A 32-year-old primigravida gave birth to a full-term healthy girl following an uneventful pregnancy and a spontaneous, uncomplicated, vaginal delivery. Prior to delivery, the mother, who had a graduate degree, had attended prenatal classes; completed a breastfeeding course; and indicated, via a questionnaire, that she was confident about her intention to breastfeed for 12 to 18 months. She was taking maternity leave and had an encouraging support system, including her spouse, family, and friends. Seventeen minutes after delivery, she had sustained skin-to-skin contact with her newborn and began breastfeeding. This contact continued for 2 hours (documented via videotape).
In a telephone conversation 2 weeks post delivery, the mother stated that the breastfeeding was “going pretty well.” A “split nipple” had caused pain (6 on a 10-point scale) but had healed quickly, and she felt this brief event had had little effect on her breastfeeding. She had experienced no other possible complications of breastfeeding, specifically, postpartum depression, need for medications, maternal health issues, insufficient milk supply, need to return to work, embarrassment when breastfeeding in public, and infant's use of a pacifier.
In a further conversation 4 weeks post delivery, the mother reported that the baby was “gassy and uncomfortable” and “difficult to feed” and that she “had a sore bottom with blisters from stool.” Two days later, the infant's pediatrician diagnosed lactose intolerance and immediately placed her exclusively on soy-based formula. The mother stated that she was “bummed about not being able to breastfeed but relieved that [her daughter's] symptoms improved within a week of being [switched] to formula.”
This report questions a diagnosis of lactose intolerance in a breastfed infant. While the infant's disposition did improve on the soy formula, this improvement does not necessarily substantiate a diagnosis of lactose intolerance, nor does it support the physician's instructions to discontinue breastfeeding. A number of other diagnostic considerations must be seriously considered.
Breastfeeding is the optimal way for infants to obtain nutrition during the first year of life and is an important goal in Healthy People 2020.1,2 Breastfeeding exclusively for the first 6 months of life is endorsed by many health organizations, including the American Academy of Family Physicians; American Academy of Pediatrics; American College of Nurse-Midwives; American College of Obstetricians and Gynecologists; American Dietetic Association; Association of Women's Health, Obstetric and Neonatal Nurses; and the National Association of Pediatric Nurse Practitioners.2,3 The Academy of Breastfeeding Medicine is a source of evidence-based practical protocols for health professionals,4 while consumer-oriented organizations, such as La Leche League, provide valuable mother-to-mother support. Breastfeeding reduces a child's risk for nonspecific GI infections, acute otitis media, asthma, obesity, type 2 diabetes, and hospitalizations secondary to lower respiratory tract infections.2,5 Breastfeeding also potentially reduces the rate of breast cancer for mothers.2
Three primary factors contribute to sustained breastfeeding: (a) initial skin-to-skin contact (placing the newborn prone on the mother's bare chest), (b) mother's intent to breastfeed, and (c) mother's participation in prenatal classes.6,7 Factors associated with early cessation of breastfeeding include use of formula supplements in the hospital; sending a new mother home with infant formula; infant's use of a pacifier; and mother's limited education, young age, unmarried status, low income, need to return to work, decreased confidence with breastfeeding, and postpartum depression.8–12 The mother in this case did not exhibit any of these negative factors. She was a participant in a study on mother-infant behaviors in the 2 hours following birth13 and gave written informed consent for ongoing contact. The study was conducted by a team led by Nancy G. Powers, MD, and approved by the Institutional Review Board at Wichita State University, Wichita, Kansas, and the hospital where the infant was born.
“Taking sufficient time to assess the breastfeeding and the infant's reactions is vital to accurately diagnose the problem's source.”
Diagnosing lactose intolerance Lactose is found in breast milk, dairy products, and infant formulas. When ingested, lactose is hydrolyzed into its monosaccharides, galactose and glucose, with the assistance of the lactase enzyme found in the brush border of the small intestine. After hydrolysis, these simple sugars are absorbed in the microvilli of the small intestine and used for nutrients.14
Lactose intolerance is identified when an infant develops such symptoms as diarrhea, abdominal pain and distention, flatulence, nausea and/or vomiting, within 30 to 180 minutes after ingesting lactose or lactose-containing products. The intolerance is caused by the absence of, or a deficiency in, the lactase enzyme, resulting in a disruption of lactose hydrolysis and absorption in the intestinal lumen. Consequently, fluid is drawn into the intestinal lumen, resulting in diarrhea. Once the undigested lactose reaches the colon, it is fermented by bacteria. The hydrogen gas and fatty acids that form subsequently cause abdominal distention and flatulence and contribute to pain, nausea, and vomiting.14
The four categories of lactose intolerance are as follows:
- Developmental—seen in neonates born at less than 34 weeks' gestation who have decreased lactase enzyme due to their immature GI tract
- Congenital—a rare condition seen in newborns subsequent to the introduction of a lactose-containing product, such as human milk or formula
- Primary—an autosomal recessive condition, uncommon before 2 to 3 years of age, in which lactase activity and production decrease as the child reaches adulthood
- Secondary—a temporary condition caused by an underlying pathologic condition that damages the intestinal wall, such as gastroenteritis, GI surgery, irritable bowel syndrome (IBS), malnutrition, celiac disease, Crohn disease, effects of broad-spectrum antibiotics, or effects of quinidine.14
Lactose intolerance can be confused with other conditions and thus misdiagnosed. These conditions include an allergy to cow's milk protein. To evaluate this possibility, a breastfeeding mother can cease consuming foods containing cow's milk products. In an interview, Nancy Powers, MD (December 2010), stated that if the newborn's symptoms improve, breastfeeding can continue, a view also held by others.14,15 The mother in this report was not instructed to avoid cow's milk and dairy products in her diet before being advised to feed her baby soy formula.
