Whole milk best for children? Not so fast

The Pediatric Insider

© 2016 Roy Benaroch, MD

A flurry of recent reports has supported the health benefits of whole-fat milk. Increased dairy fat has been linked to lower rates of diabetes, and to improved cardiovascular health. The traditional advice – that low-fat or skim milk can help reduce weight, and help improve health – may have been based on faulty assumptions about the way ingested dairy fat affects metabolism. These new studies of dairy fit in with a shift away from the “fat is bad” story to a more nuanced “some fat is bad, but other fat is good, and it’s complicated” way of looking at things.

But it’s important to remember that none of the studies driving this change were done in kids. We don’t really know the long-term health impact of full- versus low- versus no-fat milk in infants or children, and there are still some good reasons to think that lower fat dairy might be a good choice for many families.

Until about ten years ago, the AAP recommended full-fat milk starting at age 1. That changed in 2008, when a position statement about cardiovascular health supported the use of reduced-fat dairy products starting at 12 months of age if there were any concerns about overweight or a family history of obesity or heart disease (that would include just about everyone.) This recommendation was based on research showing three things: (1) growth and neurologic function was the same in children raised on low-fat milk (ie, extra fat was not needed for brain and body development); (2) lipid profiles and weights were healthier in children raised on low-fat milk; and (3) children who consumed low-fat milk tended to have healthier diets, overall, than kids drinking whole milk.

That position statement “expired”, as all AAP statements do, 5 years after it was published. Currently, the AAP officially has no position on the relative merits of these varieties of milk. (They do have a position vaguely endorsing chocolate milk in schools, and another position strongly discouraging unpasteurized milk. All AAP policies can be searched here. There are a lot of them.)

The bottom line, now: there really isn’t any solid, new information from studies in children since that 2008 AAP position. Though I agree that the adult studies are compelling, adults and children are very different, especially when looking at metabolism, growth, and the long-term health consequences of dietary choices. For example, milk constitutes a much higher proportion of caloric intake in kids than in adults (children drink more milk, and they’re smaller. Usually.) They need proportionally more calcium and vitamin D and phosphorus for growing bones. And we know overweight children are very likely to continue to struggle to maintain a healthy weight as adults.

The best current evidence in children supports the use of reduced fat milk. If that changes, I’ll let you know.

 

Milk and health: Wading thru the hype

The Pediatric Insider

© 2014 Roy Benaroch, MD

Fiona wrote in: “I’ve seen in the news recently there’s been studies showing concern about milk consumption, especially for adults. They’re linking high milk consumption to health issues later in life. Is this true? Can you write a post on this?”

Food information, like so much else on the internet, has become one-sided and anxiety-provoking. I suppose that’s because people are more likely to click on a link like “Milk is killing you” than “Milk is a nutritious food and a reasonable part of a healthy diet, but you don’t need a ton of it, and there are plenty of other sources of calcium and protein.”

In the latest kerfuffle, we’ve got the dairy peeps versus the anti-milk crowd. On one side, people say milk and other dairy products are a good source of calcium and vitamin D and protein, all of which is essential especially for growing children and people at risk for osteoporosis; on the other side are people claiming that research shows that increased milk drinking will kill you, and doesn’t help keep bones healthy anyway. Who to believe?

Let’s back up a second. Like all mammals, our newborns thrive on a liquid diet made by our mommas called “milk.” The exact composition varies by species—for instance, goat milk has no folate, because goat babies don’t need folate—but overall it’s stuff made of water, nutritive protein, fat, carbohydrates, micronutrients, and immunologically active proteins and cells. In other words, it’s food. It’s really good for newborns and little baby mammals who cannot eat solid food yet. In nature, the amount of time newborn mammals stay on mother’s milk pretty much correlates with how much time they need to grow to the point they can eat the food their mommas eat. Then they wean, and consume bamboo, penguins, green bean casseroles, or whatever else their species typically eats. After weaning, no other animal species continues to consume milk.

Humans are unique animals, because we’ve come to rely on a system of nature-taming developments called “civilization”. Farming, which dramatically increases the food availability per acre, started about 10,000 years ago; dairy milk consumption from non-human animals began maybe 5,000 years later, once goats and proto-cows and sheep were domesticated. Milk had the advantages of being cleaner and less disease-ridden than ordinary water, and also offered good, easily-digestible calories at a time when food could be scarce. Once milk-preservation methods were developed, butter and cheese and yogurt could keep fresh for a much longer time. In many cultures, dairy products became a big part of daily intake.

So, while it’s true that no other adult mammal consumes milk—which is a favorite talking point of the anti-milk crowd—no other adult mammal consumes any farmed food, or any domesticated animals, or any cooked foods, or any omelets. We are not like other animals, and our food sources are entirely unique. Yay us.

While milk and milk products are a historically reasonable thing for humans to eat, their health benefits for mammals old enough to consume ordinary food have been overblown. Yes, they’re a convenient source of calcium and protein and sometimes vitamin D (which, along with vitamin A, is added to cow’s milk—it’s not there naturally.) But these products aren’t the only source of these nutrients. Children who don’t like milk or families who don’t want to consume cow’s milk for other reasons have plenty of other, good, healthful alternatives to get these nutrients.

