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Lactose Intolerance in Infants, Children, and Adolescents Melvin B. Heyman Pediatrics 2006;118;1279 DOI: 10.1542/peds.2006-1721 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/118/3/1279.full.html PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2006 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from pediatrics.aappublications.org by guest on August 22, 2014 CLINICAL REPORT Lactose Intolerance in Infants, Children, and Adolescents Guidance for the Clinician in Rendering Pediatric Care Melvin B. Heyman, MD, MPH, for the Committee on Nutrition ABSTRACT The American Academy of Pediatrics Committee on Nutrition presents an updated review of lactose intolerance in infants, children, and adolescents. Differences between primary, secondary, congenital, and developmental lactase deficiency that may result in lactose intolerance are discussed. Children with suspected lactose intolerance can be assessed clinically by dietary lactose elimination or by tests including noninvasive hydrogen breath testing or invasive intestinal biopsy determination of lactase (and other disaccharidase) concentrations. Treatment consists of use of lactase-treated dairy products or oral lactase supplementation, limitation of lactose-containing foods, or dairy elimination. The American Academy of Pediatrics supports use of dairy foods as an important source of calcium for bone mineral health and of other nutrients that facilitate growth in children and adolescents. If dairy products are eliminated, other dietary sources of calcium or calcium supplements need to be provided. INTRODUCTION SIGNIFICANT CHANGES IN our knowledge and approach toward lactose intolerance have occurred over the past quarter century, since the first statement on lactose intolerance was published by the American Academy of Pediatrics Committee on Nutrition.1 Lactose ingestion in certain susceptible individuals can cause abdominal symptoms that are variable and can be treated with dietary restriction or enzyme replacement, depending on the amount of lactose consumed and the degree of lactase deficiency. Pediatricians and other pediatric care providers should maintain awareness of the benefits and controversies related to the consumption of dietary milk products and milk-based infant formula. The lactose content of milk often influences, correctly or not, the ultimate decision about the use or continuation of milk in the diet. Milk and dairy-product avoidance has a negative effect on calcium and vitamin D intake in infants, children, and adolescents. Other nutrients such as protein make dairy products an important source of nutrition for growing children. This revised statement will update the initial statement of 1978 while incorporating changes from the 1990 supplement2 and current state-of-theart relating to lactose intolerance. Recommendations regarding dietary calcium have been updated recently.3 Lactose, a disaccharide that comprises the monosaccharides glucose and galactose, is the primary carbohydrate found exclusively in mammalian milk. Absorption of lactose requires lactase activity in the small intestinal brush border to split the bond linking the 2 monosaccharides. A ␤-galactosidase termed "lactase-phlorizin hydrolase" (lactase) accounts for most of the lactase activity in the intestinal www.pediatrics.org/cgi/doi/10.1542/ peds.2006-1721 doi:10.1542/peds.2006-1721 All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. Key Words abdominal pain, breath tests, calcium, dietary, dairy products, diarrhea, flatulence, lactase, malabsorption, pediatric PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2006 by the American Academy of Pediatrics PEDIATRICS Volume 118, Number 3, September 2006 Downloaded from pediatrics.aappublications.org by guest on August 22, 2014 1279 mucosa.4 Lactase is found in the small intestine and localized to the tips of the villi, a factor of clinical importance when considering the effect of diarrheal illness on the ability to tolerate milk. Milk intolerance may be attributed to either the lactose or the protein content. Lactose intolerance can occur among infants and young children with acute diarrheal disease, although the clinical significance of this is limited except in more severely affected children. Symptoms of lactose intolerance are relatively common among older children and adolescents; however, associated intestinal injury is infrequently seen. Lactose intolerance is a distinct entity from cow milk–protein sensitivity, which involves the immune system and causes varying degrees of injury to the intestinal mucosal surface. Cow milk–protein intolerance is reported in 2% to 5% of infants within the first 1 to 3 months of life, typically resolves by 1 year of age, and is not the subject of this statement.5,6 DEFINITIONS Following are definitions of terms used in the remainder of this statement: ● Lactose intolerance is a clinical syndrome of 1 or more of the following: abdominal pain, diarrhea, nausea, flatulence, and/or bloating after the ingestion of lactose or lactose-containing food substances. The amount of lactose that will cause symptoms varies from individual to individual, depending on the amount of lactose consumed, the degree of lactase deficiency, and the form of food substance in which the lactose is ingested. ● Lactose malabsorption is the physiologic problem that manifests as lactose intolerance and is attributable to an imbalance between the amount of ingested lactose and the capacity for lactase to hydrolyze the disaccharide. ● Primary lactase deficiency is attributable to relative or absolute absence of lactase that develops in childhood at various ages in different racial groups and is the most common cause of lactose malabsorption and lactose intolerance. Primary lactase deficiency is also referred to as adult-type hypolactasia, lactase nonpersistence, or hereditary lactase deficiency. ● Secondary lactase deficiency is lactase deficiency that results from small bowel injury, such as acute gastroenteritis, persistent diarrhea, small bowel overgrowth, cancer chemotherapy, or other causes of injury to the small intestinal mucosa, and can present at any age but is more common in infancy. ● Congenital lactase deficiency is extremely rare; teleo- logically, infants