Nyeko et al.

BMC Pediatrics 2010, 10:31

http://www.biomedcentral.com/1471-2431/10/31
Open Access RESEARCH ARTI CLE
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Research article
Lactose intolerance among severely malnourished
children with diarrhoea admitted to the nutrition
unit, Mulago hospital, Uganda
Richard Nyeko*
1
, Israel Kalyesubula
2
, Edison Mworozi
2
and Hanifa Bachou
2
Abstract
Background: Lactose intolerance is a common complication of diarrhoea in infants with malnutrition and a cause of
treatment failure. A combination of nutritional injury and infectious insults in severe protein energy malnutrition
reduces the capacity of the intestinal mucosa to produce lactase enzyme necessary for the digestion of lactose.
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy
formula milk. However, some of these children may be lactose intolerant, possibly contributing to the high rate of
unfavorable treatment outcomes. This study was therefore designed to establish the prevalence of lactose intolerance and
associated factors in this population.
Methods: A descriptive cross sectional study involving 196 severely malnourished children with diarrhoea aged 3-60
months was done in Mwanamugimu Nutrition Unit (MNU), Mulago hospital between October 2006 and February
2007.
Results: During the study period, 196 severely malnourished children with diarrhoea were recruited, 50 (25.5%) of
whom had evidence of lactose intolerance (stool reducing substance 1 + [0.5%] and stool pH < 5.5) and it occurred
more commonly in children with kwashiorkor 27/75 (36.0%) than marasmic-kwashiorkor 6/25 (24.0%) and marasmus
17/96 (17.7%). Oedematous malnutrition (p = 0.032), perianal skin erosion (p = 0.044), high mean stool frequency (p =
< 0.001) and having 2 diarrhoea episodes in the previous 3 months (p = 0.007) were the independent predictors of
lactose intolerance.
Other factors that were significantly associated with lactose intolerance on bi-variate analysis included: young age of 3-
12 months; lack of up to-date immunization; persistent diarrhoea; vomiting; dehydration, and abdominal distension.
Exclusive breastfeeding for less than 4 months and worsening of diarrhoea on initiation of therapeutic milk were the
other factors.
Conclusions: The prevalence of lactose intolerance in this study setting of 25.5% is relatively high. Routine screening
by stool pH and reducing substances should be performed especially in the severely malnourished children with
diarrhoea presenting with oedematous malnutrition, perianal skin erosion, higher mean stool frequency and having
had 2 diarrhoea episodes in the previous 3 months.
Use of lactose-free diets such as yoghurt should be considered for children found to have evidence of lactose intolerance
and whose response on standard therapeutic milk formula is poor.
Background
Lactose intolerance is a common complication of diar-
rhoea in infants with malnutrition [1], and a cause of
treatment failure [2,3]. Prevalences of secondary lactose
intolerance have been reported to range from 26% to as
high as 100% of affected children in some patients in dif-
ferent settings [4-6]. Lactase activity is reduced in many
patients with kwashiorkor even at early ages, and carbo-
hydrate intolerance occurs more frequently in children
* Correspondence: richard_nyeko@yahoo.com
1
Department of Paediatrics and Child Health, St. Mary's hospital Lacor, Gulu,
Uganda P.O Box 180, Gulu, Uganda
Full list of author information is available at the end of the article
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with kwashiorkor (48.3%) than in those with marasmus
(15%), marasmic-kwashiorkor (20%) and healthy controls
(23.5%) [7]. Kwashiorkor is also associated with variable
degrees of malabsorption that complicate the nutritional
rehabilitation of the patients. As a consequence, patients
with this form of malnutrition also have vitamin and min-
eral depletion of variable severity and this contributes to
further damage to their small intestinal mucosa and to
the abnormal proliferation of bacteria in their gut and to
the appearance of immune deficiencies.
