HACCP to health care and has started to pilot test its program in the Veterans Administration hospital system.13
If the task ahead seems daunting, it is. It will be expensive, not only for hospitals, but for society as a whole. But health care’s most important customers— our patients and parents—are demanding safer care. As we prepare to address the public’s legitimate demands, we should not forget our internal custom-ers, the hospital’s own staff. Hospitals go to great lengths to hire the most talented, best trained, and most highly motivated personnel they can find. All too often, the staff’s best efforts are foiled by imper-fect, complex, error-prone hospital systems. It is time to treat hardworking hospital personnel, from the most exalted cardiac surgeon to the person who empties the sharps container in the ED, with the respect they deserve. From a safety perspective, true respect involves more than just creating a “safety culture” in which individuals who report errors and accidents are not blamed or punished. Hospital or-ganizations need to work much harder to make the comprehensive systems improvements that will be required to protect staff members from their own human fallibility.
Donald Goldmann, MD*‡储 Rainu Kaushal, MD, MPH*§
*Department of Medicine and ‡Quality Improvement and Risk Management Program
Children’s Hospital Boston, MA 02115
§Division of General Medicine Brigham and Women’s Hospital Boston, MA 02115
储Department of Pediatrics Harvard Medical School Boston, MA 02115
REFERENCES
1. Kozer E, Scolnik D, Macpherson A, et al. Variables associated with medication errors in pediatric emergency medicine.Pediatrics. 2002;110; 737–742
2. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients.JAMA.2001;285:2114 –2120 3. Folli HL, Poole RL, Benitz WE, Russo JC. Medication error prevention
by clinical pharmacists in two children’s hospitals.Pediatrics.1987;79: 718 –722
4. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medica-tion errors.JAMA. 1998;280:1311–1316
5. Bates DW, Teich J, Lee J, et al. The impact of computerized physician order entry on medication error prevention.J Am Med Informatics Assoc. 1999;6:313–321
6. Overhage JM, Tierney WM, Zhou XH, McDonald CJ. A randomized trial of “corollary orders” to prevent errors of omission.J Am Med Inform Assoc.1997;4:364 –375
7. Teich JM, Merchia PR, Schmiz JL, Kuperman GJ, Spurr C, Bates DW. Effects of computerized physician order entry in prescribing practices. Arch Intern Med.2000;160:2741–2747
8. Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA.1999;282:267–270
9. Leapfrog Group. Available at: www.leapfrog.com. Accessed August 26, 2002
10. Weinger MB, Pantiskas C, Wiklund ME, Carstensen P. Incorporating human factors into the design of medical devices.JAMA.1998;280:1484 11. Reason JT.Managing the Risks of Organizational Accidents. Brookfield, VT:
Ashgate Publishing Company; 1997
12. Vincent C, Taylor-Adams S, Chapman EJ, et al. How to investigate and
analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol.BMJ.2000;320:777–781
13. DeRosier J. Using health care failure mode and effects analysis: the VA National Center for Patient Safety’s Prospective Risk Analysis System. The Joint Commission Journal on Quality Improvement.2002;10:248 –257
Milk: Can a “Good” Food Be So
Bad?
ABBREVIATIONS. NSLP, National School Lunch Program; PCRM, Physicians Committee for Responsible Medicine; PETA, People for the Ethical Treatment of Animals; AAP, American Academy of Pediatrics.
S
ince at least the turn of the 20th century, the value of milk as a nutrient-dense food for chil-dren has been reflected in documents that call for its inclusion in public feeding programs (Table 1). In 1909, children in Cleveland who participated in summer programs were offered a meal of “bread, and jam and a hot dish” and could get milk in the mornings “on orders from the medical inspector.” A year later, home economics classes in Boston pre-pared sandwiches and milk for elementary school children 2 days each week. By June 1940, federal funds were allocated to provide milk for children in 15 Chicago elementary schools. The price to children was 1 cent per half-pint, with subsidies from private donations available for those who could not pay. The half-pint container of milk became a lunchtime staple for millions of North American children in 1943, when the milk program was made part of the federal school lunch program. And after President Harry Truman signed the National School Lunch Program (NSLP) into law in 1946, a half-pint of milk was 1 of 5 required components in a type A lunch, which was designed to meet one third of a child’s daily nutri-tional requirements. Children whose schools did not participate in the NSLP could purchase milk at the subsidized price of 3 cents per half-pint.1 In the1950s, federal milk subsidies to school milk pro-grams served the dual purpose of promoting a healthful food and using agricultural surpluses.1
US dietary guidance documents consistently have included dairy products as one component of a healthful diet. Nonetheless, milk consumption has been falling and with it, adequate intake of calcium, which is essential for bone health. The decline is associated with several factors, including the in-creased consumption of soft drinks and juice.2
Spe-cial interest groups have contributed to the problem as they promote research that suggests that milk consumption can cause serious and even life-threat-ening disease. Individual members have gone as far
Received for publication Nov 30, 2001; accepted May 9, 2002.