with congenital lactase deficiency would not be expected to survive before the 20th century, when no readily accessible and nutritionally 1280 AMERICAN ACADEMY OF PEDIATRICS adequate lactose-free human milk substitute was available. ● Developmental lactase deficiency is now defined as the relative lactase deficiency observed among preterm infants of less than 34 weeks' gestation. Primary Lactase Deficiency Approximately 70% of the world's population has primary lactase deficiency.7,8 The percentage varies according to ethnicity and is related to the use of dairy products in the diet, resulting in genetic selection of individuals with the ability to digest lactose (Table 1). In populations with a predominance of dairy foods in the diet, particularly northern European people, as few as 2% of the population has primary lactase deficiency. In contrast, the prevalence of primary lactase deficiency is 50% to 80% in Hispanic people, 60% to 80% in black and Ashkenazi Jewish people, and almost 100% in Asian and American Indian people.9–11 The age of onset and its prevalence differ among various populations. Approximately 20% of Hispanic, Asian, and black children younger than 5 years of age have evidence of lactase deficiency and lactose malabsorption,12 whereas white children typically do not develop symptoms of lactose intolerance until after 4 or 5 years of age. Recent molecular studies of lactase-phlorizin hydrolase (lactase) have correlated the genetic polymorphism of messenger RNA expression with persistence of lactase activity, demonstrating early loss (at 1–2 years of age) of messenger RNA expression and enzyme activity in Thai children and late (10 –20 years of age) loss of activity in Finnish children.11,13 The clinical relevance of these observations is that children with clinical signs of lactose intolerance at an earlier age than is typical for a specific ethnic group may warrant an evaluation for an underlying cause, because primary lactase deficiency would otherwise be unusual at such a young age. Although primary lactase deficiency may present with a relatively acute onset of milk intolerance, its onset typically is subtle and progressive over many years. Most lactase- TABLE 1 Prevalence of Acquired Primary Lactase Deficiency69 Examples of groups among whom lactase deficiency predominates (60%–100% lactase deficient) Near East and Mediterranean: Arabs, Ashkenazi Jews, Greek Cypriots, Southern Italians Asia: Thais, Indonesians, Chinese, Koreans Africa: South Nigerians, Hausa, Bantu North and South America: black Americans, Latinas, Eskimos, Canadian and American Indians, Chami Indians Examples of groups among whom lactase persistence predominates (2%–30% lactase deficient) Northern Europeans Africa: Hima, Tussi, Nomadic Fulani India: individuals from Punjab and New Delhi Downloaded from pediatrics.aappublications.org by guest on August 22, 2014 deficient individuals experience onset of symptoms in late adolescence and adulthood. Reports that focus on clinical symptoms of lactase deficiency are prone to subjectivity, confounding clinical diagnosis. For instance, when lactase-deficient adults were given 2 glasses of milk or 2 glasses of lactosehydrolyzed milk per day in a double-blind, crossover study, no statistical differences in symptoms of lactose intolerance were found regardless of whether the individual described himself or herself as lactose intolerant.14 Even lactose-intolerant adults may find that 1 glass of milk or a scoop of ice cream is tolerated, whereas an additional glass of milk or other milk product may produce symptoms. Because of the variation of dairy intake in each individual's diet and in the amount of lactose contained in different products, symptoms may vary and be modified by diet and by milk-containing foods (see "Management"). For these reasons, dietary history is an unreliable means to confirm or exclude the diagnosis of lactose intolerance. Secondary Lactase Deficiency Secondary lactase deficiency implies that an underlying pathophysiologic condition is responsible for the lactase deficiency and subsequent lactose malabsorption. Etiologies include acute infection (eg, rotavirus) causing small intestinal injury with loss of the lactase-containing epithelial cells from the tips of the villi. The immature epithelial cells that replace these are often lactase deficient, leading to secondary lactose deficiency and lactose malabsorption, although several reports indicate that lactose malabsorption in most children with acute gastroenteritis is not clinically important.15 Several recent studies and a meta-analysis found that children with rotaviral (and other infectious) diarrheal illnesses who have no or only mild dehydration can safely continue human milk or standard (lactose-containing) formula without any significant effect on outcome, including hydration status, nutritional status, duration of illness, or success of therapy.16–18 However, in the at-risk infant (eg, younger than 3 months or malnourished) who develops infectious diarrhea, lactose intolerance may be a significant factor that will influence the evolution of the illness. Giardiasis, cryptosporidiosis, and other parasites that infect the proximal small intestine often lead to lactose malabsorption from direct injury to the epithelial cells by the parasite. Secondary lactase deficiency with clinical signs of lactose intolerance can be seen in celiac disease, Crohn disease, and immune-related and other enteropathies and should be considered in these children. Diagnostic evaluation should be directed toward these entities when secondary lactase deficiency is suspected and an infectious etiology is not found. Young infants with severe malnutrition develop small intestinal atrophy that also leads to secondary lactase deficiency.19 Although uncommon in the United States, malnutrition is associated with lactose malabsorption and carbohydrate intolerance in developing countries.20 Lactose malabsorption has also been associated with poor growth in these countries.21 Most infants and children with malabsorption attributable to malnutrition are able to continue to tolerate dietary carbohydrates, including lactose.22 However, the World Health Organization recommends avoidance of lactose-containing milks in children with persistent postinfectious