Children with severe protein-energy malnutrition com-
monly have a reduced activity of intestinal lactase, the
enzyme responsible for the digestion of lactose [8,9], and
it has been suggested that feeding this disaccharide can
retard nutritional recovery [10]. Secondary lactase defi-
ciency can present at any age but is more common in
infancy [11,12]. This contrasts with the risks in normal
children as demonstrated by Gabr and colleagues in
Egypt: 12% in the age group 6 months to 2 years, 32% in
the age group 2-5 years, 32% in the age group 5-9 years,
and 80% in the age group 9-12 years [13].
The manifestations of lactose intolerance are watery
acidic stools, abdominal distension and excessive flatus
[14]. Perianal skin erosion is also observed frequently and
is caused by contact of acidic, watery stools with the skin
[15,16]. Lactose intolerance rates are significantly
increased in children with a history of recent diarrhoea
[17], and dehydration due to osmotic diarrhoea may be
common [14].
In one study, milk intolerance presenting as diarrhoea
was significantly more common in children with giardia-
sis [18]. Similarly, Pettoello and colleagues in Italy con-
cluded that the occurrence of lactose malabsorption of
nutritional relevance was common in children suffering
or having suffered from giardiasis (45%) [19].
The mortality of severely malnourished children is very
high (24% in the setting in which this study was carried
out) [20]. Part of this is due to dehydration which is
aggravated by lactase deficiency. Little is known concern-
ing the magnitude of lactose intolerance in this study set-
ting, yet the standard of care involves the use of lactose-
based high energy formula milk. This study was therefore
designed to establish the prevalence of lactose intoler-
ance and associated factors in this population.
Methods
Study setting
The study was undertaken at Mwanamugimu Nutrition
Unit (MNU) of Mulago hospital, Kampala, the national
referral and teaching hospital for Makerere University
College of Health Sciences. The department of Paediat-
rics and Child Health is one of the largest departments in
the hospital, admitting over 10 000 children annually. The
MNU is a 72-bed capacity unit specialized in managing
children with severe acute malnutrition with an average
monthly admission of 50-70 patients, about 50% of whom
present with diarrhoea, and this varies according to sea-
sons.
Study design
This was a descriptive cross-sectional study. The sample
size was calculated using the Leslie Kish formula [21] and
a prevalence of 15% as found by Tolboom in marasmic
Besotho children [7].
The study population consisted of severely malnour-
ished children with diarrhoea aged 3-60 months admitted
to MNU, Mulago hospital during the study period. The
WHO classification of severe malnutrition was used: A
severely malnourished child was one whose weight-for-
height was less than -3SD or less than 70% of the median
National Centre for Health Statistics (NCHS)/WHO ref-
erence median (severe wasting), or who had bilateral pit-
ting pedal oedema. The Wellcome classification was used
to classify a malnourished child as having kwashiorkor
(defined as weight-for-age between 60-80% of the median
in the presence of bilateral pitting pedal edema), maras-
mus (weight-for-age < 60% in the absence of edema), or
marasmic-kwashiorkor (weight-for-age < 60% in the pres-
ence of bilateral pitting pedal edema). Children who were
already on modified lactose-free diet were excluded.
Data collection/study procedure
The authors of this study explored the incidence of lac-
tose intolerance in the study population on the basis of a
pre-coded and pre-tested structured questionnaire and
tests in fresh stools of the participants at least 24 hours
after initiating standard lactose-based therapeutic milk
diet, with measurements of stool pH and presence of
reducing substances in faeces. The test was considered
positive if stool reducing substances were equal to or
more than 1 + (= 0.5%) and stool pH less than 5.5. Stool
microscopy was performed for fat globules, ova/cysts,
parasites (giardiasis), pus cells and yeasts (Candida albi-
cans). Recruitment into the study was by consecutive
enrollment of children who fulfilled the inclusion criteria.
