A user’s guide to the confusing world of milk

The Pediatric Insider

© 2013 Roy Benaroch, MD

Emily Z. wrote in about a recent study linking lower-fat milk with obesity. She also wondered about omega-3 fortified milk—could it be worth the money? Emily wants to know, “How did the dairy section of the store get so complicated?”

Milk sure has gotten complicated. You’ve got, of course, milk—the white stuff that comes out of cows—in different varieties of fat content, and lactose-free versions, too. And now soy milk, and rice milk, and almond milk, and hemp milk. And organic milk. Fortified with omega-3 acids, like DHA and ARA! And don’t forget goat milk, which has natural goaty goodness. AAAAAA!! How can you decide?

First, let me suggest a definition to start with: milk is a beverage that’s high in protein, and has other nutritional stuff in there too. It’s a great food for mammal babies like our own, and for about the last 8,000 years humans have domesticated animals to continue to drink milk and eat dairy products well past infancy.

Is milk necessary at all? For babies, yes—they can’t really eat other things. Rarely does one see a one-month-old thriving on Doritos Locos Tacos. By about 9 months of age, human babies are starting to get a significant chunk of their calories from solids, and by 12-15 could probably do just fine without any milk at all. Some will just refuse it. Still, milk is an easy and tasty source of protein and calcium, so it’s traditionally a part of a child’s diet for many years.

What’s with all of the milk variants, then? Are they better than ordinary cow milk?

Ordinary, full-fat milk has about 4% milkfat in the USA. It used to be thought that infants needed that high milkfat, but a 2008 AAP statement corrected that misimpression, and their most recent statement on cardiovascular health reiterated that for families with heart health or obesity concerns (that should be all of us), low fat milk is appropriate starting at age 1. A recent study from the BMJ, reviewed here, questions that wisdom by linking lower fat milk with increased weight—but that’s probably an example of logical reverse causality. Families with high weights and weight concerns choose lower fat milk, explaining the association. In other words, it’s not the milk that causes the excess weight, but the excess weight concerns that cause the choice of lowfat milk.

There’s overwhelming evidence that too many US kids get too many calories. To me, it makes sense to choose lowfat or skim milk products as soon as babies wean from mother’s milk or formula at 12 months. We’ll have to see if better evidence appears to put that in question.

When should other kinds of milk be considered?

Rice milk – this isn’t milk. It’s high-carb, and low-protein. Drink it instead of apple juice, if you want. But it isn’t a milk substitute at all.

Soy and almond milk – good for those who want to avoid cow’s milk, or for those allergic to cow’s milk. There may be some cross reactivity with soy especially, so beware. All non-mammal milk is lactose free.

Organic milk – I don’t think it’s worth the extra cost. The main concern seems to be the use of supplemental cow growth hormone by many conventional dairies to increase milk supply. There’s zero convincing evidence that this is harmful to humans, and zero biologic plausibility that it could cause trouble for our kids. To me, my main objection is that it may be unhealthy or cruel for the cows.

Raw milk – ew. Stay away from unpasteurized things loaded with nasty microorganisms, OK?

Lactose-free milk – great for those with lactose intolerance. That means babies and young children almost never need it. Lactose intolerance is essentially non-existent in newborn humans and other mammals, because human milk is loaded with lactose. It develops later in life, typically in teens or young adults.

Hemp milk – honestly, I have no idea what this is for. Sounds groovy.

Goat milk –expensive! It’s deficient in micronutrients like folate, and has no advantage over cheap and readily available cow’s milk. Still, it’s got that goat cache.

Omega-3 fortified milk – Omega-3s are so-called essential fatty acids that are part of brain and retina tissue. Children probably need some, and we really don’t know how much is ideal or sufficient. Conditions of omega-3 deficiency are difficult to identify, and may not even exist. Still, it’s probably a good idea to eat fish once in a while, or try an omega-3 supplement of some kind. I don’t know why it ought to be added to milk in particular. I wonder if they’ll make a Nestle Quik Fish Flavor?

Confusing? You bet. I pretty much just drink conventional skim. Though sometimes, a nice Café au Lait hits the spot. Mmmmm.