diarrhea (diarrhea lasting more than 14 days) when they fail a dietary trial of milk or yogurt.23 Treatment of secondary lactase deficiency and lactose malabsorption attributable to an underlying condition generally does not require elimination of lactose from the diet but, rather, treatment of the underlying condition. Once the primary problem is resolved, lactosecontaining products can often be consumed normally, and these excellent sources of calcium and other nutrients need not be unnecessarily excluded from the diet. Developmental (Neonatal) Lactase Deficiency In the immature gastrointestinal tract, lactase and other disaccharidases are deficient until at least 34 weeks' gestation.24 One study in preterm infants reported benefit from use of lactase-supplemented feedings or lactose-reduced formulas,25 and the use of lactose-containing formulas and human milk does not seem to have any short- or long-term deleterious effects in preterm infants.26 Up to 20% of the dietary lactose may reach the colon in neonates and young infants. Bacterial metabolism of colonic lactose lowers the fecal pH (5.0 –5.5 is normal), which has a beneficial effect, favoring certain organisms (eg, Bifidobacterium and Lactobacillus species) in lieu of potential pathogens (Proteus species, Escherichia coli, and Klebsiella species) in young infants. Antimicrobial agents may also affect this colonization. Congenital Lactase Deficiency Congenital lactase deficiency is a rare disorder that has been reported in only a few infants.27,28 Affected newborn infants present with intractable diarrhea as soon as human milk or lactose-containing formula is introduced. Small intestinal biopsies reveal normal histologic characteristics but low or completely absent lactase concentrations.29,30 Unless this is recognized and treated quickly, the condition is life-threatening because of dehydration and electrolyte losses. Treatment is simply removal and substitution of lactose from the diet with a commercial lactose-free formula. DIAGNOSIS Symptoms of lactose intolerance, including abdominal distention, flatulence, abdominal cramping, and (ultimately) diarrhea, are independent of the cause of lactose malabsorption and are directly related to the quantity of ingested lactose. These symptoms are not necessarily PEDIATRICS Volume 118, Number 3, September 2006 Downloaded from pediatrics.aappublications.org by guest on August 22, 2014 1281 correlated with the degree of intestinal lactase deficiency. Malabsorbed lactose generates an osmotic load that draws fluid and electrolytes into the intestinal lumen, leading to loose stool. The onset of diarrhea and other symptoms is related to the amount of lactose that is not absorbed. As little as 12 g of lactose (the amount of lactose in an 8-oz glass of milk) may be sufficient to cause symptoms in children with chronic abdominal pain.31 In addition, unabsorbed lactose is a substrate for intestinal bacteria, especially in the colon. Bacteria metabolize lactose, producing volatile fatty acids and gases (methane, carbon dioxide, and hydrogen), leading to flatulence. The fatty acids lower the fecal pH, making the fecal pH test a nonspecific but sometimes helpful marker for lactose (or other carbohydrate) malabsorption. When sufficient intestinal gas is produced by the bacterial metabolic processes to cause stimulation of the intestinal nervous system by intestinal distention, visceral (abdominal) cramping results. Initial studies using lactose hydrogen breath tests documented lactose malabsorption in up to 40% of children and adolescents presenting with abdominal pain.32 However, recent studies suggest that the prevalence of abdominal symptoms related to lactose intolerance documented by hydrogen breath tests is variable and ranges from 2% in Finnish children to 24% in southern US children.33,34 A good clinical history often reveals a relationship between lactose ingestion and symptoms. When lactose intolerance is suspected, a lactose-free diet can be tried (Tables 2 and 3).35 During a diagnostic lactose-free diet, it is important that all sources of lactose be eliminated, requiring the reading of food labels to identify "hidden" sources of lactose. Generally, a 2-week trial of a strict lactose-free diet with resolution of symptoms and subsequent reintroduction of dairy foods with recurrence of symptoms can be diagnostic. In more-subtle cases, the hydrogen breath test is the least invasive and most helpful test to diagnose lactose malabsorption. The test has been shown to be more reliable than history, because some patients think they are lactose intolerant when they prove not to be, and others prove to be lactose intolerant (lactose malabsorbers) when they think they are not.36,37 The test is performed by administration of a standardized amount of lactose (2 g/kg, up to a maxi- TABLE 2 Lactose and Calcium Content of Common Foods70,71 Dairy Products Calcium Content, mg Lactose Content, g Yogurt, plain, low fat, 1 cup Milk, whole (3.25% fat), 1 cup Milk, reduced fat, 1 cup Ice cream, vanilla, 1/2 cup Cheddar cheese, 1 oz Swiss cheese, 1 oz Cottage cheese, creamed (small curd), 1 cup 448 276 285 92 204 224 135 8.4 12.8 12.2 4.9 0.07 0.02 1.4 1282 AMERICAN ACADEMY OF PEDIATRICS TABLE 3 Hidden Sources of Lactose72 Bread and other baked goods Processed breakfast cereals Mixes for pancakes, biscuits, and cookies Instant potatoes, soups, and breakfast drinks Margarine Nonkosher lunchmeats Salad dressings Candies and other snacks mum of 25 g, equivalent to the amount of lactose in 2 8-oz glasses of milk) after fasting overnight and then measuring the amount of hydrogen in expired air over a 2- to 3-hour period. An increase (⬎20 ppm) in the hydrogen expired after approximately 60 minutes is consistent with lactose malabsorption. Factors that may produce false-negative or false-positive results include conditions affecting the intestinal flora (eg, recent use of antimicrobial agents), lack of hydrogen-producing bacteria (10%–15% of the population), ingestion of highfiber diets before the test, small intestinal bacterial overgrowth, or intestinal motility disorders. A pediatric gastroenterologist should be consulted to interpret the results of this test. The older lactose-tolerance test was previously relied on as the primary test of lactose