Reprint requests to (J.P.G.) Center on Nutrition Communication, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, 68 Harrison Avenue, 5th Floor, Boston, MA 02111. E-mail: jeanne.goldberg@tufts.edu
as to suggest that milk be eliminated from school feeding programs.
Although the primary agenda of the major interest groups is animal rights, members have found it more advantageous to focus on human health, because those arguments resonate with a far greater percent-age of the population. This article presents the evi-dence for these arguments to provide the scientific framework against which to determine whether it is necessary to reexamine the national guidelines for dairy products as a way to insure adequate calcium consumption, with a particular focus on children. We review the studies that explore the links between milk consumption and both type 1 diabetes mellitus, and lactose intolerance. These 2 topics, more than any other myths associated with risks of milk con-sumption, have received major and extended cover-age in the media and have raised broad concerns about the safety of milk for children. To examine these claims, we conducted Medline searches of the literature published on those topics in refereed jour-nals. Anti-milk advocacy organizations have argued that it is quite feasible to consume the nutrients in milk from alternative foods. To address that claim, we examine the appropriateness of calcium supple-ments and calcium-fortified foods that are available in increasing variety as replacements for milk in the diets of children.
HOW DID MILK MAKE IT TO THE 10 O’CLOCK NEWS?
The scientific arguments concerning the preva-lence of lactose intolerance and a possible link be-tween milk and type 1 diabetes mellitus have re-ceived considerable attention from the media over the past several years. Groups like the Physicians Committee for Responsible Medicine (PCRM) and People for the Ethical Treatment of Animals (PETA) have used scientific evidence related to both of these conditions, and more recently, studies that identify a link between milk consumption and prostate cancer, to support their claims. Formed in 1985, PCRM in-cludes nearly 5000 physicians and 100 000 layper-sons and promotes preventive medicine, higher eth-ical standards for research, broader access to medeth-ical services, and a plant-based diet. In December 1999, PCRM filed a lawsuit against the Advisory Commit-tee to the US Department of
Agriculture/Depart-ment of Health and Human Services Dietary Guide-lines for Americans, claiming that members of the committee had inappropriate ties to the meat, egg, and dairy industries that biased their ability to ob-jectively evaluate the Dietary Guidelines. These guidelines are the basis for federally funded nutri-tion programs, such as the School Breakfast Program, the NSLP, the Food Stamp Program, and the Special Supplemental Nutrition Program for Women, In-fants and Children. With the exception of the Food Stamp Program, milk is a component of each of these programs. PCRM requested that the Advisory Com-mittee modify its recommendation of 2 to 3 servings of dairy foods a day to include other sources of calcium, including soy-based beverages, tofu, and fortified juices. They believe the Dietary Guidelines are insensitive to the health needs of minorities, 75% of whom worldwide experience some degree of lac-tose intolerance, and that the Dietary Guidelines should support plant foods, such as green leafy veg-etables and legumes, as alternative sources in meet-ing the daily calcium requirement.
In February 2000, the Advisory Committee agreed to recommend calcium-fortified soy milk as an alter-native to milk in the Dietary Guidelines that were about to be released, although absorption of calcium from fortified soy milk is reportedly not comparable with that of cow’s milk.3 PCRM then dropped the
portion of its lawsuit concerning the composition of the Advisory Committee’s membership. In the final version of the Dietary Guidelines 2000, the language reads Milk, Yogurt, and Cheese Group (Milk Group), and a footnote explains that “. . . one cup of soy-based beverage with added calcium is an option for those who prefer a nondairy source of calcium.”4
PETA, the other of the 2 anti-dairy activist groups, believes it is unethical to drink milk because of the abuse inflicted on commercial dairy cows. In March 2000, PETA parodied the America’s Dairy Farmers and Milk Processors “Got Milk?” campaign with “Got Beer?” This campaign encouraged college stu-dents to boycott milk in favor of beer. PETA supports the substitution of calcium-fortified juices, soy milk, and rice milk for regular milk and used the “Got Beer?” campaign to assert that even beer is more nutritious than milk. In response to substantial pub-lic outcry, the campaign was dropped from college campuses. It was replaced with “Dump Dairy,” a
TABLE 1. Emphasis on Milk in Early Child Feeding Programs in the United States—Selected Examples
1909, Cleveland, Ohio: A school meal generally consisted of “bread and jam and a hot dish, such as beef stew . . . A few, on order from the medical inspector, get milk in the morning.”
