Lactose intolerance
feeding babies and children with severe diarrhoea: lactose Marion Kelly 08.09.97
Re: feeding babies and children with severe diarrhoea: lactose barbara elaine golden 08.09.97
lactose in f75/f100 André Briend 09.09.97
diarrhoea and f100/f75 Michael H.N.Golden 09.09.97
Lactose intolerance Peter Sullivan 09.09.97
lactose in infants with diarrhoea Marion Kelly 09.09.97
more on yogurt André Briend 09.09.97
RE: Lactose intolerance in acute diarrhoea Peter Sullivan 10.09.97
yoghurt ref André Briend 11.09.97
lactose and diarrhoea Marion Kelly 11.09.97
lactose and diarrhoea barbara elaine golden 15.09.97
Lactose intolerance no name 17.09.97
lactose intolerance Andre Briend 20.10.97
Re: lactose intolerance Mike Golden 20.10.97
Re: Lactose intolerance and hunger (USDA news) -COMMENTARY David Brewster 20.10.97
Re: Lactose intolerance Benjamin Torun 23.10.97
milk in malnutrition again Mike Golden 23.10.97


Date: Mon, 8 Sep 1997 12:12:08 +0000

Subject: feeding babies and children with severe diarrhoea: lactose


Dear all,

Grateful for your views on the most appropriate and cost-effective way to feed young babies and children hospitalised with severe diarrhoea, who may or may not be malnourished.

My understanding is that a low-lactose feed is recommended, but is this best achieved by giving them (i) lactose-free milk, (ii) yogurt made from ordinary milk, (iii) F75/F100 or (iv) something else.

Does anyone know the approx price of lactose-free milk, and if so, how does it compare with the cost of F75/F100 (which I understand is about US$ 3000)?

Thanks in advance,



Mon, 8 Sep 1997 18:48:06 +0100 (BST)

From: barbara elaine golden <>

Subject: Re: feeding babies and children with severe diarrhoea: lactose


I think you're wrong in assuming that infants with diarrhoea need lactose-free milk. Breastmilk's only sugar is lactose. Very very rarely do infants have 1ary lactase deficiency: 2ary lactase deficiency SOMETIMES follows acute diarrhoea. This is not a reason to change infants with acute diarrhoea to lactose-free milk. If acute diarrhoea in an infant being fed lactose-containing milk (breast or bottle/cup) persists and gains the characteristics of lactose intolerance (explosive, watery, acid 'burns' bottom, distended abdomen but infant not feverish etc) then lactose-free milk is indicated, otherwise, I would continue breast or bottle/cupfeeding the usual feed, unless refusing or vomiting ++ in which case, a diluted, not lactose-free! milk and/or ORS is indicated.

Barbara G



Clinical Senior Lecturer, Child Health

Tue, 9 Sep 1997 08:30:01 +0100 (BST)

From: (Andre' BRIEND)

Subject: lactose in f75/f100


Dear Ngonuts,

Some remarks, to reinforce Barbara's mail (if needed).

Risk of lactose induced diarrhoea is present only if lactose arrives undigested to the colon.

The risk is higher with rapid gastro intestinal transit. Gastric emptying is faster for low energy liquids, as shown by data obtained here on healthy volunteers:

1/2 gastric emptying time 500 ml
1/2 cream milk 39'
full cream milk 74'
F100 81'

Another way to examine the problem is to relate lactose content of different milk formulas to their energy content. If one assumes that gastrointestinal transit is slower for high energy feeds, this is the proper way to examine lactose content.

lactose g per 1000 kcal
Human milk 107
whole milk 60
f100 40
f75 12

There is no logic in worrying aoubt lactose content of f100 (even more F75) and advocating breast milk for children with diarrhoea (a point nobody will dispute). By the way, I think that lactose intolerance with breast milk is also avoided by a technique we should copy: small frequent feeds of milk at 37 °C.



Dr. Andé Briend

Tue, 9 Sep 1997 09:59:20 +0100 (BST)>

Subject: diarrhoea and f100/f75

From: Mike Golden


Following Marion's request this is just to remind readers that F75 and F100 are formulated specifically for the severely malnourished to be used under supervision. It is very low in iron and is not suitable for longer term feeding of normal children. Also it has not been tested specifically in the child whose primary problem is acute diarrhoea - indeed, a product with a lower osmolality would probably be better in this situation. Some children with persistant diarrhoea have an increase in stool frequency when they start F100 - a problem which is of concern to those treating these children and which we are examining with a low-osmolality version of F100.