malabsorption before the breath hydrogen test became available. Lactose intolerance was diagnosed by onset of symptoms and/or positive test results after ingestion of a standard lactose dose (2 g/kg of body weight or 50 g/m2 of body surface area; maximum 50 g in a 20% water solution). If the maximum increase in blood glucose concentration was less than 26 mg/dL after a lactose-tolerance test dose, lactose malabsorption was diagnosed. The lactose-tolerance test is not sensitive enough to determine if a subject is malabsorbing some lactose. It is also often falsely positive because of lack of an increase of blood glucose concentration attributable to normal insulin response to the carbohydrate load. Given the high rate of falsenegative and false-positive results, this test should not be used and has been replaced by the hydrogen breath test. Other tests are available in consultation with a pediatric gastroenterologist to diagnose lactose intolerance. If an underlying cause for secondary lactose intolerance is suspected, testing for intestinal etiologies includes stool examination, particularly for parasites affecting the upper gastrointestinal tract such as Giardia lamblia and Cryptosporidia species, and blood tests for celiac disease (ie, total immunoglobulin A concentration and antitissue transglutaminase antibody38,39) or immunodeficiency (quantitative immunoglobulins). Intestinal biopsy may be needed to uncover an underlying gastrointestinal mucosal problem that is causing the lactose malabsorption. Biopsies can yield direct measurement of disaccharidase concentrations to document lactase deficiency directly and assess the status of the other Downloaded from pediatrics.aappublications.org by guest on August 22, 2014 brush-border disaccharidases (sucrase, maltase, isomaltase), which may also be deficient under various circumstances. However, intestinal lactase concentrations do not seem to correlate well with symptoms of lactose intolerance.40 Newer tests may eventually yield additional detailed information pertaining to the prevalence and significance of lactose intolerance.41 For example, the [13C]lactose breath test is being considered as a test to augment the accuracy of the breath hydrogen test but is still primarily an investigational tool.42,43 In infants with diarrhea in whom lactose (or other carbohydrate) intolerance is suspected, stool can be screened for malabsorbed carbohydrate by testing fecal pH, which decreases with carbohydrate malabsorption as a result of the formation of volatile fatty acids. It should be remembered that fecal pH will normally be lower (5.0 –5.5) in infants compared with older children and adolescents because of the physiologic overload of lactose in their diets, which in turn helps to favor growth of Lactobacillus species in the colon. Fecal reducing substances can also be measured and become positive by excretion of a reducing sugar in the stools. Reducing sugars include lactose, glucose, fructose, and galactose but not sucrose. Because some patients may only malabsorb enough carbohydrates, such as lactose, to lower the fecal pH but not increase excretion of carbohydrate in the stool, the pH test is a more sensitive test for carbohydrate malabsorption. MANAGEMENT When children are diagnosed with lactose intolerance, avoidance of milk and other dairy products will relieve symptoms. However, those with primary lactose intolerance have varying degrees of lactase deficiency and, correspondingly, often tolerate varying amounts of dietary lactose. Lactose-intolerant children (and their parents) should realize that ingestion of dairy products resulting in symptoms generally leads to transient symptoms without causing harm to the gastrointestinal tract (as compared with celiac disease or allergic reactions, including milk-protein intolerance, that can lead to ongoing inflammation and mucosal damage). Although lactose malabsorption does not predispose to calcium malabsorption,44 avoidance of milk products to control symptoms may be problematic for optimal bone mineralization. Children who avoid milk have been documented to ingest less-than-recommended amounts of calcium needed for normal bone calcium accretion and bone mineralization.45,46 Lactose-free and lactose-reduced milks (and lactosefree whole milk for children younger than 2 years) are widely available in supermarkets and can be obtained with WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) vouchers. Although lactose-free milk is more expensive than regular milk, some major chain stores sell less-expensive lactose-free milk under their own brand names. Beyond infancy, substitutes for cow milk based on rice, soy, or other proteins are readily available and are generally free of lactose, although the nutrient content of most of these milks is not equivalent to cow milk. Other mammalian milks, including goat milk, are not free of lactose. Tolerance to milk products may be partial, so that dietary maneuvers alone may help avoid symptoms in some individuals. Small amounts of lactose in portions of 4 to 8 oz spaced throughout the day and consumed with other foods may be tolerated with no symptoms.47–51 Some children are able to drink 1 to 2 glasses of milk each day without difficulty but cannot tolerate more without developing symptoms.14 Many lactose-intolerant individuals who are intolerant of milk can tolerate milk chocolate52 and/or yogurt (plain better than flavored), because the bacteria in the yogurt partially digest the lactose into glucose and galactose before consumption.53,54 In addition, yogurt's semisolid state slows gastric emptying and gastrointestinal transit, resulting in fewer symptoms of lactose intolerance.55 Furthermore, ingestion of other solid foods delays gastric emptying, providing additional time for endogenous lactase to digest dietary lactose. Aged cheeses tend to have lower lactose content than other cheeses and, thus, may also be better tolerated. Finally, oral lactase-replacement capsules or predigested milk or dairy products with lactase are readily available and will often permit a lactoseintolerant individual to be able to take some or all milk products freely.56 Because the vitamin D content in milksubstitute products varies, labels must be checked to verify the vitamin D content of individual brands. Even