Recent research has raised valid questions about the wisdom of considering cow’s milk to be an essential part of the diet. A 2014 Swedish study, widely reported in the press, is touted to have shown that higher milk consumption increased overall mortality and did not improve bone health. But the study relied on self-reported food intake dairies, and the study subjects were divided into many cohorts, only some of which showed these effects. And epidemiologic studies like these are fraught with issues of potential reverse causality and uncontrolled confounders. The authors of the study itself went out of their way to list these and other limitations of their study, and explicitly warned people not to change their eating habits until their study could be replicated and better understood; nonetheless, when reported in the press, the study was characterized as having proven that milk will kill you. That’s not what the study showed—that’s what the scaremongers want you to believe.

Milk is fine as a reasonable part of a diet. It’s not essential (at least after weaning), and if you or your children don’t care for milk or would rather eat and drink other things, that’s fine. It certainly shouldn’t be a huge part of any human’s diet after weaning, any more than any other one single foodstuff should account for most of what anyone eats. Want your family to eat healthy? Do these things:

• Eat as a family
• Don’t eat too much.
• Eat a variety of things.
• Slow down and enjoy your food.
• Cook, clean, and shop together.
• Grow vegetables in your garden.
• And stop reading or even clicking on internet scare sites about food!

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.

Got (raw) milk, again?

The Pediatric Insider

© 2010 Roy Benaroch, MD

I wrote about this once before, and in retrospect I wimped out. Let me be more clear this time: drinking raw milk is a bad idea.

The Consumer Health Digest is a weekly email newsletter I highly recommend as an excellent source of news about important health topics, health quackery, and consumer health issues. From this week’s update:

Another raw milk warning issued.

The FDA and several state agencies are alerting consumers to an outbreak of campylobacteriosis associated with drinking raw milk that originated from the Forest Grove Dairy in Middlebury, Indiana.

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm206311.htm

At least 12 confirmed cases were reported in Michigan. Raw milk is unpasteurized milk from hoofed mammals, such as cows, sheep, or goats. Since 1987, the FDA has required all milk  packaged for human consumption to be pasteurized before being delivered for introduction into interstate commerce. Pasteurization heats milk to a specific temperature for a set period of time and kills harmful bacteria, such as listeriosis, salmonellosis, campylobacteriosis, typhoid fever, tuberculosis, diphtheria and brucellosis. FDA’s pasteurization requirement also applies to other milk products, with the exception of a few aged cheeses. From 1998 to 2008, 85 outbreaks of human infections resulting from raw milk consumption were reported to the U.S. Centers for Disease Control and Prevention. These outbreaks included a total of 1,614 reported illnesses, 187 hospitalizations and 2 deaths. Proponents often claim that raw milk is more nutritious than pasteurized milk and is inherently antimicrobial, thus making pasteurization unnecessary. These claims, however, are false.

[Barrett S. Why raw milk should be avoided. Quackwatch, Dec 22, 2003]

http://www.quackwatch.org/01QuackeryRelatedTopics/rawmilk.html

There are no health benefits to consuming raw milk, and clearly there can be dire consequences. Just say “no” to raw, unpasteurized milk.

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.

Slim Fast for kids

The Pediatric Insider

© 2009 Roy Benaroch, MD

Josie’s wondering if sharing her Slim Fast shake is a good idea: “My son is almost 2 (2 months shy) and ever since I let him have a sip of my Slim Fast shake (those chocolate milk drinks in a can), he cries and cries for one everyday. I understand that they are completely insufficient at providing him with the fat, protein, vitamins and minerals he needs on a daily basis, but my question is, is it horribly wrong for me to let him have one every once in a while?  The whole point in those shakes are to give you the minerals and vitamins you need, minus the fat, right? Other than the times I do let him have one, he eats plenty and has a very well balanced diet.”

From their web site, here’s a list of typical Slim Fast ingredients: fat-free milk, water, sugar, gum arabic, calcium caseinate, cellulose gel, canola oil, potassium phosphate, soybean lecithin, mono and diclycerides, artificial flavors, carrageen and dextrose. (Most of the flavors are more-or-less like this, with some variations.) After those items are a long list of added vitamins and minerals. I don’t see anything offensive in the list, though this wouldn’t be appropriate for those with milk or soy allergies.

Looking further at the label, an 8 oz Slim Fast has 220 calories, including 3 grams of fat, 35 grams of sugar, and 10 grams of protein. For comparison:

(all per 8 oz)	Calories	Fat, grams	Protein, grams	Sugar, grams
Slim Fast	220	3	10	35
Apple Juice	120	0	0	28
Skim Milk	80	0	8	11
Whole Milk	150	8	8	13

To me, the striking thing about Slim Fast is how high it is in sugar—higher than any of these other choices. It sort of has the protein content of milk, the sugar content of juice, and the fat of low-fat milk. It’s also very calorie-dense, much more so than even whole milk.