Refusing milk from a cup

The Pediatric Insider

© 2009 Roy Benaroch, MD

 

Analise is trying to get her daughter to continue drinking milk: “My daughter is 14 months old and will only drink milk from a bottle. We introduced a sippy cup at 9 months but made the mistake of only putting water in it. Now she associates the cup with water and the bottle with milk. We’re in the process of weaning her from the bottle but don’t know how to convince her to drink milk from a cup. Do you have any tips or is it just try, try again until she accepts it? Thanks for any behavioral insight or advice!”

 

First, let me get myself in trouble with the dairy council and moms everywhere by letting this secret out: there is no essential need for toddlers to drink milk. It’s a good source of protein and calcium, sure, but there are plenty of other good sources. Lots of children stop drinking milk, and many adults never touch the stuff. There’s no reason to consider milk something crucial for children to drink once they’re outside of the young baby years and able to take solids well.

 

At fourteen months, whether or not your child is willing to drink milk from a cup, you ought to stop using baby bottles. They’re bad for her teeth, and they’re preventing her from developing normal eating habits. Don’t worry that your child won’t get enough fluids—she’ll drink water, and she will not become dehydrated without milk.

 

Though milk isn’t essential, it’s handy and most children continue to drink it. There are, of course, tricks worth trying to get her to drink milk from a cup:

 

• Add a little milk to the water in a cup, and day-by-day start adding more milk and less water. In a few weeks, you can wean up to full strength milk. Do this gradually and maybe she won’t notice.
• Add something to the milk to make it extra tasty: chocolate syrup, or maybe a mashed-up, very soft banana. Little girls (and boys) deserve a little chocolate in their lives.
• Try a different sort of cup, like one with a straw—maybe even a crazy bendy cool straw.
• Make sure she sees you and dad drinking milk from a cup. You two can even use sippy cups for a little while. If parents don’t drink milk, children are far less likely to want it.
• If you’ve been using whole milk, give 2% or skim a try. Older advice did recommended whole milk, but that’s not necessary.
• Try a different sort of milk, like soy or almond milk. These provide similar amounts of protein and calcium as cow’s milk. Rice milk, on the other hand, is a low-protein beverage more similar to juice than milk—stay away from it if you’re looking for something with nutritional value for your children.

 

What to do during the transition? Don’t worry about it. There is no reason a child can’t go weeks or months or even years without milk. If your daughter gets the impression that milk is something very special and important, she’s less likely to touch the stuff—this is called “yanking your parents’ chain,” a skill that all children learn sooner or later. Don’t get caught up in the drama by letting her know you’re worried about this. Win the chain-yanking match by dropping your end.

 

If in the long run your daughter still won’t touch milk, you’ll need some other good calcium sources:

 

• Any other dairy: cottage cheese, yogurt, cheese, ice cream
• Calcium fortified juices
• Calcium supplements, like the little chocolate squares marketed for women as Viactive
• Non fat dry milk powder. Don’t mix this in water to try to drink it—blecch—but sprinkle it in casseroles, soups, eggs, sauces, that kind of thing. Once it mixes in it’s just about impossible to taste. Think of it as cheap calcium –n- protein powder.

 

Try some simple tricks to see if you can get your daughter back on milk, but remember there is no hurry here, and this is not a crucial or even a very important issue. Milk is easy and cheap, but there are many other nutritious things your daughter can take that can replace milk if she’s decided she just won’t drink it any more.

Lactose intolerance

Poornima asked about lactose intolerance and supplements: “Does a lactose intolerant child need calcium supplements? If so, which ones? I thought the soy milk is calcium fortified- but I do understand that there are brands that are not.”

I looked at labels at the grocery store today, and the common brands of soy milk are calcium and vitamin D fortified—they have essentially the same content of these nutrients as cow’s milk. There are probably smaller brands that are not fortified, so it’s best to check the label.

Lactose intolerance is common in adults, especially among African- and Asian-Americans. However, it is virtually non-existant in babies. Human breast milk is loaded with lactose, and our babies are very good at digesting this natural sugar. Their guts are loaded up with lactase, the enzyme needed for lactose digestion. As children get older, many start to lose this lactase activity and may begin to have trouble digesting lactose. When that happens, symptoms like bloating, abdominal pain, and gassy diarrhea can occur. Because many adults are lactose intolerant, baby formula companies take advantage of this fear to sell special lactose-reduced formulas. Don’t fall for this—the chance of baby being lactose intolerant is probably one in a million.

