactose foods per portion. Continue to introduce lactose containing foods, including foods with medium lactose. If symptoms return, go back to the previous tolerated stage for 2 weeks and try again. In addition to very low and medium lactose content foods, continue to introduce lactose-containing foods, including one portion from the high lactose category.
Cheese 1oz
Most hard cheeses have very small amounts of lactose and are unusually well tolerated. Eg. cheddar, red leicester, caerphilly, stilton, parmasan Cheese spread, cottage cheese, soft cheeses eg. ricotta, marscapone, dolchelate Cheese spread, quark

 
Yoghurts & fromage-frais 60g 125g Larger portion
Greek yoghurt, Goat’s yogurt, all yoghurts and fromage-frais Yoghurts and fromage-frais, Low fat fruit yoghurts, Organic whole milk yoghurt Natural whole or fruit yoghurt, Low fat natural yoghurt, Diet/low calorie yoghurts
Dairy desserts & creams 2oz 4 – 6oz Larger portion
Half fat cream, Single, Double, Whipping, Clotted cream, UHT Spray Cream, Fresh Cheese Cake 1 scoop ice cream, Frozen cheesecake, Trifle with cream, 1 chocolate mousse 2 scoops ice cream, 10mls Angel Delight, 150g tinned rice pudding, 100mls Custard
Hidden milk
1 x small slice cake, 4 chocolate digestives, 1 chocolate coated biscuit eg. 2 finger kit-kat, 100g egg custard tart 1 milk chocolate bar, 125mls whole milk, 70mls evaporated milk, 1 tblsp skimmed milk powder, 40mls condensed milk
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nutritional composition of milk alternatives

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If you have a child who has lactose intolerance or cow’s milk allergy, chances are you need to think about the nutritional composition of milk alternatives. Cow’s milk and its products are good sources of calcium and trace elements like iodine in the UK diet.  As someone who takes nutrition seriously, a Paediatric Dietitian and mother of 3 growing teenagers, I would like to point out that the nutritional composition of milk alternatives available in our shops is shockingly poor.  It does not serve consumers well, has insufficient nutrition for infants, children or teens, and for those who depend on the nutrients milk would normally provide.  The missing nutrients and their physiological roles are as follows:

  • calcium – for growth and maintenance of strong bones, blood clotting
  • iodine – for neurological development during pregnancy, control of metabolism, thyroid function
  • Vitamin B2 – for healthy skin, eyes and nervous system, releasing energy from food
  • protein – for growth and repair of all body tissues, immune function
  • Vitamin B12 – assists in maturing red blood cells, absorption of iron
  • lactose – the milk sugar – food for the beneficial lactobacillus genus of bacteria, maintenance of a healthy intestinal microbiota

Exciting range of nut milks
I was quite excited to see such an explosion of nut milks now routinely available; and on researching this recently, felt somewhat aggrieved to see such poor nutritional composition.  Nuts are one of nature’s most incredibly nutritious foods – high in calories, protein, essential fats, minerals like zinc, calcium, iron and magnesium as well as B vitamins. They are also (currently) fairly conflict-free and sustainable. There are not many foods you can say that about! Unfortunately none – and yes I do actually mean NONE – of that goodness is retained in the resultant, washed out and expensive product marketed as milk.  Some have no calcium, no protein, no minerals no vitamins, and poor calories. Mil for mil they are 7 times the price.

Compare the nutritional composition of milk alternatives in the chart below, and take care to ensure that you choose ones with higher calories and protein for young children, ensuring they are fortified with calcium, and where possible Vitamin D and other vitamins.

Type of Milk Calories Protein Calcium Vitamin D Extras
Whole Cow’s Milk 69 3.3 120 Low Wide range of nutrients
Cow’s Milk formula 66 1.3 65 1.2 Full range of nutrients
Mature Breast Milk 67 1.3 35* Varies Wide range of nutrients
Goats Milk 70 2.8 120 Low Wide range of nutrients
Arla Lactose Free Milk 56 3.3 120 Low Wide range of nutrients
KoKo unsweetened 16 0.2 120 0.75 Nothing
Oatly Original 46 1.0 120 1.5 Vitamins
Innocent Hazelnut Milk 72 1.0 0 0 Nothing
Innocent Almond Milk 37 1.4 0 0 Nothing
Alpro Soya Original 42 3.3 120 0.75 Vitamins
Alpro Cashew Milk 23 0.5 120 0.75 Vitamins
Alpro Soya Growing-Up 1-3 64 2.5 120 1.5 Iodine, Vitamins
Rice Dream plus calcium 50 0.1 120 0.75 Not for <5years
  • absorption of calcium from breast milk is extremely efficient, but infants needs for calcium from 6-12 months through are high.  Check out  good sources of calcium if weaning your cow’s milk allergic infant.
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innovative treatments in cow’s milk allergy

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Innovative treatments in cow’s milk allergy is the last in this 5-part blog series on Cow’s Milk Allergy in Infancy and is best read following positive outcomes for cows milk allergy.

Infants who develop Cows Milk Allergy (CMA) usually outgrow it before they start school. Until recently, dietary treatment was based on strict cow’s milk avoidance for long periods; typically 1-2 years. Introduction is now advised at an earlier age, especially for those with delayed reactions affecting the gut. Starting with tiny amounts of baked milk as early at 9 months, identifies those infants who are ready to start building tolerance. It is now believed that strict avoidance for long periods is unhelpful in promoting tolerance.¹ Infants with more severe (IgE) reactions do take longer to outgrow their allergy, and care needs to be taken to make introductions safely for those infants.

Active Allergy Management
Active Allergy Management is one of today’s most innovative treatments in cow’s milk allergy. It can be described as the deliberate, early introduction of tiny amounts of milk proteins in a controlled way. Effective and safe for the majority of infants with CMA, the timing of this introduction depends upon age and the type and severity of previous reactions. See my blog identifying symptoms of cow’s milk allergy for more information. Tolerance to baked milk is now used as a marker of readiness for the next steps of cows milk reintroduction.²  This step-wise approach is known as the Milk Ladder, the earliest introduction of which can begin for non-IgE CMA around 9 months. Actively exposing an infant and educating the immune system in this way, enables young children to eat a normal diet at any earlier age.

The Infant Microbiota
The infant microbiota describes the total number of microbes living in an infants gut. Recent research shows earlier tolerance to cow’s milk using CMA treatment formulas with the added probiotic microbe strains Lactobacillus rhamnosus or Bifidobacteria breve . Other treatment formulas with added prebiotic co-factors (specialised sugars called oligosaccharides) may also be helpful, by providing food for these beneficial microbes. Breast feeding is known to be protective for food allergy. Although the mechanisms are not entirely understood, the higher numbers of lactobacillus and bifidobacteria which dominate the microbiota of breast fed babies are likely to be involved. Intimately involved with educating the immune system, the infant microbiota has a key role to play in allergy development and management.  Specialised formulas are now available (on GP prescription) which mimic the breast milk provision of those beneficial microbe species alongside prebiotic co-factors that help colonise the infant microbiota, with earlier resolution for children with Cow’s Milk Allergy.

  1.  Dietary baked milk accelerates the resolution of cow’s milk allergy in children, Kim JS et al 2011
  2. Tolerance to baked and fermented cow’s milk in children with IgE mediated and non IgE mediated CMA in patients under 2 years, Uncuoglu A et al, 2017

Next An introduction to the Infant Microbiome

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