1914–15, The normal school and all high schools except 2 are provided with lunch services . . . a typical “menu” offered a selection from about 15 items, including milk.
1910, Boston, Massachusetts: An experimental program of midmorning lunch for elementary school children was prepared 3 days a week by students in home economics classes; 2 days a week children were served sandwiches and milk.
1914, Pinellas County, Florida: Experiment conducted by the health officer to see the effect of a half pint of milk a day.
1940, Chicago, Illinois: First federally subsidized milk program in 15 elementary schools in low-income areas of the city. Duplicated in 123 schools in New York city later that year.
1941: Extension of milk program to Omaha, Nebraska; Ogden, Utah; Birmingham, Alabama; St Louis, Missouri; and Boston and Lowell-Lawrence area, Massachusetts.
1943: Nationwide: Milk incorporated into federally subsidized lunch program and designated a “Type C” lunch. 1946: NSLP. Type A lunch to include a half pint of milk.
campaign featuring advertisements for “missing” cows, a play on efforts to locate missing children by displaying their photographs on milk cartons.
In 1999, the question of whether milk should be the primary source of calcium in school-feeding pro-grams became a political issue in Massachusetts. State Senator Dianne Wilkerson of Boston endorsed the efforts of PCRM and supported the replacement of milk with calcium-fortified beverages. Wilkerson argued that children with lactose intolerance who drink milk during the school day experience de-creased academic performance. At that time, she pro-posed a bill authorizing the State Departments of Public Health and Education to appoint an advisory committee that would jointly review the federally funded programs of which milk is a component and to assess whether adequate provision is made for people with lactose intolerance. The bill was ap-proved by the Massachusetts State Legislature. The advisory committee authorized by that bill consid-ered the relevant evidence and concluded that both the Department of Education and the Department of Public Health have basic policies that offer an appro-priate selection of calcium-rich foods, including al-ternatives to regular dairy products, to federally funded programs for children.
MILK CONSUMPTION AND TYPE 1 DIABETES: IS THERE A CONNECTION?
Since the hypothesis of a relationship between milk consumption and type 1 diabetes was first pro-posed nearly 2 decades ago, research has focused almost exclusively on feeding practices during the first year of life. The results of those studies, which include both animal experiments and observations in humans, remain inconclusive.5–18 The applicability
of animal studies to human populations is uncertain, and observational human studies are susceptible to recall bias, selection factors, and confounding. None-theless, in 1994, the American Academy of Pediatrics (AAP) modified its infant feeding guidelines to in-clude recommendations for those at risk of type 1 diabetes. Specifically, families with a strong history of type 1 diabetes were “strongly encouraged” to avoid feeding commercially available cow’s milk for-mula to infants. Substitution of soy-based forfor-mulas for all infants, regardless of risk category, was not recommended because of animal studies linking soy protein intake to the development of type 1 diabe-tes.19
In 2000, the Juvenile Diabetes Research Founda-tion InternaFounda-tional issued a posiFounda-tion paper concluding that there is no compelling scientific evidence to support the claim that drinking cow’s milk increases the risk of type 1 diabetes in children or adults.20
In the past decade, 3 studies with relatively strong designs have reported data related to the cow’s milk hypothesis. The Diabetes Autoimmunity Study in the Young is a cohort study comprising siblings and offspring of persons with type 1 diabetes.14Initially
analyzed as a case-control study, at baseline partici-pants included 18 children ranging in age from 9 months to 7 years with subclinicalcell immunity (a condition that precedes the development of type 1
diabetes). Consumption of cow’s milk, other dairy foods, cereal, fruit, vegetable, or meat protein by either 3 months or 6 months old did not differ be-tween cases and controls. Contrary to what the cow’s milk hypothesis would predict, children with -cell autoimmunity were breastfed slightly longer than controls (P⬍.07). As a nested case-control study, in which the investigators apply the case-control method to prospective data, this study avoids the potential for bias attributable to differential recall. However, its statistical power is limited by the small numbers of study subjects with-cell immunity.
