How to Manage Lactose Intolerance

Setia Budi S.
Introduction
• Lactase enzyme : hydrolysis of lactose to glucose + galactose in the small intestine
(duodenum – yeyunum)

• Lactase deficiency : measured deficiency of the lactase enzyme (biopsy of intestinal mucosa)

• Lactose malabsorption : the process of incomplete lactose hydrolysis in the small intestine
(digestion & absorption)

• Lactose intolerance (LI) : clinical syndrome of lactase deficiency

• Definition (LI) : clinical syndrome of lactase deficiency characterized by symptoms of flatulence,

abdominal pain, vomiting, frequent flatus, redness of the anal area (erythema
natum) and diarrhea

* Lebenthal E, et all.Lactase deficiency, lactose malabsorption, and lactose intolerance.

Texbook of gastroenterology and nutition in infancy, 1989
• Prevalence
• In Ind 2014, LI (causes of diarrhea) in children aged < 3 years: 9,1%; in children aged 4 years:
21,7% ; in children aged 5 years 28,6%, and in children aged 6-11 years: 58 %.
In Manado, LI was 63,2% in diarrhea. In Jakarta 2008, LI was 23,1 % in acute diarrhea, while
in prolonged dirrhea: 40 %.

• LI in native Americans and Australians: 67-100%, 90% in most Asian Countries

* Hegar B,dkk.Aktivitas enzim laktase pada murid TKK. MKI 1977

* Elizabeth Yohmi, dkk. Intoleransi laktosa pada anak dengan nyeri Perut Berulang. Sari Pediatri 2001
Lactase deficiency
1. Primary lactase deficiency
a. Developmental lactase deficiency
Usually in premature babies, because lactase enzyme activity is not optimal

b. Congenital lactase deficiency

There is no lactase enzyme in the intestinal epithelial brush border. This disorder is rarely
found and last for life

c. Genetical lactase deficiency

This disorder arises slowly from the age of 2-5 years to adulthood. Occurs in races that do not consume
milk routinely and are autosomal recessive inheritance

* Boediarso A. Perkembangan laktase dan hubungannya dgn makanan bayi. Sari Pediatri 1993
* Lebenthal E, et all.Lactase deficiency, lactose malabsorption, and lactose intolerance.
Texbook of gastroenterology and nutition in infancy, 1989
2. Secondary lactase deficiency

- The presence of gastrointestinal diseases that cause damage to the

small intestinal mucosa (Infections, malnutrition, over growth bacteria,
IBD, drugs)
- Temporary

* Boediarso, A. Sakit Perut Berulang. Naskah lengkap SINAS BKGAI. Banjarmasin 2000
* Lebenthal E, et all.Lactase deficiency, lactose malabsorption, and lactose intolerance.
Texbook of gastroenterology and nutition in infancy, 1989
Pathophysiology

* Lactose Glucose + Galactose

Hydrolysis
(Lactase enzyme)

* Lactose Bacterial fermentation Lactic acid + SCFA (Acetic + butyric

≠ hydolysis + propionic acids) + H+ + CO2
(lactase )

* Buller HA, et all. Clinical aspect of lactose intolerance in children and adults. Scand J Gastroenterol 1991
Osmotic Diarrhea
Nutrient

Not absorbed

Bacterial fermentation

Organic acids

Osmotic pressure increases

Attract liquid

Diarrhea
Clinical symptoms
Depending on :

• Lactase enzyme activity ( influenced by factors: age, genetic

background, integrity of the small intestinal membrane and the small
intestinal transit time)
• The amount of lactose
• Intestinal transit time
• Colonic flora

* Buller HA. Lactase phlorizin hydrolase. Disertasi. University of Amsterdams 1990.

* Boediarso A. Perkembangan laktase dan hubungannya dgn makanan bayi. Sari Pediatri 1993
Clinical symptoms .......