among population groups with significant lactose intolerance, the importance of dietary dairy products has been stressed. For example, the National Medical Association recently recommended that black people consume 3 to 4 servings per day of low-fat milk, cheese, and/or yogurt and that lactose-free milk be used as an alternative for those who are intolerant of these other products to help reduce the risk of nutrient-related chronic diseases such as hypertension and diabetes.57 Milk and dairy products are often well tolerated by many children with underlying inflammatory conditions of the intestines, including Crohn disease and ulcerative colitis, in whom the prevalence of lactose intolerance does not seem to be any greater than in the general population.58–61 Lactose-Free Formulas In developed countries, even in the case of acute gastroenteritis, enough lactose digestion and absorption are preserved so that low-lactose and lactose-free formulas have no clinical advantages compared with standard lactose-containing formulas except in severely undernourished children, in whom lactose-containing formuPEDIATRICS Volume 118, Number 3, September 2006 Downloaded from pediatrics.aappublications.org by guest on August 22, 2014 1283 las may worsen the diarrhea and lactose-free formulas may be advantageous.62 Breastfed infants should be continued on human milk in all cases.57 This has also been reviewed recently in the American Academy of Pediatrics' practice guideline for acute gastroenteritis.63 The use of lactase in formulas for preterm infants has been noted above. Although lactose-free cow milk–protein-based formulas are readily available and popular, no studies have documented that these formulas have any clinical impact on infant outcome measures including colic, growth, or development.64 Lactose, Calcium Absorption, and Bone Mineral Content Recent evidence indicates that dietary lactose enhances calcium absorption and, conversely, that lactose-free diets result in lower calcium absorption.65 Thus, lactose intolerance (and lactose-free diets) theoretically may predispose to inadequate bone mineralization, a problem now recognized in many other disorders affecting pediatric patients.45,46 The effects of lactose-free diets in childhood on long-term bone mineral content and risk of fractures and osteoporosis with aging remains to be clarified. Calcium homeostasis is also affected by protein intake, vitamin D status, salt intake, and genetic and other factors, making long-term studies essential to determine the risks of each or all of these to bone health. Recent studies suggest that in the future, genetic testing may be useful for identifying individuals at increased risk of lactase deficiency and consequent diminished bone mineral density,66 potentially allowing early intervention with dietary manipulation or nutrient supplementation. Recent research has even suggested that gene-replacement therapies might someday be available for susceptible individuals.67 SUMMARY Lactose intolerance has been recognized for many years as a common problem in many children and most adults throughout the world. Although rarely life-threatening, the symptoms of lactose intolerance can lead to significant discomfort, disrupted quality of life, and loss of school attendance, leisure and sports activities, and work time, all at a cost to individuals, families, and society. Treatment is relatively simple and aimed at reducing or eliminating the inciting substance, lactose, by eliminating it from the diet or by "predigesting" it with supplemental lactase-enzyme replacement. Calcium must be provided by alternate nondairy dietary sources or as a dietary supplement to individuals who avoid milk intake. 2. Lactose intolerance attributable to primary lactase deficiency is uncommon before 2 to 3 years of age in all populations; when lactose malabsorption becomes apparent before 2 to 3 years of age, other etiologies must be sought. 3. Evaluation for lactose intolerance can be achieved relatively easily by dietary elimination and challenge. More-formal testing is usually noninvasive, typically with fecal pH in the presence of watery diarrhea and hydrogen breath testing. 4. If lactose-free diets are used for treatment of lactose intolerance, the diets should include a good source of calcium and/or calcium supplementation to meet daily recommended intake levels. 5. Treatment of lactose intolerance by elimination of milk and other dairy products is not usually necessary given newer approaches to lactose intolerance, including the use of partially digested products (such as yogurts, cheeses, products containing Lactobacillus acidophilus, and pretreated milks56,68). Evidence that avoidance of dairy products may lead to inadequate calcium intake and consequent suboptimal bone mineralization makes these important as alternatives to milk. Dairy products remain principle sources of protein and other nutrients that are essential for growth in children. COMMITTEE ON NUTRITION, 2005–2006 Frank R. Greer, MD, Chairperson Jatinder J. S. Bhatia, MD Stephen R. Daniels, MD, PhD Melvin B. Heyman, MD Marcie B. Schneider, MD Dan W. Thomas, MD Robert D. Baker, Jr, MD, PhD LIAISONS Sue Ann Anderson, PhD, RD Food and Drug Administration Donna Blum-Kemelor, MS, RD US Department of Agriculture Margaret P. Boland, MD Canadian Paediatric Society Laurence Grummer-Strawn, PhD Centers for Disease Control and Prevention Capt Van S. Hubbard, MD, PhD National Institutes of Health Benson M. Silverman, MD Food and Drug Administration STAFF Raymond J. Koteras, MHA CONCLUSIONS REFERENCES 1. Lactose intolerance is a common cause of abdominal pain in older children and teenagers. 1284 AMERICAN ACADEMY OF PEDIATRICS 1. American Academy of Pediatrics, Committee on Nutrition. The practical significance of lactose intolerance in children. Pediatrics. 1978;62:240 –245 Downloaded from pediatrics.aappublications.org by guest on August 22, 2014 2. American Academy of Pediatrics, Committee on Nutrition. 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Wharton B, Howells G, Phillips I. Diarrhoea in kwashiorkor. Br Med J. 1968;4:608 – 611 22. Habte D, Hyvarinen A, Sterky G. Carbohydrate malabsorption in kwashiorkor. Ethiop Med J. 1973;11:33– 40 23. World Health Organization, International Working Group on Persistent Diarrhoea. Evaluation of an algorithm for the treatment of persistent diarrhoea: a multicenter study. Bull World Health Organ. 