So: there’s nothing inherently wrong with Slim Fast, though if you use it as a substitute for milk (even whole milk), your child will get far more calories than you might expect. It’s meant to be a substitute for food. A little now and then will do no harm, but regular consumption of it as a beverage may end up putting your child at risk for overweight. A more cynical person might say that the manufacturer thinks that’s not such a bad idea.

Eating your curds and …

Poornima, an official blog regular, asked, “I have a question on whey proteins. I see it everywhere now- everyone talks about it. Do you think it is a good idea to give whey protein to kids?”

This is the second time it’s come up in one day, so I might as well tackle what seems to be an evolving food fad: whey. There’s even a website, www dot wheyprotein dot com, extolling whey’s many virtues. Apparently it’s been popular among body builders for years, and according to that site the manufacturers are working hard to popularize whey for the rest of us.

Whey is one of the major proteins in milk—it’s the watery stuff that holds cottage cheese together, the stuff between the curds that Little Miss Muffet enjoys. As such, it’s a perfectly good protein, and dairy products are a good part of a balanced diet. It’s certainly not essential, but it’s a reliable and tasty source of protein, calcium, and vitamins A&D (in fortified milk.)

There’s nothing I can find that looks especially unique or powerful about whey. It’s just the latest in a string of food fads—remember soy? green tea? How about dark chocolate, pomegranates, or red wine? All of these are good for you in their own ways, but none of them is a substitute or improvement on a good, balanced, healthy diet.

We’re all looking for simple solutions, magic pills, or the one food that’ll cure obesity and hair loss. But a healthy diet is one that relies on a mix of healthy items from many different sources. You want healthy? Avoid trans-fats and fats from animal sources, eat unprocessed whole grains, and (most importantly) don’t consume more calories than you need. That’s it.

There is no “superfood.”

Except maybe the dark chocolate. Mmmmm……..

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.

Got (raw) milk?

Jill said, “My pediatrician recently had a bit of a fit when she learned we were feeding our 4 year old raw unpasteurized milk. I don’t understand why this is such a big deal. Can you explain? We get our milk from my father in law who raises cattle so this is the only milk my four year old has ever drank.”

I had a hard time with this question—most of the information I could find was either from very pro-raw milk advocacy groups, or from rather bland statements from health authorities urging people to “just say no” to unpasteurized milk. I’d like to say I’ve found some good science and statistics comparing the risk of straight-from-the-farm, unpasteurized milk to commercial milk. But I haven’t.

Pasteurization itself is a fabulous way to disinfect natural foods like milk and juice. It usually involves heating milk to 165 degrees for 15 minutes (there are other protocols), which dramatically reduces the bacterial content of the milk. And there are some nasty bacteria that can thrive in milk, including forms of tuberculosis, listeria (a potential cause of miscarriages), and diarrhea-causing campylobacter, to name a few. Pasteurization reduces, but does not eliminate, the risk of infection from consuming milk. The terms “unpasteurized” and “raw” milk are pretty much used interchangeably.

I did find this statistic: between 2002 and 2007, the Centers for Disease Control tracked 1007 illnesses traced to raw milk or cheese, including two deaths. During that same time period, there was an outbreak of listeria from pasteurized milk in Massachusetts that killed three men and probably led to at least one miscarriage.

The FDA recommends avoiding unpasteurized milk, and several states have banned its sale. Some states allow it if an unappetizing gray color additive is added (it can still be used safely to feed animals.)

It’s important that farms that collect milk for consumption without pasteurization practice very clean, hygienic farming. Unfortunately, I doubt most large commercial farms do this; they probably rely on the pasteurization to “make up” for their crowded, factory-like conditions.

If families are going to consume raw milk, I would certainly recommend that they investigate the farm thoroughly, and stick with a small local source. Good hygiene is essential at every step. The milk has a short shelf-life, even when refrigerated. People with immune-compromising conditions, the elderly, pregnant women, and babies would all be at special risk for more severe infections, and should stay away from unpasteurized products.

Outgrowing milk allergy

Kelly posted: “My daughter just turned one year old and has started the switch from breastmilk to cow’s milk. She has broken out in a rash each of the three times she has had cow’s milk, so we are switching back to breastmilk temporarily. If she does turn out to have a milk allergy, what’s the likelihood that she will grow out of it? And, does the milk allergy extend to milk-based products like cheese, yogurt and cottage cheese?”

True milk allergy (sometimes called “milk protein allergy” or “IgE mediated allergy” or “type 1 hypersensitivity”) causes either hives, wheezing, severe vomiting, or a drop in blood pressure that can cause unconsciousness. Of these reactions, hives are by far the most common and the most benign. The rash is raised pink blobs, occurring anywhere on the body. For some reason, they sometimes seem to prefer the armpits or just around the belly button. Hives itch, and each individual raised area resolves on its own within twelve hours. More hives can follow, but no single spot stays in the exact same place for very long.

Children who have hives triggered by milk will usually outgrow their allergy. It may take a few years, but by kindergarten age over 90% of these children will be able to tolerate milk.