Clearly, it is our goal to harmonise the dietary management of severe malnutrition and persistant diarrhoea - a child with both conditions gets quite different dietary management depending upon the outlook of the doctor he first sees.

Best wishes,


Prof. Michael H.N.Golden

Date: Tue, 09 Sep 1997 16:34:45 +0000

From: (Peter Sullivan)

Subject: Lactose intolerance


Dear Ngonuts,

I think that it is important not to overstate the problem of lactose intolerance in children with acute diarrhoea and agree with Andre and Barbara that continued breast feeding is imperative.

Even though breast milk contains a greater concentration of lactose than cow milk it is well-tolerated in acute diarrhoea - it has a lower osmolality and higher enzyme content ( as well as all its other manifold benefits) and is given in smaller quantities and more frequently than non-brest-milk feeds.

In formula-fed or straight cow milk fed infants, however, lactose intolerance MAY be a problem but usually in those younger infants with very severe diarrhoea and who are also malnourished . The options for these children include the following:

1. A proprietary low-lactose formula such as soy-formula. The problem here is their cost and lack of availability. This is not a viable option in most developing countries.

2. The use of yoghurt as Marion suggested. Yoghurt contains its own beta-galactosidase and has been shown to alleviate lactose malabsorption and would be a viable option.

3. The most promising option, however, in my view would be the use of foods fermented with Lactobacilli. Acute diarrhoea in malnourished children significantly alters the balance of the enteric microflora and, coupled with lactase deficiency secondary to small intestinal mucosal damage, the increase in lactose delivered to the large bowel creates a "brew" in the colon leading to the explosive watery acidic diarrhoea that Barbara described. "Probiotic" therapy with Lactobacillius sp. or Bifidobacteria sp. incorporated into fermented products could aid recolonisation of the large bowel as well as improving intestinal permeability, inhibiting bacterial attachment and invasion of intestinal cells. Several studies have demonstrated how this approach can attenuate acute episodes of diarrhoea.

This is an inexpensive technology very appropriate for use in developing countries which has not been exploited to its full advantage.

I hope these thoughts are useful and not considered to be a "privileged view of the bloody obvious"

Best wishes



Dr Peter B Sullivan MA MD FRCP FRCPCH

University of Oxford, Department of Paediatrics

John Radcliffe Hospital, Oxford OX3 9DU, UK

Tel: Int-44-1865-220934, Fax: Int-44-1865-220479


Date: Tue, 9 Sep 1997 18:20:50 +0000

Subject: lactose in infants with diarrhoea



To everyone who has responded to my query:

Many thanks for so many prompt replies and such helpful advice! I whole-heartedly and completely take Barbara's and Andre's points about the value of breastmilk, but was particularly interested in Peter Sullivan's comments (certainly not a privileged view of the bloody obvious!) concerning young artificially-fed babies with severe diarrhoea (many of whom are malnourished), since this is one of the groups for which low-lactose feeds have been most strongly advocated by the implementing agency in the particular situation that I have been asked to advise on. My initial suggestion of using yogurt rather than lactose-free milk was met with some uncertainty as to whether it would be suitable for the youngest babies (< 6 months).

Peter, I'd be grateful if you could give me references for the studies you mentioned, together with any specific suggestions/recipes for any other fermented foods that might be of use in the feeding of young artificially-fed babies with severe diarrhoea.

Thanks also to Mike G for info on F75 and F100 in this context, and for setting up the network in the first place and helping me join -- I'm amazed at what good value I'm getting!!!

best wishes to all,



Wed, 10 Sep 1997 09:46:30 +0200 (METDST)

From: (Andre' BRIEND)

Subject: more on yogurt


Dear NGO nuts,

Here are some statements of the obvious about the use of yogurt in diarrhoea/malnutrition (It took me several years to understand that. Sorry for those who have known all this for years).

As Peter said, yogurt has some potential advantages to feed the malnourished child or children with diarrhoea (I don't want to preempt his further comments about this point).

The idea of using yogurt in relief has been bounced around for several years but bumped into the problem of finding an adequate ferment.

