1. Lactose Intolerance or Milk Allergy? WIC and Nutrition Services Department of Health and Senior Services

2. What is Lactose Intolerance? Inability to digest significant amounts of lactose, which is the predominant sugar in milk A result of lactase insufficiency, the enzyme essential for the conversion of lactose into glucose and galactose

3. Types of Lactose Intolerance Congenital Very rare Primary Develops after 2 years of age Secondary Usually resolves in 1-2 weeks

4. Symptoms of lactose intolerance Intolerance does not involve the immune system Nausea, cramping, bloating, abdominal pain, gas, diarrhea Symptoms may begin from 15 minutes to several hours after eating food with lactose

5. Prevalence of Lactose Intolerance An estimated 30 to 50 million American adults are lactose intolerant 90% of Asian Americans 80% of African Americans 62-100% of Native Americans 53% of Mexican Americans 15% of Caucasians

6. What is Milk Allergy? An abnormal immune system reaction to proteins in the cow’s milk Triggered by a combination of genetically inherited factors and early introduction of cow’s milk or soy protein into an infant’s diet www.foodallergy.org

7. Symptoms of Milk Allergy An immune system reaction Swelling, sneezing, nausea, vomiting, hives, rash, itching, runny nose, coughing, difficulty breathing, gas, diarrhea Anaphylactic reaction possible Symptoms may begin within seconds or up to several hours after eating the food See your Doctor

8. What are the options? Lactose Intolerance At risk of developing allergy Milk Allergy Infants Breastmilk, Soy or lactose free formula Breastmilk or hypo- allergenic formula Breastmilk, Soy or prescribed formula Children and Women Milk as tolerated NA Eliminate milk

9. Review the Options Breastfeeding is the best option for most infants.

10. Infants at risk for food allergy Exclusive breastfeeding is recommended Eliminate foods that cause infant allergies from the mother’s diet while she is breastfeeding Delay solid foods until 6 months of age 1 year of age: Introduce cow’s milk 2 years of age: Introduce eggs 3 years of age: Introduce peanuts, other nuts, fish, shellfish

11. Bright Futures in Practice - Nutrition Available in every WIC agency and at www.brightfutures.org/nutrition/index.html www.brightfutures.org/nutrition/index.html

12. Infants with milk allergy Breastfeeding Alternatives to breastfeeding Soy formula Hypoallergenic formula Avoid milk products or foods with milk

13. Children and Women with milk allergy Eliminate milk Casein or caseinate Casein hydrolysate Dried milk solids Lactolbumin Lactate solids Sweetened condensed milk Whey or whey solids

14. Children and Women with milk allergy Substitute other foods to provide missing nutrients Cook with alternative foods Alter recipes and meals Avoid cross-contamination Learn strategies for coping with restaurant meals and special occasions Conduct food challenges (with medical support)

15. Infants with lactose intolerance Breastfeed Alternatives to breastfeeding Soy formula Lactose free formula

16. Children and Women with Lactose Intolerance Eat or drink small servings Know your personal tolerance level Eliminating milk and other dairy foods may pose nutritional risks

17. Tips for Tolerance Experiment with gradually larger amounts Drink milk with a meal rather than alone Eat smaller, more frequent portions Choose aged cheeses lower in lactose Try dairy foods with active cultures Read labels Kosher foods that say “parev” or “parve” are milk-free

18. Some lactobacillus or sweet acidophilus milks are no lower in lactose and may not be tolerated any better than other forms of milk.

19. Special food products Lactose-reduced or lactose-free milk and other dairy foods Add lactase enzyme to fluid milk LactaidTM CactraseTM DairyEaseTM Chew or swallow a lactase supplement before eating lactose rich foods

20. Lactose-free foods Broth-based soups Plain meat, fish and poultry Plain fruits and vegetables Tofu Breads, cereal and crackers made without milk, dry milk, or whey

21. Alternative Sources of Calcium Vegetables: cooked/raw broccoli, turnip and collard greens, kale, Chinese cabbage Fish/Seafood: canned sardines and salmon with edible bones, raw oysters Calcium-fortified orange juice Calcium-fortified soymilk Tofu processed with calcium salts Almonds

22. Calcium = 1 cup milk 8 cups spinach, raw 1 ½ cups turnip greens, cooked 2 ¼ broccoli, raw 5 cups red beans, cooked 3 oz. sardines, canned with edible bones 1 ½ cups orange juice, calcium fortified 2 ¼ cups soy beverage, calcium fortified

23. Calcium education power point presentations, calcium intake requirements, functions of calcium, and information regarding risks of inadequate intake of calcium are available at: www.dhss.mo.gov/Calcium/#education

24. Calcium-Related Health Problems Osteoporosis Colon and Rectal Cancer Hypertension and Stroke Overweight and Obesity

25. WIC Policy Non-contract and exempt formulas for infants or WIC-eligible medical foods for women and children require a prescription.

26. For children and women with lactose intolerance documented by the CPA, cheese may be issued as a substitute for milk.

27. USDA encourages programs to offer alternative types of milk for children who are lactose intolerant.

28. In schools and childcare settings Schools and childcare providers must make substitutions for severe food allergy. Schools and childcare providers may provide substitutions for food intolerances. Services funded through IDEA include Purchase of special foods Purchase of feeding equipment Consultation with a registered dietitian www.fns.usda.gov/cnd/guidance

29. Child Nutrition and WIC Reauthorization Act 2004 Schools and childcares must offer a variety of fluid milk with different fat contents. Schools and childcares may offer flavored and unflavored milk and lactose-free milk. Schools and childcares may substitute a non- dairy beverage that is nutritionally equivalent to fluid milk and fortified with calcium, protein, vitamin A and D to levels found in cow’s milk.

30. For More Information… STTM 2 Calcium: pg 26-27 Food Allergies: pg 113 Calcium and Osteoporosis: pg 127-130

31. For more information… Rita Arni, RD, LD WICNS Child Nutrition Team Leader 573-751-6183 arnir@dhss.mo.gov Jean Trae, PhD, RD, LD WICNS Child Nutrition Coordinator 573-751-6183 traej@dhss.mo.gov