Diagnosing lactose intolerance is best done by trial and error. If you think your older child has this, take her off milk for a week or so. Then on a day without other big plans, give her a nice big milkshake. Yum! If an hour or so later she’s in the bathroom miserable, she’s probably lactose intolerant. Though there are medical tests to confirm this, they’re difficult to do in children and rarely necessary.

Treatment consists mainly of avoiding lactose sources—that is, all dairy products. Items that are cooked or heated will have less lactose than ordinary milk. Everyone who is lactose intolerant has a “threshold level,” beyond which symptoms will occur. This threshold will be very low for some people (say, only ½ a slice of cheese pizza), while others might be able to tolerate a bit more (maybe one small glass of milk, but no more.) Experiment to find out what the threshold is so you can avoid going over the limit.

There are supplements sold to help with lactose intolerance, usually enzymes that are said to be able to replace the natural effect of lactase. Some people find these effective, but most do not. Almost all natural lactase activity occurs far into the small intestine, and most of any swallowed enzyme is likely broken down long before the food makes it that far down. Still, lactase supplements are safe and feel free to use them if they seem to help.

In a typical American diet, diary products are the major source of both calcium and vitamin D. For infants, milk and dairy are also a significant source of protein and calories. If your child can’t tolerate dairy, you should discuss her individual needs with her pediatrician to make sure that she’s getting enough of these nutrients.

I am not drinking that

Susan posted, “My 19-month old does not like whole milk. He nursed exclusively for a year. Then I would nurse him and pump. I would mix the pumped breastmilk with whole milk for when he went to daycare. Now I am trying to wean him completely but am reluctant to because he does not like to drink anything. He still nurses when he wakes up and just before he goes to bed. I feel like I need to keep doing this so that he gets some hydration. He does not like to drink in general, only taking sips of water or juice from a sippy cup at mealtime. He has had lots of problems with constipation and I have to give him Miralax in small doses every day. I can’t force him to drink but I don’t know what to do. I have also tried soy milk and giving the milk a flavor like chocolate or strawberry. He still has no interest. Help!”

You’re going to have to take a leap of faith here: when your son is thirsty, he will drink. If he’s neurologically normal, his hypothalamus will provide him with an irresistible desire to drink when his body needs fluids. He may not drink as much as you think he needs, but he will drink enough to stay healthy.

Reflux and bones

Just last week I published an article on gastroesophageal reflux (often abbreviated “GERD”). I wrote “All of these medications for GERD are really quite safe, which may be one reason why so many physicians use them indiscriminately for children who probably don’t even have reflux disease.”

Well, I think I missed the boat on this one.

Who needs more vitamin D?

A question from Allison: “I just read that 40% of children are thought to be vitamin D deficient. How can we figure out if our child falls into that 40%? Should we give vitamin D supplements just in case? What should we do to make sure they stay vitamin D healthy?”

The honest, insider answer to these excellent questions is: we don’t know. We don’t know how much vitamin D a child ought to ingest every day, and we don’t even know what the “normal” blood levels of vitamin D should be!

Which supplements are best for kids?

Andrea posted: “I have two children, ages 4 yrs. and 15 months. Both are very picky eaters. The youngest is quite difficult – he spits out all meats and most fruits/vegetables. I know that a balanced diet is the best answer and that is my goal, but for now I am very interested in supplements. What do you recommend for toddlers? One year olds? And how do you determine the appropriate dosage for each child? I recently read about the benefits of fish oils – do you recommend this supplement? Are there any resources that you recommend where I can learn more about dietary supplements?”

Fortunately, most of the food in the developed world is fortified with multiple vitamins and minerals. With very few exceptions (we’ll talk about those later), vitamin deficiencies are just about unheard of in the United States, at least among children who have ready access to food. On the other hand, an ordinary multivitamin with safe doses of vitamins is going to be harmless, and may put your mind at ease.