All ferments we found from the industry to produce yoghurt had the major disadvantage of being very sensitive to theat. They have to be kept in a cold chain, very much like vaccine.

The logistics is difficult. The idea did not really take off.

Another alternative would be to use locally available ferments. Herdkeepers have produced yoghurts for thousands of years before the industry. The problem here is that we never know whether they are safe in terms of contamination, and, to a lesser extent, production of D lactic acid (see below). Some work is needed to assess the safety of these traditional locally available ferments.

Yogurt traditionnally is not advised in young children, because it produces D lactic acid which is not metabolised and may in theory produce acidosis. We don't know how it is metabolised in the malnourished child and whether this is a real problem. I understood that production of D lactic acid is more pronounced in hot climates and when fermentation is prolonged.

A breakthrough would be to have a ferment producing only L lactic acid (you can find some on the market) and which would be heat resistant (I never heard of such a bug). Several of us asked around for such a bug but did not find it (to be fair, we did not ask wfp, I am afraid).

Any suggestion, comment, experience from the field most welcome.



Dr. André Briend

Date: Wed, 10 Sep 1997 16:10:04 +0000

From: (Peter Sullivan)

RE: Lactose intolerance in acute diarrhoea


Dear Ngonuts,

Marion asked for some references on the subject of yoghurt and fermentation and I have attached a selection from my database.

With reference to Andre's comments about D-Lactic acid I suspect that the possibility of metabolic acidosis in malnourished children fed yoghurt is a more theoretical than real risk as the quantity of D-lactic acid is likely to be very small. Nevertheless, this aspect has never (to my knowledge) been formally studied.

There is quite a lot of experience with fermentation of foods - a traditional method of food processing in some countries (eg nono and DogiK in Nigeria) and these have been used succesfully in the management of both acute and persisitent diarrhoeal disease in children. I have suggested that Jeya Henry who has much more experience of this than I do should perhaps give us the benefit of his comments.

Here are the references:

1. Gallagher CR, Molleson AL, Caldwell JH. Lactose intolerance and fermented dairy products. J Am Diet Assoc 1974; 65:418 419.

2. Lembcke JL, Brown KH. Effect of milk containing diets on the severity and duration of childhood diarrhea. Acta Paediatr 1992; 81 Suppl 381:87 92.

3. Gendrel D, Dupont C, Richard Lenoble D, Gendrel C, Chaussain M. Feeding lactose intolerant children with a powdered fermented milk. J Pediatr Gastroenterol Nutr 1990; 10:44 46.

4. Bhutta ZA, Molla AM, Issani Z, Badruddin S, Hendricks K, Snyder JD. Nutrient absorption and weight gain in persistent diarrhea: comparison of a traditional rice lentil/yogurt/milk diet with soy formula. J Pediatr Gastroenterol Nutr 1994; 18:45 52.

5. Shermak MA, Saavedra JM, Jackson TL, Huang SS, Bayless TM, Perman JA. Effect of yogurt on symptoms and kinetics of hydrogen production in lactose malabsorbing children. Am J Clin Nutr 1995; 62:1003 1006.

6. Nizami SQ, Bhutta ZA, Molla AM. Efficacy of traditional rice lentil yogurt diet, lactose free milk protein based formula and soy protein formula in management of secondary lactose intolerance with acute childhood diarrhoea. J Trop Pediatr 1996; 42:133 137.

7. Dewit O, Boudraa G, Touhami M, Desjeux JF. Breath hydrogen test and stools characteristics after ingestion of milk and yogurt in malnourished children with chronic diarrhoea and lactase deficiency. J Trop Pediatr 1987; 33:177 180.

8. Isolauri E, Juntunen M, Rautanen T, Sillanaukee P, Koivula T. A human Lactobacillus strain (Lactobacillus casei sp strain GG) promotes recovery from acute diarrhea in children. Pediatrics 1991; 88:90 97.

9. Garvie EI, Cole CB, Fuller R, Hewitt D. The effect of yoghurt on some components of the gut microflora and on the metabolism of lactose in the rat. J Appl Bacteriol 1984; 56:237 245.

10. Vesa TH, Marteau P, Zidi S, Briet F, Pochart P, Rambaud JC. Digestion and tolerance of lactose from yoghurt and different semi solid fermented dairy products containing Lactobacillus acidophilus and bifidobacteria in lactose maldigesters is bacterial lactase important? Eur J Clin Nutr 1996; 50:730 733.