1996;74:479 – 489 24. Antonowicz I, Lebenthal E. Developmental patterns of small intestinal enterokinase and disaccharidase activities in the human fetus. Gastroenterology. 1977;72:1299 –1303 25. Erasmus HD, Ludwig-Auser HM, Paterson PG, Sun D, Sankaran K. Enhanced weight gain in preterm infants receiving lactase-treated feeds: a randomized, double-blind, controlled trial. J Pediatr. 2002;141:532–537 26. Shulman RJ, Feste A, Ou C. Absorption of lactose, glucose polymers, or combination in premature infants. J Pediatr. 1995; 127:626 – 631 27. Lifshitz F. Congenital lactase deficiency. J Pediatr. 1966;69: 229 –237 28. Savilahti E, Launiala K, Kuitunen P. Congenital lactase deficiency: a clinical study on 16 patients. Arch Dis Child. 1983; 58:246 –252 29. Asp NG, Dahlqvist A, Kuitunen P, Launiala K, Visakorpi JK. Complete deficiency of brush-border lactase in congenital lactose malabsorption. Lancet. 1973;2(7824):329 –330 30. Freiburghaus AU, Schmitz J, Schindler M, et al. Protein patterns of brush border fragments in congenital lactose malabsorption and in specific hypolactasia of the adult. N Engl J Med. 1976;294:1030 –1032 31. Gremse DA, Greer AS, Vacik J, DiPalma JA. Abdominal pain associated with lactose ingestion in children with lactose intolerance. Clin Pediatr (Phila). 2003;42:341–345 32. Barr RG, Levine MD, Watkins JB. Recurrent abdominal pain of childhood due to lactose intolerance. N Engl J Med. 1979;300: 1449 –1452 33. Kokkonen J, Haapalahti M, Tikkanen S, Karttunen R, Savilahti E. Gastrointestinal complaints and diagnosis in children: a population-based study. Acta Paediatr. 2004;93:880 – 886 34. Webster RB, DiPalma JA, Gremse DA. Irritable bowel syndrome and lactose maldigestion in recurrent abdominal pain in childhood. South Med J. 1999;92:778 –781 35. Drugs.com. Lactose free diet. Available at: www.drugs.com/ CG/LACTOSE㛭FREE㛭DIET.html. Accessed August 18, 2005 36. Di Palma JA, Narvaez RM. Prediction of lactose malabsorption in referral patients. Dig Dis Sci. 1988;33:303–307 37. Suarez FL, Savaiano DA, Levitt MD. A comparison of symptoms after the consumption of milk or lactose-hydrolyzed milk by people with self-reported severe lactose intolerance. N Engl J Med. 1995;333:1– 4 38. Hill ID, Dirks MH, Liptak GS, et al. Guideline for the diagnosis and treatment of celiac disease in children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2005;40: 1–19 39. National Institutes of Health. NIH consensus development conference on celiac disease. Available at: http://consensus.nih. gov/2004/2004CeliacDisease118html.htm. Accessed August 18, 2005 40. Gupta SK, Chong SK, Fitzgerald JF. Disaccharidase activities in children: normal values and comparison based on symptoms and histologic changes. J Pediatr Gastroenterol Nutr. 1999;28: 246 –251 41. Vonk RJ, Lin Y, Koetse HA, et al. Lactose (mal)digestion evaluated by the 13C-lactose digestion test. Eur J Clin Invest. 2000; 30:140 –146 42. Hiele M, Ghoos Y, Rutgeerts P, Vantrappen G, Carchon H, Eggermont E. 13CO2 breath test using naturally 13C-enriched lactose for detection of lactase deficiency in patients with gastrointestinal symptoms. J Lab Clin Med. 1988;112:193–200 43. Koetse HA, Stellaard F, Bijleveld CM, et al. Non-invasive detection of low-intestinal lactase activity in children by use of a combined 13CO2/H2 breath test. Scand J Gastroenterol. 1999;34: 35– 40 44. Tremaine WJ, Newcomer AD, Riggs BL, McGill DB. Calcium absorption from milk in lactase-deficient and lactase-sufficient adults. Dig Dis Sci. 1986;31:376 –378 45. Stallings VA, Oddleifson NW, Negrini BY, Zemel BS, Wellens R. PEDIATRICS Volume 118, Number 3, September 2006 Downloaded from pediatrics.aappublications.org by guest on August 22, 2014 1285 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. Bone mineral content and dietary calcium intake in children prescribed a low-lactose diet. J Pediatr Gastroenterol Nutr. 1994; 18:440 – 445 Di Stefano M, Veneto G, Malservisi S, et al. Lactose malabsorption and intolerance and peak bone mass. Gastroenterology. 2002;122:1793–1799 McBean LD, Miller GD. Allaying fears and fallacies about lactose intolerance. J Am Diet Assoc. 1998;98:671– 676 Johnson AO, Semenya JG, Buchowski MS, Enwonwu CO, Scrimshaw NS. Adaptation of lactose maldigesters to continued milk intake. Am J Clin Nutr. 1993;58:879 – 881 Hertzler SR, Savaiano DA. Colonic adaptation to the daily lactose feeding in lactose maldigesters reduces lactose intolerance. Am J Clin Nutr. 1996;64:232–236 Pribila BA, Hertzler SR, Martin BR, Weaver CM, Savaiano DA. Improved lactose digestion and intolerance among AfricanAmerican adolescent girls fed a dairy-rich diet. J Am Diet Assoc. 2000;100:524 –528 Hertzler SR, Huynh BC, Savaiano DA. How much lactose is low lactose? J Am Diet Assoc. 1996;96:243–246 Jarvinen RM, Loukaskorpi M, Uusitupa MI. Tolerance of symptomatic lactose malabsorbers to lactose in milk chocolate. Eur J Clin Nutr. 2003;57:701–705 Kolars JC, Levitt MD, Aouji M, Savaiano DA. Yogurt: an autodigesting source of lactose. N Engl J Med. 1984;310:1–3 Boudraa G, Benbouabdellah M, Hachelaf W, Boisset M, Desjeux JF, Touhami M. Effect of feeding yogurt versus milk in children with acute diarrhea and carbohydrate malabsorption. J Pediatr Gastroenterol Nutr. 2001;33:307–313 Labayen I, Forga L, Gonzalez A, Lenoir-Wijnkoop I, Nutr R, Martinez JA. Relationship between lactose digestion, gastrointestinal transit time and symptoms in lactose malabsorbers after dairy consumption. Aliment Pharmacol Ther. 2001;15: 543–549 Medow MS, Thek KD, Newman LJ, Berezin S, Glassman MS, Schwarz SM. Beta-galactosidase tablets in the treatment of lactose intolerance in pediatrics. Am J Dis Child. 1990;144: 1261–1264 Wooten WJ, Price W. The role of dairy and dairy nutrients in the diet of African Americans. J Natl Med Assoc. 2004;96(12 suppl):5S–31S Pfefferkorn MD, Fitzgerald JF, Croffie JM, Gupta SK, Corkins MR, Molleston JP. Lactase deficiency: not more common in pediatric patients with inflammatory bowel disease than in patients with chronic abdominal pain. J Pediatr Gastroenterol Nutr. 2002;35:339 –343 Kirschner BS, DeFavaro MV, Jensen W. Lactose malabsorption 1286 AMERICAN ACADEMY OF PEDIATRICS 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. in children and adolescents with inflammatory bowel disease. Gastroenterology. 