A quick assessment for complications including hypo-
thermia, dehydration and/or shock and severe infections
was done by the principal investigator. Any necessary
resuscitation management was instituted before recruit-
ment into the study. The purpose of the study was
explained to the parents/caretakers, including pretest
HIV counseling and informed consent were obtained for
participation in the study. Children whose caretakers
declined HIV test were still recruited if they were willing
to participate and consented for the study.
Laboratory procedure
Blood samples were obtained for an HIV test. Post test
counseling was done as soon as results were obtained. All
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children found to be HIV positive were referred to the
Paediatric Infectious Disease Clinic (PIDC) for appropri-
ate management and their mothers referred to the adult
clinic for appropriate care as well. The HIV test was done
under an arrangement of routine counseling and testing
(RCT) that was already operational in the unit. CD4
counts were not done.
Stool pH was tested using narrow range pH papers after
dissolution of the fresh stool specimen in distilled water,
while presence of reducing substance was tested by use of
Benedict's solution.
Quality control was ensured by using one qualified lab-
oratory technologist to carry out the analysis of samples
using an established reputable laboratory of Mulago
National Referral Hospital.
Data management and analysis
Data was coded and entered into a computerized data-
base using Epidata 3.1. All data collected was cross-
checked for completeness and accuracy and cleaned
before analysis. The analysis was done using the Statisti-
cal Package for Social Sciences (SSPS II) software. Cate-
gorical variables were summarized as frequencies and
proportions, while continuous variables as means,
median and standard deviations (SD).
In the bi-variate analysis, odds ratios, 95% confidence
interval (CI), and chi-square test were used to measure
the strength of association between the factors consid-
ered and the dependent variable, while the student's t-test
was used for continuous variables.
Multivariate analysis using logistic regression was used
to determine the factors that were independently associ-
ated with lactose intolerance. P-value < 0.05 was consid-
ered for statistical significance. Results were summarized
in texts, tables and bar graphs.
Ethical considerations
The study was approved by the Ethics and Research
Committee of the School of Health Sciences, Makerere
University, and the Uganda National Council for Science
and Technology. Voluntary informed consent was
obtained from the parents/caretakers before participating
in the study. Confidentiality was observed throughout the
study. All children found to be HIV positive were referred
to PIDC and their mothers to the adult HIV clinic for fur-
ther management.
Results
The study included 196 children 3-60 months of age
(mean age 15.5 months and median 12 months). Sixty
four (32.7%) of the study children were HIV positive and
only one of them was on antiretroviral therapy, 113
(57.7%) were males and only 50.0% (98/196) had up to-
date immunization.
The prevalence of lactose intolerance was 25.5% by
these criteria and was highest among the children in the
age group 3-12 months (68.0%), with 90% of the cases
occurring in the first two years of life. The prevalence
then markedly reduced after 24 months of age, a trend
that mirrors the prevalence of severe malnutrition (Figure
1).
Lactose intolerance occured more commonly in chil-
dren with kwashiorkor {27/75 (36.0%), [p=0.011]} than
marasmic-kwashiorkor {6/25 (24.0%), [p=1.000]} and
marasmus {17/196 (17.7%), [p=0.021]} (Table 1).
At bivariate analysis, child's age and immunization sta-
tus (Table 2), duration of exclusive breastfeeding and
effect of starting therapeutic milk (Table 3) were all sig-
nificantly associated with lactose intolerance. Also signif-
icant were duration of diarrhoea, diarrhoea episodes in
the previous 3 months and stool frequency (Table 4).
Vomiting, body temperature, hydration status, presence
of oedema, perianal skin erosion, and abdominal disten-
sion were the other significant clinical characteristics
(Table 5).
At multivariate analysis, oedematous malnutrition,
perianal skin erosion, high mean stool frequency and
having two or more diarrhoea episodes in the previous 3
months were the independent predictors of lactose intol-
erance (Table 6).