11. Perdigon G, Nader de Macias ME, Alvarez S, Oliver G, Pesce de Ruiz Holgado AA. Prevention of gastrointestinal infection using immunobiological methods with milk fermented with Lactobacillus casei and Lactobacillus acidophilus. J Dairy Res 1990; 57:255 264.


12. Darling JC, Kitundu JA, Kingamkono RR, et al. Improved energy intakes using amylase digested weaning foods in Tanzanian children with acute diarrhea. J Pediatr Gastroenterol Nutr 1995; 21:73 81.

13. Olukoya DK, Ebigwei SI, Olasupo NA, Ogunjimi AA. Production of DogiK: an improved Ogi (Nigerian fermented weaning food) with potentials for use in diarrhoea control. J Trop Pediatr 1994; 40:108 113.

14. Willumsen JF, Darling JC, Kitundu JA, et al. Dietary management of acute diarrhoea in children: Effect of fermented and amylase digested weaning foods on intestinal permeability. J Pediatr Gastroenterol Nutr 1997; 24:235 241.

15. Shornikova A, Casas IA, Isolauri E, Mykkanen H, Vesikari T. Lactobacillus reuteri as a therapeutic agent in acute diarrhea in young children. J Pediatr Gastroenterol Nutr 1997; 24:399 404.


Dr Peter B Sullivan MA MD FRCP FRCPCH

University of Oxford, Department of Paediatrics, John Radcliffe Hospital

Oxford OX3 9DU, UK

Tel: Int-44-1865-220934, Fax: Int-44-1865-220479


Date: Thu, 11 Sep 1997 10:03:38 +0200 (METDST)

From: (Andre' BRIEND)

Subject: yoghurt ref


Here is another good ref on yoghurt:

Boudraa G et al. Effect of feeding yogurt vs milk in children with persistent diarrhea. J Pediatr Gastroenterol Nutr 1990; 11: 509-12.



Dr. André Briend

From: Marion Kelly

Date: Thu, 11 Sep 1997 16:38:02 +0000

Subject: lactose and diarrhoea


Dear Andre, Barbara, Peter, Mike and anyone else who might be listening in:

Thanks for all your observations, and for the references from Peter (I will need to order these as our library is rather limited). I have attempted to pull together your comments and drawsome conclusions - pls see below (apologies to anyone who finds this too bloody obvious; I don't mind admitting I'm learning all the time, with your help):

(a) Babies and children with diarrhoea should be breastfed.

(b) There is some risk of secondary lactose intolerance in babies with servere diarrhoea, especially if they are not breastfed and also malnourished. However, there is no need to put any infant with diarrhoea on low-lactose feeds unless they exhibit distinct signs of lactose intolerance.

(c) In the specific case of young non-breastfed infants with severe diarrhoea and signs of lactose intolerance, there are 3 options: (i) diluted lactose-containing milk (or infant formula) feeds; (ii) yogurt and/or other foods fermented with Lactobacilli; (iii) lactose-free milk.

(d) When questions of cost, logistics and safety are taken into account, expert opinion is divided as to which of these 3 options is most appropriate in emergency situations.

Grateful for any comments on the above, including comments from Jeya Henry, as suggested by Peter. I hope we will be able to discuss this further in Birmingham on 7 November.

best regards,



From: barbara elaine golden <>

Subject: lactose and diarrhoea

Date: Mon, 15 Sep 1997 14:06:05 +0100 (BST)


Dear Marion,

I agree with your 'conclusions' from the discussion you instigated, but feel moved to emphasise that (c)(i)(diluted lactose-containing milks) should be under close observation as, in my experience, the symptoms of full-blown 2ary lactase deficiency tend to persist unless lactose intake is drastically reduced, in which case intake of everything's inadequate! For this condition, soya formula's a good alternative. In fact, the full-blown picture's uncommon and many infants with apparent lactase deficiency, after a few days' diluted feeds, are back to full lactose-containing feeds. Incidentally, in Jamaica, we rarely had to put severely malnourished infants on lactose-free milks because of lactase deficiency. I didn't think malnourished infants were particularly prone to 2ary lactase deficiency. Is it different elsewhere?





