Tools for Practice


#321 “Not Milk?”: Avoiding lactose-containing products during acute pediatric diarrhea (Free)


CLINICAL QUESTION
Do lactose-containing formulas/diets worsen acute pediatric diarrhea?


BOTTOM LINE
Breastfed children should continue breastfeeding. In formula-fed children under two years, temporarily switching to lactose-free infant formula shortens diarrhea duration by ~18 hours and reduces treatment failure (9% versus ~17% control) at 24-72 hours. The effects of cow’s milk are investigated in only three small, older randomized controlled trials and results are likely unreliable.



CFPCLearn Logo

Reading Tools for Practice Article can earn you MainPro+ Credits

Join Now

Already a CFPCLearn Member? Log in



EVIDENCE
  • Results statistically different unless stated.
  • Four systematic reviews with 22-33 RCTs, 2215-2973 mostly hospitalized (clinically stable) formula-fed children with acute diarrhea receiving oral rehydration.1-4
    • Lactose-free versus lactose-containing products (infant formula/foods): Focusing on the largest systematic review (children’s ages 1-28 months),
      • Duration of diarrhea:1 Reduced by 18 hours with lactose-free formulas/foods.
        • Median diarrhea duration (calculation by PEER): ~2.75 versus ~3.5 days (lactose-containing).
      • Treatment failure (typically: Continued/worsening diarrhea or vomiting, need for rehydration, or weight loss).
        • 9% versus 17% (lactose-containing),1 number needed to treat (NNT)=14 over 24-72 hours.
        • Duration of hospitalization1 and weight:1,2,4 No difference.
      • Results of other systematic reviews similar.2-4
      • Diluted versus non-diluted lactose-containing formula.
    • Systematic review (9 RCTs, 687 children)1 found diluted (25-50%) lactose-containing formula reduced treatment failure: 11% versus 17%, NNT=17 over 24-72 hours.
      • Other found similar results.4
      • Diarrhea duration1,3,4 and weight:1,2 No difference.
    • RCTs in above systematic reviews comparing full-strength cow’s milk to:
      • Diet without milk: 2 RCTs5,6 (~70 children each, mean ages: 7-15 months)
        • Diarrhea duration: No difference.5,6
      • Diluting milk: 1 RCT7 (62 children, mean age: 22 months).
        • Treatment failure: No difference.
      • Limitations:
        • Many RCTs unblinded;1,5,6,7 baseline illness duration not reported;1-4 statistics difficult to clinically interpret.2,4
        • RCTs investigating the effects of cow’s milk are old5-7 (>30 years old) and not generalizable (gave cow’s milk to infants at 3-6 months).5
        • No RCTs in older children.
Context
  • Acute diarrhea guidelines recommend:
    • Continued (or increased) breastfeeding, including during initial rehydration.8,9
    • Resumption of usual diet after rehydration.10,11
  • While guidelines suggest that changing/diluting formula may be unnecessary, recommendations were made prior to currently available systematic reviews.10,11


Latest Tools for Practice

#348 How to Slow the Flow III: Tranexamic acid for heavy menstrual bleeding (Free)

In premenopausal heavy menstrual bleeding due to benign etiology, does tranexamic acid (TXA) improve patient outcomes?
Read 0.25 credits available

#347 Chlorthali-D’OH!: What is the best thiazide diuretic for hypertension?

Which thiazide diuretic is best at reducing cardiovascular events in hypertension?
Read 0.25 credits available

#346 Stress Urinary Incontinence: Pelvic floor exercises or pessary? (Free)

How effective are pelvic floor exercises or pessaries for stress urinary incontinence?
Read 0.25 credits available

This content is certified for MainPro+ Credits, log in to access


Author(s):

  • Candra Cotton BSc Pharm
  • Jennifer Potter MD CCFP
  • Samantha Moe PharmD

1. MacGillivray S, Fahey T, McGuire W. Cochrane Database Syst Rev. 2013; 2013(10):CD005433.

2. Gaffey MF, Wazny K, Bassani DG, et al. BMC Public Health. 2013; 13 Suppl 3(Suppl 3): S17.

3. Florez ID, Veroniki A-A, Al Khalifah R, et al. PLoS ONE. 2018; 13(12): e0207701.

4. Brown KH, Peerson JM, Fontaine O. Pediatrics. 1994 Jan ;93(1):17-27.

5. Romer H, Guerra M, Pina JM, et al. J Pediatr Gastroenterol Nutr. 1991; 13:46-51.

6. Isolauri E, Vesikari T, Saha P, et al. J Pediatr Gastroenterol Nutr. 1986; 5:254-261.

7. Dugdale A, Lovell S, Gibbs V, et al. Arch Dis Child. 1982 ; 57(1) : 76-8.

8. World Health Organization. UNICEF: Clinical management of acute diarrhea WHO/Unicef joint statement. 2004. Available at : https://www.who.int/publications/i/item/WHO_FCH_CAH_04.7 Accessed June 2, 2022.

9. A Leung, T Prince, Canadian Paediatric Society, Nutrition and Gastroenterology Committee. Paediatr Child Health. 2006; 11(8):527–531.

10. King CK, Glass R, Bresee JS, et al. MMWR Recomm Rep. 2003; 52(RR-16):1-16.

11. Farthing M, Salam M, Lindberg G, et al. World Gastroenterology Organisation Global Guidelines: Acute diarrhea in adults and children: a global perspective. 2012. Available at : https://www.worldgastroenterology.org/guidelines/acute-diarrhea. Accessed June 2, 2022.

Authors do not have any conflicts of interest to declare.