Discussion
The 25.5% prevalence of lactose intolerance in the 196
severely malnourished children with diarrhoea accords
with a previous finding in a Senegalese study of 26% [4],
but lower than that reported in other studies [5,6], a dif-
ference that might be explained by the difference in sam-
ple size and study population. Nonetheless, the
prevalence of lactose intolerance in the current study is
still significantly high, a fact that could be a plausible con-
tributing factor to the unfavorable outcome that has
Figure 1 Age distribution by lactose tolerance.
68
48.6
22
38.4
4
8.2
2
2.7
4
2.1
0
10
20
30
40
50
60
70
80
P
e
r
c
e
n
t
a
g
e
3-12mo 13-24 25-36 37-48 49-60
Age in months
Intolerant
Tolerant
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Table 1: Lactose tolerance by type of malnutrition
Characteristics Lactose
intolerant
N = 50(%)
Lactose tolerant
N = 146(%)
OR 95% CI p-value
Kwashiorkor:
Yes 27(36.0) 48(64.0) 2.40 1.25-4.61 0.011*
No 23(19.0) 98(81.0)
#Marasmic-kwash:
Yes 6(24.0) 19(76.0) 0.91 0.34-2.43 1.000
No 44(25.7) 127(74.3)
Marasmus:
Yes 17(17.7) 79(82.3) 0.44 0.22-0.85 0.021*
No 33(33.0) 67(67.0)
*P-value significant (< 0.05), OR = Odd's ratio, CI = 95% confidence interval,
# Marasmic-kwashiorkor
Table 2: Baseline characteristics of the study population and lactose intolerance
Characteristics Lactose
intolerant
N = 50(%)
Lactose tolerant
N = 146(%)
OR 95% CI p-value
Sex:
Male 27(23.9) 86(76.1) 0.82 0.43-1.56 0.545
Female 23(27.7) 60(72.3)
Age in months:
3-12 34(32.4) 71(67.6) 2.25 1.14-4.42 0.018*
Above 12 16(17.6) 75(82.4)
Birth order:
First 18(31.0) 40(69.0) 1.49 0.75-2.95 0.250
Second 32(23.2) 106(76.8)
Immunization status:
Not up to-date 39(39.8) 59(60.2) 5.23 2.48-11.03 < 0.001*
Up to-date 11(11.2) 87(88.8)
Measles in the previous 3 months:
Yes 18(35.3) 33(64.7) 1.90 0.94-3.83 0.070
No 31(22.3) 108(77.7)
HIV status:
HIV+ve 19(29.7) 45(70.3) 1.42 0.72-2.80 0.315
HIV-ve 28(23.0) 94(77.0)
*P-value significant (< 0.05), OR = Odd's ratio, CI = 95% confidence interval
Some caretakers were unsure, hence the ones considered (190/196) do not add up to 196
Only those with confirmed HIV status were considered (186/196) hence they do not add up to 196. HIV by rapid test for age 18 months
and DNA PCR for age < 18 months.
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remained a challenge in the management of severely mal-
nourished children, more so those with diarrhoea.
Evidence of lactose intolerance occurred more fre-
quently in children with kwashiorkor 27/75 (36.0%) than
in those with marasmic-kwashiorkor 6/25 (24.0%) and
marasmus 17/96 (17.7%), a finding consistent with that by
Tolboom and colleagues [7]. This might not be surprising
and seems to reinforce the fact that kwashiorkor is asso-
ciated with variable degrees of malabsorption, with pro-
tein and energy as well as vitamin and mineral
deficiencies of variable severity that contributes to intes-
tinal mucosal damage, in addition to oxidative stress. Fail-
ure of the intestinal barrier from bacterial overgrowth
and passage of lipopolysaccharide to the systemic circula-
tion and uncontrolled stimulation of the inflammatory
mechanisms probably also have a part to play.