Date: Fri, 17 Oct 1997 10:16:00 -0400 (EDT)

Subject: Lactose intolerance



USDA ARS News Service

A researcher with the Children's Nutrition Research Center in Houston, Texas, may have an insight on a tragic medical mystery that some pediatricians call "paradoxical re-feeding response." The problem: Some malnourished children die during treatment instead of being revived.

Buford Nichols, a pediatrician at the Houston center, headed a study that suggests prolonged hunger in infants may suppress part of the genetic coding for lactase. This enzyme digests the milk sugar lactose. Nichols' study is the focus of an article just published in the medical journal Gastroenterology.

The Houston center is administered jointly by USDA's Agricultural Research Service and Baylor College of Medicine.

Most starving children and infants respond well to international treatment efforts. But 10 to 20 percent get sicker and die. If Nichols' findings are validated by other similar studies, they may generate discussion among physicians on the value of lactose-free treatments when others don't succeed. This hunger-related intolerance appears fundamentally different from genetically inherited lactose intolerance. The difference appears to occur on the cellular level. The good news: Unlike adult lactose intolerance, this condition is temporary. It abates after the child receives adequate nutrition.

Nichols found the cellular lactase connection by studying 29 infants recovering from malnutrition at a clinic at the University of Sao Paulo in Brazil. The infants had not responded well to re-feeding formulas, but intestinal biopsies ruled out diseases that might have affected recovery.

Nichols compared tissue samples from the malnourished infants to those of 10 well-fed infants hospitalized for a life-saving surgery that required removal of some intestinal tissue. The comparison led Nichols to his conclusions.

Lactose can come in many formsQfrom human breast milk to some nations' international food-relief products. USDA's Farm Service Agency, on the other hand, provides lactose-free corn-soy or wheat-soy blends for U.S. relief efforts overseas.

Date: Mon, 20 Oct 1997 09:21:58 +0200 (METDST)

From: (Andre' BRIEND)

Subject: lactose intolerance


Dear NGO nut's

I guess the paper referred to in the previous mail on lactose intolerance is the one quoted below. Better to go back to the original paper rather than rely on a press release.

The sentence at the end of the press release :

"USDA's Farm Service Agency, on the other hand, provides lactose-free corn-soy or wheat-soy blends for U.S. relief efforts overseas."

is not in the original paper. A simpe comparison of weight gains or survival of children on lactose containing f/75 and f100 and lactose free CSB shows that lactose in not the most important problem in feeding malnourished kids.

US made CSB obviously is not the solution to the problems raised in Nichols's paper. The last sentence of the press release is not info, but dishonest manipulation.



Nichols, B.L., Dudley, M.A., Nichols, V.N., Putman, M., Avery, S.E., Fraley, J.K., Quaroni, A., Shiner, M., and Carrazza, F.R. Effects of malnutrition on expression and activity of lactase in children. Gastroenterology 112(3):742-751, 1997.

Mots-cles : malnutrition; activity; children; adult-type hypolactasia; protein-energy malnutrition; polymerase chain-reaction; disaccharidase activities; chronic diarrhea; phlorizin hydrolase; intestinal lactase; absorption; infants; malabsorption; small-intestine; Intestines; Methods; Proteins; Adult; malnourished children;

reduction Notes : BL Nichols, Baylor Coll Med, Childrens Nutr Res Ctr, USDA ARS, Dept Pediat, 1100 Bates St, Houston, TX 77030 USA

Background & Aims: Many malnourished infants have reduced lactase specific activity in the small intestine. The aim of this study was to test the hypothesis that the hypolactasia of malnourished infants results from transcriptional suppression of lactase expression. Methods: Biopsy specimens were studied from two groups of infants: 29 with malnutrition and 10 normally nourished controls with normal morphology and lactase activity. Results: In malnourished infants, lactase messenger RNA (mRNA) was reduced to 32% and sucrase to 61% of normal. Lactase and sucrase enzyme proteins and activities were lower in malnourished infants, and partial villus atrophy was present.

The genotype of adult hypolactasia was not present. Conclusions: Because the hypolactasia of malnourished children was associated with much lower lactase than sucrase mRNA abundance and because the epigenetic suppression, which accounted for the reduction of sucrase mRNA, was inadequate to explain the greater reduction of lactase mRNA, this study concludes that malnutrition suppresses lactase gene transcription or mRNA stability in infants. The reductions of lactase mRNA, distinct from those found in adults with genetic hypolactasia, explain the low lactase activities commonly found in malnourished infants.