The Childhood Diabetes in Finland study used a prospective design, which avoids potential recall bi-as.12 Investigators enrolled 725 unaffected siblings
between the ages of 3 and 19 along with 801 children newly diagnosed with type 1 diabetes. Because geno-typing for the HLA class II alleles thought to be involved in type 1 diabetes was available on a dis-proportionate number of children who progressed to clinical diabetes, the data were analyzed in a nested case control design, rather than as a classic prospec-tive study. Controls matched on critical factors were selected from among the siblings who did not progress to type 1 diabetes during the follow-up period. Although the proportion of cases and con-trols who had been breastfed for at least 2 months or had received cow’s milk supplement before 2 months old did not differ between cases and con-trols, a larger proportion of cases had consumed 3 or more glasses of milk daily before entering the study. More than twice as many cases as controls carried the risk conferring HLA allele. In the presence of these markers, the relative risk associated with high con-sumption of milk in childhood exceeded fivefold. Although the broad age range of the subjects in this study is wide and the data do not permit an exami-nation of the relationship between time of milk ex-posure and age at onset of the disease, these data support the hypothesis that there may be a subset of at-risk children for whom cow’s milk consumption promotes the development of type 1 diabetes.
Lastly, a second case-control study, The Finnish type 1 Diabetes Prediction and Prevention Study, identified almost 3000 infants at genetically in-creased risk for the development of type 1 diabetes by their HLA status.13The interim report was based
on the first 65 infants to become islet cell antibody-positive before age 4 and 390 control children who were islet cell antibody-negative. Short-term breast-feeding (⬍2 months) and the early introduction (⬍4 months) of cow’s milk or cow’s milk-based infant formula each independently predisposed genetically susceptible young children to progressive signs of
-cell autoimmunity. These findings are entirely con-sistent with the current AAP infant feeding recom-mendations, but have no real relevance to milk con-sumption in school-aged children.
Although there may be a role for milk proteins in
identifying persons who are genotypically at risk, Harrison and Honeyman15 argue for a role for
im-mune mucosal function in the development of type 1 diabetes. Based on their review of the literature, they conclude that apparent heightened immunity in chil-dren with the HLA allele is not specific to cow’s milk, but reflects enhanced immunity to dietary proteins in general. They suggest it would be more fruitful to explore immune function in mucosal tissue and its relationship to the etiology of type 1 diabetes. From this perspective, the observed protective effects of breastfeeding would originate with constituents in breast milk that promote intestinal wall maturation, whereas the observed detrimental effects of cow’s milk proteins would reflect impaired mucosal func-tion and would be nonspecific. This hypothesis would explain many of the seemingly contradictory observations, including the potent diabetogenicity of plant-based proteins found in soy and wheat.
At the time AAP released their statement, they called for a prospective, randomized trial to deter-mine the relationship between cow’s milk consump-tion and diabetes. Seven years later, the only 2 pro-spective studies we found12,14were not randomized.
The issue could not be put to rest entirely, how-ever, without an intervention trial. Fortunately such a trial is getting underway. Funding for an interna-tional randomized, controlled study designed to identify any possible role of cow’s milk in the devel-opment of type 1 diabetes in children who are genet-ically at risk was awarded to several research groups in October 2001. That multicenter trial, which is planned to last at least 5 years, will provide the data that are necessary to more definitively address any remaining question about a relationship between cow’s milk and type 1 diabetes.
Given evidence available at the present time, it would seem that type 1 diabetes develops in only 5% of individuals at risk based on familial disease; pro-teins in wheat and soy seem to be more potent dia-betogens than those found in milk; and that the critical timing of exposure to potential diabetogens remains unclear. There are clearly insufficient data to support the claim that milk contributes to type 1 diabetes in school-aged children.
LACTOSE INTOLERANCE: THE EXTENT AND PRACTICAL IMPLICATIONS OF THE CONDITION
It is difficult to precisely track the beginnings of the perception that milk should be eliminated from the diets of large groups of minorities, which is the argument used by groups who advocate broadening the dairy guidelines within federally funded feeding programs. In all likelihood, it was set in motion when the consumer press began to widely publish the re-sults of studies that were based on diagnostic proce-dures that exaggerated the extent of lactose intoler-ance.21Advertisements for lactose-free products may
have further contributed to confusion about the se-verity of the problem.