Most children (68%) with lactose intolerance were
infants 3-12 months, a finding consistent with several
other studies [3,12]. This, however, contrasts with the
risks in normal children as demonstrated by Gabr and
colleagues in Egypt [13], a difference attributed to the fact
that in normal children, lactose intolerance is mainly due
to primary lactase deficiency which increases with age
(becomes apparent by 5 years of age), as opposed to sec-
ondary lactase deficiency which, though can present at
any age, is more common in infancy [11]. In our study,
there was a gradual decrease in the prevalence of lactose
intolerance from 68% in the age group 3-12 to 2% in the
37-48 age groups, with a slight rise thereafter to 4%
among the 49-60 age groups which could be attributed to
underlying primary lactose intolerance which becomes
apparent by 5 years of age, possibly aggravated by the
diarrhoea and severe malnutrition.
Children with lactose intolerance were more likely to
have a higher mean stool frequency (8 motions in 24
hour period) [p < 0.001], a finding consistent with that by
Ozmert and colleagues in Turkey [12]. This is not surpris-
ing since unabsorbed lactose that is not metabolized by
Table 3: Feeding practices associated with lactose intolerance
Characteristics Lactose
intolerant
N = 50(%)
Lactose tolerant
N = 146(%)
OR 95% CI p-value

Still
breastfeeding:
Yes 11(24.4) 34(75.6) 0.87 0.40-1.90 0.719
No 34(27.2) 91(72.8)
#
Duration of EBF:
< 4 months 25(35.7) 45(64.3) 2.24 1.16-4.33 0.015*
4 months 25(19.8) 101(80.2)
Ever had
problems with
cow's milk:
Yes 3(50.0) 3(50.0) 3.04 0.59-15.59 0.175
No 47(24.7) 143(75.3)

Effect of
starting
therapeutic
milk:
Diarrhea
worsened
25(35.2) 46(64.8) 2.88 1.41-5.86 0.003*
No effect 17(15.9) 90(84.1)
Therapeutic
milk:
F75 41(25.6) 119(74.4) 1.03 0.45-2.38 0.938
F100 9(25.0) 27(75.0)
*P-value significant (< 0.05), OR = Odd's ratio, CI = 95% confidence interval
Only children in the breastfeeding age range (3-24 months) were considered; hence they do not add up to 196.
# Duration of exclusive breastfeeding, Fisher's Exact Test
Only for those who had diarrhoea at admission, hence they do not add up to 196, (178/196).
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Table 4: Diarrhoea characteristics associated with lactose intolerance
Characteristics Lactose
intolerant
N = 50(%)
Lactose tolerant
N = 146(%)
OR 95% CI p-value
Duration:
14 days 26(34.2) 50(65.8) 2.08 1.08-3.99 0.026*
< 14 days 24(20.0) 96(80.0)
Watery stool:
Yes 34(26.8) 93(73.2) 1.21 0.61-2.40 0.583
No 16(23.2) 53(76.8)
Blood in stool:
Yes 2(40.0) 3(60.0) 1.99 0.32-12.24 0.603
No 48(25.1) 143(74.9)
Antibiotic use
during
diarrhoea:
Yes 25(24.8) 76(75.2) 0.92 0.48-1.75 0.802
No 25(26.3) 70(73.7)
Use of local
herbs:
Yes 13(26.0) 37(74.0) 1.040 0.50-2.16 0.927
No 37(25.3) 109(74.7)
Diarrhea
episodes in the
previous 3 mo
2 40(47.1) 45(52.9) 8.98 4.13-19.52 < 0.001*
One 10(9.0) 101(91.0)
Fat globules in
stool
Yes 3(60.0) 2(40.0) 4.60 0.75-28.34 0.106
No 47(24.6) 144(75.4)
Yeasts in stool
(Candida
albicans):
Yes 29(27.6) 76(72.4) 1.27 0.67-2.43 0.467
No 21(23.1) 70(76.9)
Pus cells in stool:
Yes 6(20.0) 24(80.0) 0.693 0.27-1.81 0.452
No 44(26.5) 122(73.5)
Frequency of
stool in 24 hrs:
9.48(2.35) 5.81(2.20) < 0.001*
*P-value significant (< 0.05), OR = Odd's ratio, CI = 95% confidence interval,
Student t-test used for mean stool frequencies (standard deviations). Fisher's Exact Test
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the colonic bacteria to organic acids would remain in the
colonic lumen and lead to osmotic diarrhoea. Further-
more, undigested lactose may attract such an amount of
water in the jejunum-ileum that the colon cannot handle,
with the speed of transit also a contributing factor in the
whole process.