1981;81:829 – 832 Mishkin S. Dairy sensitivity, lactose malabsorption, and elimination diets in inflammatory bowel disease. Am J Clin Nutr. 1997;65:564 –567 Bernstein CN, Ament M, Artinian L, Ridgeway J, Shanahan F. Milk tolerance in adults with ulcerative colitis. Am J Gastroenterol. 1994;89:872– 877 Kukuruzovic RH, Brewster DR. Milk formulas in acute gastroenteritis and malnutrition: a randomized trial. J Paediatr Child Health. 2002;38:571–577 American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Practice parameter: the management of acute gastroenteritis in young children. Pediatrics. 1996;97:424 – 435 Heubi J, Karasov R, Reisinger K, et al. Randomized multicenter trial documenting the efficacy and safety of a lactose-free and a lactose-containing formula for term infants. J Am Diet Assoc. 2000;100:212–217 Abrams SA, Griffin IJ, Davila PM. Calcium and zinc absorption from lactose-containing and lactose-free infant formulas. Am J Clin Nutr. 2002;76:442– 446 Obermayer-Pietsch BM, Bonelli CM, Walter DE, et al. Genetic predisposition for adult lactose intolerance and relation to diet, bone density, and bone fractures. J Bone Miner Res. 2004;19: 42– 47 During MJ, Xu R, Young D, Kaplitt MG, Sherwin RS, Leone P. Peroral gene therapy of lactose intolerance using an adenoassociated virus vector. Nat Med. 1998;4:1131–1135 Sanders ME, Klaenhammer TR. The scientific basis of Lactobacillus acidophilus NCFM functionality as a probiotic. J Dairy Sci. 2001;84:319 –331 Johnson JD. The regional and ethnic distribution of lactose malabsorption. In: Paige DM, Bayless TM, eds. Lactose Digestion: Clinical and Nutritional Implications. Baltimore, MD: Johns Hopkins University Press; 1981:11–22 US Department of Agriculture. National nutrient database for standard reference. Available at: www.nal.usda.gov/fnic/ foodcomp/search. Accessed August 18, 2005 Matthews RH, Pehrsson PR, Farhat-Sabet M. Sugar content of selected foods: individual and total sugars. US Department of Agriculture, Human Nutrition Information Service; 1987. Available at: www.nal.usda.gov/fnic/foodcomp/Data/Other/ herr48.pdf. Accessed August 18, 2005 National Digestive Diseases Information Clearinghouse. Lactose intolerance. Available at: http://digestive.niddk.nih.gov/ ddiseases/pubs/lactoseintolerance. Accessed August 18, 2005 Downloaded from pediatrics.aappublications.org by guest on August 22, 2014 Lactose Intolerance in Infants, Children, and Adolescents Melvin B. Heyman Pediatrics 2006;118;1279 DOI: 10.1542/peds.2006-1721 Updated Information & Services including high resolution figures, can be found at: http://pediatrics.aappublications.org/content/118/3/1279.full.h tml References This article cites 65 articles, 17 of which can be accessed free at: http://pediatrics.aappublications.org/content/118/3/1279.full.h tml#ref-list-1 Citations This article has been cited by 15 HighWire-hosted articles: http://pediatrics.aappublications.org/content/118/3/1279.full.h tml#related-urls Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Committee on Nutrition http://pediatrics.aappublications.org/cgi/collection/committee _on_nutrition Nutrition http://pediatrics.aappublications.org/cgi/collection/nutrition_s ub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pediatrics.aappublications.org/site/misc/Permissions.xht ml Reprints Information about ordering reprints can be found online: http://pediatrics.aappublications.org/site/misc/reprints.xhtml PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2006 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from pediatrics.aappublications.org by guest on August 22, 2014
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Data presentation highlights falling crime, ambulance response times
Crime is down, the town's new vehicle fleet is saving gas, and ambulance response times are improving.
Those are some of the highlights from the end-of-the-year DartStat report. The town teams up with the University of Massachusetts Boston to collect and analyze data on a variety of town services and programs through DartStat. The goal is to use the data to improve efficiency in town government.
The report noted that in 2017, crime fell by 4.84 percent overall. Reports went from 2,361 in 2016 to 2,252 in 2017.
Crime data was divided into four categories. Overall crimes against persons fell by six percent. Crimes against persons includes crimes such as kidnapping, rape, assault, and statutory rape.
The largest crime in that category was simple assault, which fell by four reports from 204 in 2016 to 200 in 2017. Intimidation was down from 127 to 117, and kidnapping went from nine cases in 2016 to only one in 2017. The only crime included in this section with an increase was forcible fondling, from one case in 2016 to three in 2017.
Crimes against society increased by 26 percent from 2016, although the number of crimes reported was much smaller than crimes against persons. Drug and narcotics violations are up, from 38 instances in 2016 to 43 in 2017. Other areas measured in crimes against society included pornography/obscene materials, prostitution, and weapon law violations. Under ten instances of each were reported.
In Group B crimes, which include miscellaneous crimes, reports increased by six percent. Driving under the influence cases fell by 30 percent to 35; liquor law violations are also down from 22 to 12; trespassing increased by 83 percent to 22; and "all other offenses" rose from 402 to 457.
For the first time, DartStat collected data on STAT Ambulance services and response times to see how close the numbers come to what the service is contractually required to provide.
"Until the last contract there was never any criteria as to what the response times should be," said Town Administrator David Cressman. "This is the first time that this was done, and it was done largely through the initiative of Chief Szala and myself at that time."
The results from March to December 2017 showed District No. 3 is the busiest in terms of medical calls, with an average volume of ten calls per day, hovering around 350 calls a month. District No. 1 averages five calls per day. District 2 receives a total of 25 calls per month.
