Tools for Practice Outils pour la pratique

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

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

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

La lecture d'articles d'outils de pratique peut vous permettre de gagner des crédits MainPro+

Join Now S’inscrire maintenant

Already a CFPCLearn Member? Log in

Déjà abonné à CMFCApprendre? Ouvrir une session

  • 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.
  • 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
Derniers outils pour la pratique

#359 Topical corticosteroids for atopic dermatitis - More than skin deep

What are the benefits/harms of topical corticosteroids for atopic dermatitis in adults/children?
Read Lire 0.25 credits available Crédits disponibles

#358: Any berry good solutions to preventing UTIs: Cranberries?

Do cranberry products prevent recurrent urinary tract infections (UTIs)?
Read Lire 0.25 credits available Crédits disponibles

#357: Overcoming Resistance: Antipsychotics for difficult to treat depression

In patients with treatment-resistant depression, is adding an atypical antipsychotic to current therapy safe and effective?
Read Lire 0.25 credits available Crédits disponibles

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

Ce contenu est certifié pour les crédits MainPro+, Ouvrir une session

  • 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 : 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 : Accessed June 2, 2022.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.