Dr. André Briend

Date: Mon, 20 Oct 1997 09:48:24 +0100

From: Michael Golden <>

Subject: Re: lactose intolerance


The finding by Nichols et al is quite unexceptional and should not change our practice at all. It has no implications for policy or management. The finding of a low lactase in the mucosa of severely malnourished children has been described repeatedly over the past 40 years. The only new thing is the measurement of the lactase mRNA level - which turns out to be exactly as one would have predicted.

The reference to "lactose free" CSB in the press release, with the implication that CSB is equlivalent in child feeding to milk products without lactose, is, in my opinion, dishonest and unworthy of the USDA; I wonder if Bufort Nichols is aware that his results are being used for this purpose, and if so, I doubt if he approves.

Best wishes,


Prof. Michael H.N.Golden

Date: Mon, 20 Oct 1997 09:36:29 +0930

Subject: Re: Lactose intolerance and hunger (USDA news) -COMMENTARY


I realise that there has already been considerable discussion on the network of lactose intolerance, which mainly related to community feeding programs and essentially pointed out that lactose intolerance was not a major problem in that context. However, I must object to the news summary of Buford Nichols study, which so far I have only read the abstract. But there has already been considerable work on lactose intolerance in hospitalised children with severe malnutrition (marasmus and kwashiorkor) [refs 1-5]. This has shown that intestinal mucosal damage causes reduced disaccharidase levels affecting lactase most, then the sucrase-isomaltases and glucoamylase least. The correlation between mucosal damage and disaccharidases is imperfect on biopsies which may be due to patchy mucosal changes and the limits of light microscopy.

Poley used the scanning electron microscope to study 230 American infants with chronic diarrhoea[12], which may also be relevant for tropical enteropathies. Firstly, excess mucus covering the mucosal surface may explain why carbohydrate intolerance occurs in spite of normal light microscopy and disaccharidase activity. A thick layer of mucus can be a formidable barrier to absorption and may enhance bacterial growth in the small intestine. The mucus is a host defence in response to microbial invasion, antigen-antibody complexes, plant lectins and hypertonic solutions. It has been found to occur in non-specific diarrhoea, giardiasis, food intolerance and cystic fibrosis. Secondly, increased cell shedding and extrusion of cytoplasm is presumed to be a response to microorganisms or other antigens and was found in cases with depressed disaccharidase levels as well as in some children with clinical intolerance but normal light microscopy histology.

There is still controversy about the use of a milk-based diet in the treatment of persistent diarrhoea. In a Peruvian trial, a milk-based diet with 6 g/kg/day of lactose was compared to a lactose-hydrolysed diet, and established that the lactose diet caused higher purging (669 vs 386 g/day) which increased the risk of dehydration and decreased energy intake[7]. An INCAP study of Guatemalan kwashiorkor cases also compared whole milk with a lactose-hydrolysed milk in rehabilitation [8]. The weight gain between groups was similar but the milk group had more diarrhoea between days 2-5. A study of Australian Aboriginal children with diarrhoea and failure to thrive [6] found significantly higher weight gain in hospital on lactose hydrolysed milk (4.8 ?0.8 g/kg/day) compared to whole milk (2.2 ?0.75 g/kg/day). This is an important study because lactose intolerance is very high in these children (with whom I now work) due to the poor hygiene and weaning diet. An Algerian study showed that a yoghurt shortened diarrhoeal duration, with a lower stool output and greater weight gain than milk, presumably due to a 44% lower lactose content [9] A case-control Indian study of a milk diet in persistent diarrhoea showed that milk formula had better outcomes than unmodified cow's milk [10]. Neither stool reducing substances nor breath hydrogen tests improved the predictive value of clinical parameters, such as young age, wasting and fever, in predicting the need for a low lactose diet. Rather than expensive low lactose formulas, these authors recommend the use of fermented milk or milk-cereal combinations.