High prevalence of lactose intolerance among children
having had two or more diarrhoea episodes in the previ-
ous 3 months as found in this study has also been
reported elsewhere [17]. Recurrent episodes of diarrhoea
result in repeated disruption of the intestinal villi with
shortened regeneration and maturation time, predispos-
ing to intestinal lactase deficiency.
Lactose intolerance was more likely in children with
persistent diarrhoea (34.2%) compared to acute diarrhoea
(20.0%). Fagundes-Neto and colleagues in Brazil reported
a similar finding (33.3% and 18.2% in persistent and acute
diarrhoea respectively) [5]. This supports the observation
that the lactase enzyme is localized to the tips of the
intestinal villi, a factor of clinical importance when con-
sidering the effect of diarrhoeal illness on the ability to
tolerate lactose. Persistent diarrhoea also results in a
more prolonged and extensive damage of the intestinal
mucosa and the immature epithelial cells that replace
these are often lactase deficient, leading to secondary
lactase deficiency and lactose malabsorption [11]. Con-
versely, lactose intolerance prolongs and increases the
severity of diarrhoea [15].
Thirty five children (70%) with lactose intolerance pre-
sented with perianal skin erosion (p < 0.001), a finding
Table 5: Clinical characteristics of the severely malnourished children
Characteristics Lactose
intolerant
N = 50(%)
Lactose tolerant
N = 146(%)
OR 95% CI p-value
History of fever 31(62.)) 92(63.0) 0.96 0.49-1.86 0.898
History of vomiting 35(70.0) 76(52.1) 2.15 1.08-4.27 0.027*
History of cough 35(70.0) 116(79.5) 0.60 0.29-1.25 0.170
Temperature
(37.5C)
10(20.0) 41(28.1) 0.64 0.29-1.40 0.261
Temperature (35C) 12(24.0) 10(6.8) 4.30 1.72-10.70 0.001*
Oedema 33(66.0) 67(45.9) 2.29 1.17-4.47 0.014*
Severe pallor 1(2.0) 3(2.1) 0.97 0.10-2.40 1.000
Dehydration 31(62.0) 60(41.1) 2.34 1.21-4.52 0.011*
Oral thrush 11(22.0) 38(26.0) 0.80 0.37-1.72 0.570
Lymphadenopathy 4(8.0) 11(7.5) 1.07 0.32-3.52 1.000
Perianal erosion 35(70.0) 28(19.2) 9.83 4.73-20.44 < 0.001*
Abdominal
distension
20(40.0) 24(16.4) 3.39 1.66-6.93 0.001*
Hepatomegally 21(42.0) 47(32.2) 1.53 0.79-2.95 0.209
Splenomegally 4(8.0) 8(5.5) 1.50 0.43-5.21 0.506
*P-value significant(< 0.05), OR = Odd's ratio, CI = 95% confidence interval, Fisher's exact test
Table 6: Logistic regression model for factors independently predicting lactose intolerance
Characteristics Odd Ratio 95% CI p-value
Immunization status 2.60 0.85-7.93 0.093
Diarrhea episodes in previous
3 months
4.88 1.53-15.55 0.007*
Oedema 3.40 1.11-10.40 0.032*
Perianal erosion 3.07 1.03-9.16 0.044*
Frequency of stool/24 hrs 0.59 0.48-0.74 < 0.001*
* P-value significant (< 0.05), OR = Odd's ratio, CI = 95% confidence interval
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that has been documented [15]. In the presence of lactose
intolerance, unabsorbed lactose gets metabolized by the
colonic bacterial flora to organic acids and this is respon-
sible for perianal skin erosion in children with diarrhoea
[16].