• Nausea
• Vometing
• Abdominal pain (most symptoms of LI in children over 5 years)
• Bloated
• Frequent flatus
• Diarrhea
• Erythema natum

* Meer SB. Forget PP, et all. Gastroesophagial reflux in children with recurrent abdominal pain , Acta Ped 1992.
* Buller HA. Lactase phlorizin hydrolase. Disertasi. University of Amsterdams 1990.
Diagnosis approach
1. Elimination and provocation
2. Analysis of stool : found acid and reducing agent in the stool after eating lactose
• Clini test ( positive two or > 0,5% means there is lactose malabsorption )
• Stool chromatography : identifies the presence of sugar in the stool
• Stool pH ( normal stool pH 7-8 ) : → in LI : < 6
3. Lactose tolerance test : the test measures the ability of the intestine to absorb lactose. Patients are fasted for 4-8 hours, then given
lactose solution 2 gr/KgBB in a concentration of 20%. Blood sugar level were checked for 2 hours at intervals of 30 minutes. An increase in
blood sugar levels of less than 20 mg% of the basal value is considered abnormal
4. Breath Hydogen Test (BHT) : Non-invasive examination. Measuring the level of H+ released through the breath air as a result of lactose fermentation
by the colon flora. Patients are fasted for 4-6 hours, then given a 2gr/KgBB lactose solution in a concentration of 20% or 10% for < 6 months of age..
Breath air samples are taken every 30 minutes for 2 hours. The concentration of H+ gas is measured by lactometer / chromaatography. Diagnosis of
lactose malabsorption when the H+ level increases is equal to or more than 20 ppm compare to the basal value
5. Intestinal biopsy and measurement of lactose activity : gold standard for examining lactase activity. Normal value for nonates: 38 ± 4 U/g

* Lebenthal E, et all. Lactase deficiency, lactose malabsorption, and lactose intolerance.

Texbook of gastroenterology and nutition in infancy, 1989
• Diagnosis : Clinical Symptoms + Investigation

• Management
• Rehydration
• BM continued
• Avoidance of milk:
• Diarrhea without dehydration or diarrhea with no severe dehydration : normal formula milk is continued
• Diarrhea without dehydration or diarrhea with no severe dehydration with clinical symptoms of severe
lactose intolerance can be given lactose-free formula milk
• Diarrhea with severe dehydration can be given lactose-free formula milk
• Avoidance of dairy products
• Oral enzyme supplementation (lacteeze, lactaid)

* Hegar, B. Seputar Kesehatan Anak, IDAI 2012

* Melvin BH. Lactose intolerance in Infants, Children and Adolescents. Pediatrics 2006
• The treatment of documented lactose intolerance is removal of lactose from the diet in the form of lactose-
free formulas

* Wilson J. Newborn and Infant Nursing Reviews, Vol 5, No 4 (December), 2005

Probiotik ..... ?
• Probiotic in fermentation milk can reduce or diminish lactose intolerance condition because it can
increase the activity of lactase enzyme at small intestines.
•
• Probiotics promote lactose digestion in LI by increasing the overall hydrolytic capacity in the small
intestine and increasing the colonic fermentation. Probiotics can decrease lactose concentration in
fermented products, and increase active lactase enzyme entering the small intestine with the fermented
products.
Probiotik ...........
• Hydrolysis of lactose in the milk product and in the small intestine
* Vonk RJ, et all. Probiotics and lactose intolerance. http://dx.doi.org/10.5772/51424.2012

• Probiotics that are beneficial organisms that can alleviate lactose intolerance symptoms through increased
hydrolysis of lactose in intestine and decrease the osmotic load of lactose and delaying gastric emptying,
thus slows down the intestinal transit. Probiotics could lead to a promising method in prevention or
management of lactose intolerance.
* Devaraja Gayathri and Vasudha M. “Lactose Intolerance with Special Emphasis on Probiotics for Management”. EC Nutrition 13.5 (2018)

• Probiotics and synbiotics to alleviate symptoms of gastrointestinal disorders including lactose intolerance.

* Arnold JW, et all. Nutrients 2018, 10, 1517; doi:10.3390/nu10101517 - www.mdpi.com/journal/nutrients

• Probiotic in fermentation milk can reduce or diminish lactose intolerance condition
because it can increase the activity of lactase enzyme at small intestines.

• Probiotics promote lactose digestion in LI by increasing the overall hydrolytic

capacity in the small intestine and increasing the colonic fermentation. Probiotics
can decrease lactose concentration in fermented products, and increase active
lactase enzyme entering the small intestine with the fermented products.
Thank You For Your Attention