My objection to the summary of Nichols study is the substitution of"hunger" for malnutrition in children. ANOREXIA is the problem more than hunger. It is not hunger that damages the gut but living in a contaminated environment (microbiologically-speaking) or "tropical enteropathy syndrome" along with certain enteric infections acutely. This confusion of hunger and malnutrition in children is almost analagous to the different meaning of "shock" in medicine (hypotension) and the popular meaning (fright). But a more important objection is the final sentence: "USDA's Farm Service Agency, on the other hand, provides lactose-free corn-soy or wheat-soy blends for U.S. relief efforts overseas." Remember that Nichols study was in hospitalised children with severe malnutrition. In this context, what evidence is there that CSB or WSB are superior to milk? In kwahiorkor, we studied a similar maize-soy blend in a time-randomised non-blinded trial compared to milk of 533 children (rather more than Nichols 29 children). We found that milk (the standard treatment) to be superior in terms of improvements in intestinal permeability, mortality, sepsis and weight gain.[14] We also found that the low lactose content of phase 1 milk (initiation of cure) of 1.7g/kg/day was associated with more diarrhoea than the cereal diet, whereas the 8.7g/kg/day of lactose in high energy milk started by the second week of rehabilitation was tolerated with no more diarrhoea than the cereal diet, confirming Nichol's results of improvement in lactase levels with re-feeding.

My conclusion is that normal lactose-containing milk does lead to more diarrhoea in hospitalised children with malnutrition and/or persistent diarrhoea, but is still superior to cereal diets. But the initial use of a low lactose milk would be best for these children. Food aid agencies seem very slow to consider these findings, and the arrogance of the recent WFP commentary on the network was all too typical of my contact with them in the field. But I do accept that their main business is not hospital children, and this is also true of NGONUT. But the appalling mortality levels of malnutrition in African hospitals also needs to be addressed by nutrition programs.

Yours sincerely

David Brewster, Associate Professor of Paediatrics

Darwin Clinical School, Northern Territory, Australia




1. Leslie J, MacLean WC, Jr., Graham GG. Effect of an episode of severe malnutrition and age on lactose absorption by recovered infants and children. Am J Clin Nutr 1979; 32: 971-974.

2. Torun B, Solomons NW, Caballero B, Flores-Huerta S, Orozco G, Pineda O. The effect of dietary lactose on the early recovery from protein-energy malnutrition. II. Indices of nutrient absorption. Am J Clin Nutr 1984; 40: 601-610.

3. Solomons NW, Torun B, Caballero B, Flores-Huerta S, Orozco G. The effect of dietary lactose on the early recovery from protein-energy malnutrition. I. Clinical and anthropometric indices. Am J Clin Nutr 1984; 40: 591-600.

4. Prinsloo JG, Wittmann E, Kruger H. Lactose absorption and mucosal disaccharidases in convalescent pellagra and kwashiorkor children. Arch Dis Child 1971; 46: 474

5. Romer H, Urbach R, Gomez MA, et al. Moderate and severe protein energy malnutrition in childhood: effects on jejunal mucosal morphology and disaccharidase activities. J Pediatr Gastroenterol Nutr 1983; 2: 459-464.

6. Mitchell JD, Brand J, Halbisch J. Weight-gain inhibition by lactose in Australian Aboriginal children. A controlled trial of normal and lactose hydrolysed milk. Lancet 1977; 1: 500-502.

7. Sazawal S, Bhan MK, Bhandari N. Type of milk feeding during acute diarrhoea and the risk of persistent diarrhoea: a case control study. Acta Paediatr 1992; 81 Suppl 381: 93-97.

8. Penny ME, Brown KH. Lactose feeding during persistent diarrhoea. Acta Paediatr 1992; 81 Suppl 381: 133-138.

9. Caballero B, Solomons NW, Torun B, Pineda O. Calcium metabolism in children recovering from severe protein-energy malnutrition. J Pediatr Gastroenterol Nutr 1986; 5: 740-745.

10. Boudraa G, Touhami M, Pochart P, Soltana R, Mary JY, Desjeux JF. Effect of feeding yogurt versus milk in children with persistent diarrhea. J Pediatr Gastroenterol Nutr 1990; 11: 509-512.

11. Penny ME, Paredes P, Brown KH. Clinical and nutritional consequences of lactose feeding during persistent postenteritis diarrhea. Pediatrics 1989; 84: 835-844.

12. Poley JR. The scanning electron microscope: how valuable in the evaluation of small bowel mucosal pathology in chronic childhood diarrhea? Scanning Microsc 1991; 5: 1037-1062.

