#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.
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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.
- Duration of diarrhea:1 Reduced by 18 hours with lactose-free formulas/foods.
- 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.
- Diet without milk: 2 RCTs5,6 (~70 children each, mean ages: 7-15 months)
- Lactose-free versus lactose-containing products (infant formula/foods): Focusing on the largest systematic review (children’s ages 1-28 months),
- 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
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