Lactose intolerance is the inability to completely digest lactose, the sugar in milk. In the small intes-tine, the enzyme lactase splits lactose into 2 simple sugars, glucose and galactose. If insufficient lactase is
produced and lactose is not digested, it travels to the large intestine where it is fermented by bacteria into organic acids and gas. This gas, along with the os-motic effect of unabsorbed lactose and water, is re-sponsible for the symptoms of lactose intolerance, which can include abdominal fullness, cramps, and diarrhea.22
The prevalence varies across different ethnic groups, but ⬃25% of American adults experience some degree of lactose intolerance.23–26The severity
of symptoms also varies, ranging from quite mild to severe. Curiously, severity of reported symptoms is not consistent with intestinal lactase activity.
Lactose intolerance is easily diagnosed by a hydro-gen breath test, which is a reliable, economical, and noninvasive procedure. Patients are given a test dose of 12 g of lactose, the amount present in a single cup of milk. The breath is then measured for hydrogen, which is produced as bacteria ferment the undi-gested sugar. Patients may also be asked to describe their symptoms during the test. Of note is that in double-blind studies, the relationship between the existence of lactase deficiency and symptoms re-ported is inconsistent. Many people with low lactase levels report little discomfort, whereas others with no demonstrated deficiency report significant dis-comfort.27
To complicate the picture further, many individu-als self-diagnose the condition without confirmation of the diagnosis by hydrogen breath test.28 –30 They
may completely avoid milk and other dairy foods, despite the fact that clinical studies do not support such drastic measures even among those in whom a diagnosis of lactose intolerance has been confirmed. Simply anticipating the possibility of discomfort may cause individuals to experience abdominal pain and cramping after eating dairy foods. Children of par-ents who are lactose intolerant may learn to avoid milk and to consider it a cause of abdominal discom-fort, regardless of whether they can digest lactose.31
Some individuals suffering from abdominal dis-tress mistakenly attribute their discomfort to lactose intolerance when they are actually suffering from irritable bowel syndrome, a condition that has no known cause.27 Acute gastrointestinal illness can
cause temporary lactose intolerance and may lead to continued, unnecessary avoidance of milk. The prob-lem is compounded even further by the common perception that lactose intolerance is an “allergy.” Because so many people recognize the need to avoid the offending food in the case of true food allergies, this has translated to “avoidance” as the appropriate treatment for lactose intolerance.
A large series of studies that included minorities, adults, and children found that 1 to 2 cups of milk was tolerated with few or no symptoms in most lactase-deficient subjects when the milk was spaced evenly throughout the day and consumed with food.22,23,31–36 In one double-blind, randomized,
lactose-free or regular yogurt.36More than two thirds
of the lactose-intolerant women reported that their symptoms were milder than expected between the 2 treatment periods. Half said they would be willing to continue consuming these dairy foods to meet their calcium requirement. These findings have recently been replicated in younger African American adoles-cents.37 These findings should not be surprising
given the results of studies conducted among Afri-can tribesmen, such as the Masai ⬎20 years ago. Among these people, the prevalence of lactose intol-erance has been estimated to reach over 60%, but they routinely consume considerable quantities of milk without symptoms.38
In controlled studies, it has been demonstrated that people who have trouble digesting lactose can improve their tolerance by consuming at least some dairy products that contain lactose.39In the study of
African American adolescents,37 subjects with
lac-tose maldigestion tolerated a diet rich in dairy foods. Subjects in that study demonstrated a decrease in breath hydrogen with increased dairy consumption. For those who associate milk consumption with symptoms, dairy alternatives exist. These include hard cheeses, yogurt, and the large variety of lactase-treated dairy products and lactase tablets.
IS IT FEASIBLE FOR CHILDREN TO ACHIEVE ADEQUATE AMOUNTS OF CALCIUM WITHOUT
MILK AND MILK PRODUCTS?
Most anti-milk advocates recognize the impor-tance of calcium in the diet of children. However, they argue that it is relatively simple for children to get adequate calcium without consuming dairy products. This approach raises several questions. First, is it feasible to provide adequate amounts of calcium from nondairy foods? Second, what is the role of calcium-fortified foods in meeting require-ments for this nutrient? Third, is it appropriate to disregard the other nutrient contributions of milk, aside from calcium? And finally, are calcium supple-ments a viable alternative for children?