While other studies have reported significant associa-
tion of lactose intolerance with giardiasis [18,19], only
one child in the current study was found to have giardia-
sis and she had no evidence of lactose intolerance. Possi-
bly, this was because of a less sensitive method used (wet
stool preparation), as the 'string test' of duodenal con-
tents would have been more preferable. Six of the study
participants had Cryptosporidia on modified ZN stain,
only one of whom had evidence of lactose intolerance and
this was not statistically significant. Similarly, in one
patient an enteropathogen (salmonella non-typhi) was
detected in stool cultures, with no evidence of lactose
intolerance. None but one of the HIV positive patients in
the study had been started on antiretroviral treatment
during the study and she had no evidence of lactose intol-
erance.
Our study had limitations in that we did not use the
breath hydrogen test which is the gold standard because
it is expensive, cumbersome to use on a large scale and
requires the patient to fast, in addition to use of a lactose
load (procedures not desirable in severely malnourished
children on highly regulated dietary management). It was
not possible to exclude pre-existing/primary disturbances
of lactose digestion, including chronic environmental
entropathies. Other associated food allergies could not
also be excluded. It was also not possible to determine a
causal relationship between the different factors and lac-
tose intolerance as this required a different study design.
Conclusions
The prevalence of lactose intolerance in severely mal-
nourished children with diarrhoea in the study setting of
25.5% is relatively high, especially in the 3-12 months age
group. Clinical predictors of lactose intolerance in
severely malnourished children included oedematous
malnutrition, perianal skin erosion, higher mean stool
frequency and having 2 diarrhoea episodes in the previ-
ous 3 months. Lactose intolerance should be considered
and routine screening by stool pH and reducing sub-
stance undertaken in these children.
Use of lactose-free diets such as yoghurt should be con-
sidered for children found to have evidence of lactose
intolerance and whose response on the standard therapy
is poor.
Conflict of interests
The authors declare that they have no competing inter-
ests.
Abbreviations
MNU: Mwanamugimu Nutrition Unit; PIDC: Paediatric Infectious Disease Clinic;
HIV: Human Immunodeficiency Virus; RCT: Routine Counseling and Testing;
WHO: World Health Organization; ZN: Ziehl-Neelsen
Authors' contributions
RN was the initiator of the study and contributed to the study design, data col-
lection, and interpretation of results. IK, EM and HB contributed to the study
design, interpretation of results and drafting of the manuscript. All authors
have read and approved the final manuscript.
Acknowledgements
We acknowledge all the staff of the nutrition unit and the department of Pae-
diatrics, Mulago hospital for their support and inputs towards this study. A spe-
cial tribute goes to the parents/caretakers and the children who participated in
this study.
Author Details
1
Department of Paediatrics and Child Health, St. Mary's hospital Lacor, Gulu,
Uganda P.O Box 180, Gulu, Uganda and
2
Department of Paediatrics and Child
Health, College of Health Sciences, Makerere University, Kampala, Uganda, P.O
Box 7072, Kampala, Uganda
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Received: 19 March 2009 Accepted: 6 May 2010
Published: 6 May 2010
This article is available from: http://www.biomedcentral.com/1471-2431/10/31 2010 Nyeko et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. BMC Pediatrics 2010, 10:31
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Cite this article as: Nyeko et al., Lactose intolerance among severely mal-
nourished children with diarrhoea admitted to the nutrition unit, Mulago
hospital, Uganda BMC Pediatrics 2010, 10:31
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