Other confounding conditions include oversupply of breast milk and overactive milk ejection reflex. Oversupply typically is seen when the mother has more milk than the baby can drink and results in the infant's not consuming the fattier hindmilk toward the end of the feeding. The infant's high-volume, low-fat intake results in fast gastric clearance and a large lactose load in the small intestine, causing symptoms that resemble lactose intolerance. Overactive milk ejection reflex occurs when the mother's let-down reflex is either too fast for the baby to handle or too forceful. The baby often will swallow excessive air as it tries to cope with the rapid flow of a large volume of milk, leading to excessive gas, abdominal distention, fussiness, and loose bowel movements (interview, Powers).
Diagnosis and management When symptoms of apparent lactose intolerance manifest, taking sufficient time to assess the breastfeeding and the infant's reactions is vital to accurately diagnose the source of the problem. A knowledgeable PA can provide valuable support throughout this process and recommend studies to facilitate the diagnosis. In the breastfed infant, maternal oversupply or overactive milk ejection is more common than true lactose intolerance. Both conditions are typically diagnosed by history and physical examination without the need for laboratory tests.
The management of oversupply depends upon the cause. Short frequent feedings are addressed by offering only one breast per feeding episode. Each breast is used only every 4 to 6 hours, which will initially cause some engorgement but over time will decrease production. If a woman is expressing extra breast milk and storing it, Powers recommends that she gradually stop. Reduction of milk supply continues until the baby's symptoms improve. In addition, mothers who have an overactive milk ejection reflex can try posture feeding (lying on her side or reclining with baby on top) or expressing milk onto a cloth until the flow slows sufficiently for the baby to tolerate the feeding.
If improvement does not occur within 1 to 2 weeks of starting breastfeeding management, further workup may proceed for lactose intolerance. Laboratory studies include an evaluation of fecal pH to assess undigested sugars,14,15 a hydrogen breath test, and a blood lactose tolerance test. The latter, though valid, is not often used in clinical practice. PAs can be instrumental in suggesting that this test be included in an evidence-based assessment. A diet in which lactose-containing products are removed from the infant's diet for 2 weeks can also be implemented to see if symptoms abate. Parents then reintroduce lactose products and observe the infant for the return of any symptoms. If symptoms abate and then return, the infant may be lactose-intolerant.
Treatment Once a diagnosis of lactose intolerance is made, treatment can begin. Lactose-free infant formulas are the only treatment available for infants who have congenital or developmental lactose intolerance. Secondary lactose intolerance in the breastfed infant can be treated by continued breastfeeding. Although human milk contains lactose, it is antimicrobial and anti-inflammatory and contains growth factors for GI mucosa. Superior to any of the infant formulas, human milk is usually well-tolerated during conditions that predispose to brush border injury and may avoid or shorten the period of lactose malabsorption (interview, Powers). Alternatively, temporary consumption of a lactose-free diet or bowel rest and treatment of the underlying pathology can be implemented.14 Infants can be given lactose-free formula until the intestinal wall has healed. Breastfeeding mothers who are not encouraged to continue breastfeeding their infants throughout periods of acute gastroenteritis can express and save their breast milk until the infant is fully thriving and the stool is of normal consistency. When these are achieved, breastfeeding may be reintroduced. If diarrhea returns after reintroduction, the amount of time until reintroduction is lengthened.15,16
- Lactose intolerance can take one of four forms: developmental, congenital, primary, or secondary.
- Symptoms suggestive of lactose intolerance may be due to an allergy to cow's milk protein, oversupply of breast milk, or an overactive milk ejection reflex.
- Depending on the cause of the symptoms, some mothers may be able to continue to breastfeed.
This case reveals how quickly a diagnosis that was made to support the health of the infant became a barrier to breastfeeding. Based on current research in lactose intolerance and the timeline of this infant's complications with breastfeeding, the probability is high that lactose intolerance was not the primary cause of the presenting difficulties. The symptoms could have resulted from maternal oversupply or overactive milk ejection. JAAPA
2. Gartner LM, Morton J, Lawrence RA, et al. Breastfeeding and the use of human milk. Pediatrics.
3. Centers for Disease Control and Prevention (CDC). Major health professional organizations' policies and positions on promoting breastfeeding. CDC Web site. http://www.cdc.gov/breastfeeding/policy/index.htm
. Updated July 15, 2011. Accessed March 7, 2013.
4. Wight NE, Cordes R, Chantry CJ, et al. ABM clinical protocol #3: hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate, revised 2009. Breastfeed Med.
5. Chandran L, Gelfer P. Breastfeeding: the essential principles. Pediatr Rev
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10. Santo LC, de Oliveira L, Giugliani ER. Factors associated with low incidence of exclusive breastfeeding for the first 6 months. Birth.
11. Ladomenou F, Kafatos A, Galanakis E. Risk factors related to intention to breastfeed, early weaning and suboptimal duration of breastfeeding. Acta Paediatr.
12. Dunn S, Davies B, McCleary L, et al. The relationship between vulnerability factors and breastfeeding outcome. J Obstet Gynecol Neonatal Nurs.
13. Powers NG, Parham DF, Goldberg LR. Overcoming barriers to investigating mother-infant interactions in the first two hours of life. J Hum Lact.
14. Heyman MB, American Academy of Pediatrics Committee on Nutrition. Lactose intolerance in infants, children, and adolescents. Pediatrics.
15. Bartrop RW, Hull D. Transient lactose intolerance in infancy. Arch Dis Child.
16. Hošková A, Šabacký J, Mrskoš A, Pospíšil R. Severe lactose intolerance with lactosuria and vomiting. Arch Dis Child.