Milk and other dairy products contribute⬎70% of the calcium intake in the United States. The Ade-quate Intake for children is 1300 mg per day. Three cups of milk provide 900 mg, and the rest can be consumed in a varied diet. Achieving that level of intake without dairy products requires careful atten-tion to selecatten-tion of foods that naturally contain some calcium and others to which it is added. Unfortu-nately, calcium is found in significant amounts in relatively few foods. These foods are not consumed consistently in large amounts by most of the popu-lation and tend not to be popular with children (Ta-ble 2).
Variation in the bioavailability of calcium in foods further challenges the goal of meeting requirements without dairy foods. Bioavailability refers to the amount of calcium available for use by the body and that is dependent, in part, on both the calcium load and substances in food that bind calcium. The cal-cium in milk is⬃30% bioavailable.40Of the 300 mg of
calcium in a glass of milk, 90 mg would expected to be absorbed. By comparison, accounting for calcium load size, to absorb that amount of calcium from broccoli, a vegetable in which calcium is highly bio-available, it would be necessary to consume two and one fourth cups.41
Calcium binders such as oxalic acid—found in vegetables such as rhubarb, spinach, chard, and beet greens—and phytic acid, found in the outer layers of cereal grains, drastically reduce calcium’s bioavail-ability.40,42– 45 A cup of spinach, for example,
pro-vides⬎240 mg of calcium, but to absorb an amount of calcium equal to that in milk, it would be neces-sary to consume over 8 cups.41
Major brands of calcium-fortified orange juice con-tain the same amount of calcium per unit volume as milk, but use different calcium compounds. Pub-lished data on the bioavailability of these com-pounds in the juice are lacking. Since the introduc-tion of calcium-fortified orange juice several years ago, calcium has been added to a number of juices and to other foods. Other fortified juices typically
TABLE 2. Alternative Nondairy Sources of Naturally Occurring Calcium and From Foods Fortified With Calcium
Food Serving Size Calories Calcium (mg)
Natural sources
Almonds 11⁄2oz 250 100
Broccoli, chopped 1⁄2c 22 36
Cabbage, Chinese 1⁄2c 10 79
Mustard greens, frozen 1⁄2c 14 76
Tofu prepared with calcium sulfate 1⁄2c 76 138
Selected calcium-fortified sources Dry cereals
Kellogg’s Cocoa Crispies 3⁄4c 120 100
General Mills’ Kix with calcium 11⁄3c 120 150
Quaker’s Life 3⁄4c 120 100
Hot cereal
Oatmeal, instant 1⁄2c 70 109
Crackers and bars
Kellogg’s Nutri-Grain bars 1 bar 140 200
Nabisco’s fortified graham crackers 8 (30 g) 110 150
Juices
Minute Maid’s drink box 6.75 oz 100 100
Apple & Eve’s juice box 8.45 oz 120 100
Tropicana or Minute Maid’s orange juice 1 c 110 350
contain 100 mg of calcium per serving (Table 2). Routine dependence on these fortified foods requires careful planning to ensure that children will con-sume adequate amounts of the mineral.
Even if fortified orange juice was the primary source of calcium, a child would need to drink 3 cups of juice to obtain the amount in 3 cups of milk. According to the most recently available data, only 1 in 5 elementary school age children consumes any citrus juice and on average, the amount consumed is under 2 ounces.46There are no data as to how much
of the juice consumed by children is calcium-forti-fied. If children were to consume the 3 cups of for-tified juice, it would provide 330 calories, about the same amount that would be provided in an equiva-lent amount of 1% fat milk. For a 10-year-old child, that represents 16.5% of total calories, but few of the other nutrients found in milk. Milk is an inexpensive source of high-quality protein and provides 31% of the riboflavin in the American diet. Fluid milk is also routinely fortified with vitamins A and vitamin D. In fact, milk is the only significant food source of Vita-min D, a nutrient critical to the utilization of calcium that is particularly important in winter months.
Fortified soy milk represents another potential al-ternative source of and is often recommended by anti-milk advocates. Unfortunately, these products vary in their nutrient profiles. Moreover in our ex-perience, relatively few children readily accept them. Although fortified soy milk products represent a potential alternative, until there are standards for nutrient fortification of these foods, they should not be encouraged except in specific cases and selected with guidance from the pediatrician or nutrition pro-fessional.