13. Rana SV, Gupta D, Vaiphei K, Bhardwaj S, Mehta SK. Effect of mild malnutrition on disaccharidase activity and glucose uptake in intestinal brush border vesicles of growing monkeys. Scand J Gastroenterol 1995; 30: 451-455.

14. Brewster DR, Manary MJ, Menzies IS, Henry RL, O'Loughlin EV. Comparison of milk and maize-based diets in kwashiorkor. Arch Dis Child 1997; 76: 242-248.

15. Brewster DR, Manary MJ, Menzies IS, O'Loughlin EV, Henry RL. Intestinal permeability in kwashiorkor. Arch Dis Child 1997; 76: 236-241.

16. Brewster DR, Manary MJ, Graham SM. Case management of kwashiorkor: an intervention project at 7 Nutritional Rehabilitation Centres in Malawi. Eur J Clin Nutr 1997;51: 139-147.

17. Phillips AD, Avigid S, Sacks J, Rice SJ, France NE, Walker-Smith JA. Microvillous surface area in secondary disaccharidase deficiency. Gut 1980; 21: 44-48.

Date: Wed, 22 Oct 1997 16:12:27 -0500

From: Benjamin Torun <>

Subject: Re: Lactose intolerance


The problem of transient lactase (and other disaccharidases) deficiency in severe malnutrition has been known for many years. The discussion about safety and practicality of using milk and milk-based diets to treat such children is, again, nothing new. Although there have been (and still are) some advocates against such feeding practices, most experts (clinicians, research scientists, public health workers) agree that the huge majority of severely malnourished children tolerate dietary amounts of lactose fed as part of milk or milk products. The issue here is not whether such products will produce non-dehydrating diarrhea, minute intestinal bleeding without clinical consequences, or functional alterations of the gut, but whether lives will be saved by providing adequate therapeutic diets to children when other nutritious foods are not available or may be too costly for parents and health services in developing countries.

As long as treatment is supervised (and this must be so in all cases, regardless of the dietary treatment used) and health workers know how to recognize and deal with diarrhea and dehydration, there is no reason to avoid using milk --unless it is known that a specific patient is intolerant.

The implication that 10-20% of severely malnourished children may die when fed milk is a gross exaggeration that may have dangerous consequences if it prevents the use of milk-based diets by health care workers with little or no experience in treating malnourished patients, and does a serious disservice to Buford Nichols and colleagues.


Benjamin Torun, M.D., Ph.D., Head, Human Nutrition Unit,

Institute of Nutrition of Central America and Panama.

INCAP -- Calzada Roosevelt, Zona 11, Apartado Postal 1188

Guatemala, Guatemala

Tel: [502] 471-9913, 471-5655, 472-3762 Fax: [502] 473-6529



Date: Thu, 23 Oct 1997 10:34:36 +0100

From: Michael Golden <>

Subject: milk in malnutrition again


Benny Torun's caution about focusing unnecessary attention upon lactose intolerance, and extrapolation from experiments designed to examine molecular events to nutrition policy and practice is important.

In the late 1970s lactase deficiency was a political disease in the USA.

The essence of the problem was that scientists attacked the provision of milk to developing countries on the ground that this product caused diarrhoea - the black lobby took this message and distorted it to "white donors deliberately causing diarrhoea in their black brothers and sisters".

The World Council of Churches, amongst others, immediately suspended all DSM shipments "until the problem could be resolved". I was working with severe malnutrition in Haiti at the time: at a stroke, we had nothing to give to the children and could not make therapeutic diets: the mortality rate sored and remained high for many months until we could get an alternate supply and train the staff to a new routine. The idea that lactose intolerance was detrimental to these children (supported by many scientists who measured enzyme levels in biopsies/gave unphysiological doses of lactose to volunteers and extrapolated their results) caused a great many deaths, some of which I witnessed in frustration, as we gradually built up a herd of cows in the hospital grounds to provide fresh milk for our patients and become independent of the whims of the scientific fashion in the USA.

I am frustrated that this spectre should still be raised, 20 years later, by such a body as the USDA, solely from results of mRNA levels in intestinal biopsies obtained from a highly selected group of patients - if the unnecessary deaths of the past, are to be avoided in the future the press-release by the USDA needs to be refuted.

Best wishes,


Prof. Michael H.N.Golden