A policy that promotes calcium supplements as a dietary alternative for children brings other prob-lems, as well. For many families, it would represent an additional expense they could not afford. More-over, we have been unable to find published studies that document the level of compliance with the use of calcium supplements, and there is no basis to suggest that calcium supplements would be a rea-sonable alternative for children.
SHOULD THERE BE A CHANGE IN NATIONAL FEEDING PROGRAM POLICIES REGARDING THE
PROVISION OF MILK?
A rational look at the risks and benefits of consum-ing milk and milk products suggests that the current guidelines to insure adequate calcium intake are grounded in strong science. Calcium intake is al-ready insufficient in the United States, where osteo-porosis is a major and rapidly growing public health problem. Although it does not seem reasonable to insist that children who do not want to drink milk be required to take it anyway, milk should be available to all who choose it and efforts to promote consump-tion among school-aged children should continue. The argument that milk consumption in childhood “causes” type 1 diabetes is equivocal at best. The claim that milk causes children to suffer discomfort so severe that it disrupts their ability to learn is exaggerated. For those who do experience
discom-fort associated with milk consumption, alternatives are already available in some school systems and should be made available in others.
If we believe that youngsters should understand that a variety of foods from several basic groups of food are the foundation of a healthful diet, then we should communicate that message in the classroom, in the school feeding environment, and in the home. It is a relatively easy task to teach them that calcium is critical to the health of their skeleton and that the major source of calcium is milk and milk products. It is a far more difficult task to teach children that they can sometimes obtain calcium from such foods as breakfast bars, waffles, orange juice, and an increas-ingly long list of other foods where calcium is not normally found but to which it may be added. Al-though it is possible to consume adequate dietary calcium without dairy products, to do so requires acceptance of careful planning and monitoring by parents and caregivers and consumption of large amounts of foods that are typically not a regular part of the diets of most children in the United States. Such a major shift in food consumption patterns seems unlikely.
Jeanne P. Goldberg, PhD, RD Sara C. Folta, MS
Center on Nutrition Communication
Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy
Tufts University Boston, MA 02111
Aviva Must, PhD*‡
*Department of Family Medicine and Community Health
Tufts University School of Medicine
‡Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University
Boston, MA 02111
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Maternal Infections Are Depressing
ABBREVIATIONS. NE, neonatal encephalopathy; CP, cerebral palsy.
N
eonatal encephalopathy (NE) is the best very early predictor for term infants of later cere-bral palsy (CP), the most common acquired disorder of movement and tone in children.1Al-though CP was once attributed to adverse perinatal events, population-based studies identify antenatal rather than intrapartum antecedents.1,2Recent
stud-ies suggest that the disease process may be active postnatally.3,4
Half of all CP occurs in children born at term. The few studies available strongly support the associa-tion of maternal intrauterine infecassocia-tion with CP in term infants.5 There is an even stronger association
(10 of 10 studies of term infants) for maternal fever or clinical chorioamnionitis and NE manifested by de-pressed transition, altered tone, need for respiratory support or seizures.6While more intensively studied,
the association of maternal infection with CP is equivocal for infants born prematurely, perhaps be-cause of our lack of a normal control population and difficulty in adjusting for the degree of immaturity and comorbid conditions.5,6
In 1998, Nelson et al3 published a case-control
study notable for 3 findings: 1) the association of maternal infection (clinically diagnosed or based on histologic evidence of placental inflammation) with NE, 2) the association of both infection and NE with later development of CP, and 3) evidence that af-fected newborns had very high blood concentrations of inflammatory cytokines. The association of high
Received for publication Jul 22, 2002; accepted Jul 22, 2002.
Address correspondence to Rodney E. Willoughby, Jr, MD, Pediatrics In-fectious Diseases, Johns Hopkins Hospital, 600 N Wolfe St/Park 256, Bal-timore, MD 24287-4933. E-mail: rwilloug@jhmi.edu
DOI: 10.1542/peds.110.4.826
2002;110;826
Pediatrics
Jeanne P. Goldberg, Sara C. Folta and Aviva Must
Milk: Can a ''Good'' Food Be So Bad?
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DOI: 10.1542/peds.110.4.826
2002;110;826
Pediatrics
Jeanne P. Goldberg, Sara C. Folta and Aviva Must
Milk: Can a ''Good'' Food Be So Bad?
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