"I think this gives us a sense of what's going on," Cressman said. "It could set a baseline for the town to start having further discussions."
The report also analyzed "shute time," defined as the time between a 911 call being received and an ambulance responding. From March to May the time was between 52 seconds and 2 minutes. Times dropped off to around one minute after that point.
Overall, the average en-route response time for "priority one" calls - the most serious - was 5:46.
Times for priority one and two calls should not exceed eight minutes and a monthly average of six minutes. Priority three calls were just above 7:15. The limit is 20 minutes and an average of 15 minutes.
Also new to the report this year is measures of fuel efficiency and mileage of town-owned vehicles. The report divided it into departments, from the highway department to the Board of Health, from October to December.
The top fuel-efficient departments are also ones which use the town's fleet of fuel-efficient vehicles. The Building Department scored the highest, averaging 37.52 miles per gallon. The Board of Health averaged 24.28; Select Board, 33.3; and Animal Control, 12.23.
"Hopefully the Select Board and Finance Committee can use this, as well as the Capital Improvements Committee, at raising the issue of how can we make the fleet more fuel efficient," Cressman said.
Other data sets to note: in the Department of Public Works, all but three of ten departments have not had a work-related injury in 100 days. Solar permits have continued a downward trend. Since reaching a peak of 416 in fiscal year 2016, it fell to 168 in 2017 and 53 in 2018, although the fiscal year is not yet over.
The report also provided an update on several major road projects in Dartmouth. The Padanaram causeway and bridge project is set to be complete in the spring of 2018.
Engineering has been reinstated for the planned relocation of Tucker Road, which would move the Tucker Road/Route 6 intersection to line up with Hathaway.
A grant-funded reconstruction of Rogers Street from Dartmouth Street to Clarks Cove will include updated sidewalks.
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subset: commoncrawl


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Fossilized errors such as those above tend not to affect comprehension although they might be stigmatised due to the fact that they often reflect errors that are typical of very basic-level learners (such as omission of 3 rd person "s). Since fossilized errors do not generally trigger misunderstanding and hence do not prompt a clarification request from the listener, the learner may simple never notice them or be aware that they are there. The noticing hypothesis (see below) suggests that unless the speaker notices such errors, it is unlikely that he or she will correct them.
What is the difference between contrastive analysis and interlanguages? Post your comments Post Anonymously Please enter the code:


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Nursery Teacher
Our class teacher is Miss Burgess who is also the Art subject co-ordinator.
Teaching Assistant
We are lucky to have Miss Cruddas as our teaching assistant in Nursery. She enjoys creative activities and is a very good cake maker! Miss Cruddas also supports during lunch club alongside Mrs Hoque and Ms Boyd.
Class studies
This Spring term nursery will be exploring 'Opposites'. The aim is to develop the children's language and understanding about important concepts such as old and new, big and small and fast and slow.
This will create lots of discussion, investigation and discovery in both maths and science as well as creating opportunities for the children to relate to their own experiences and listen to stories about the theme.
For the second part of the spring term we will look at changes in the environment and think about growing, including planting our own seeds.
If you have any resources you think will be of use to us please let me know, many thanks.
In phonics, we will begin learning about how to be aware of the sounds around us and creating sounds of our own using different resources. In maths we will be reciting number and counting objects on a regular basis as well as exploring shapes.
P.E. will be on a Friday and although your child does not need a P.E kit they will need to take off and put back on their shoes, socks and jumpers/cardigans so don't be surprised if they are a little dishevelled at the end of the day!
Homework packs which support early communication and language skills will be sent out on a Friday and library books each Monday.
Please look out for letters and notices about show and tell and other activities this term and don't hesitate to come and speak to Miss Burgess if you have any questions.
Nursery Spring 2018 Newsletter


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Popular rapper AKA has announced on Twitter that he and his girlfriend Bonang Matheba had broken up. The couple have been together for two years.
Myself and Bonang have decided to call it quits. I feel like I need to put this out there so we can both move on. I wish her all the best and I will always love her. ❤
Bonang cryptically sent out a tweet - perhaps alluding to the break-up.
"Choose joy... once you choose and place your attention on wanting to flow there, the universe will shift for you and inspire you to the action needed to take you there...."
If we recall, earlier this year the rapper made an announcement that they were no longer a couple, only to confirm later that the "break-up" was just a PR stunt.
Should we expect or a new song or this is finally over?


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Ms McGill said as Mayweather got closer she could read his lips. He was punching her in the head and he was stomping on her sholder [sic]. Apparently, Mayweather hired Doralie, also known as Bad Medina, as his masseuse, but things took a twist, which make it that his sessions were free; unless of course, if you take all the lavish spending into consideration. She said Mayweather had argued with her over child support for Ayanna. No, but I had bruises on my body and contusions and [a] concussion because the hits were to the back of my head. He faced up to 34 years in prison, but pleaded guilty to reduced charges after a deal with prosecutors. Ms Harris claimed to have been physically abused by Mayweather at least six times before the final beating. Several months later, Ms Brim attested that she and Mayweather were at a mall with their daughter. A and stay at the condo. She lived with her mother Mandy and five siblings, but is now touring the world with the Money man, going to NBA games and sitting courtside next to Jay-Z and Beyonce. He requested to be released early because the low-quality food and water apparently threatened his health. He was handed a day sentence as a result.


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For endurance athletes such as road runners, trail runners, bikers, triathletes among others, proper fueling before any type of physical activities is the number one thing to consider. I remember when I joined my first full-marathon, I was anxious on how I could properly fuel up my body. I've read so many articles providing tips on proper nutrition before running a marathon, and most if not, all suggest to "carbo-load." Continue reading "Climbing Every Mountain with U.S. Potato-Packed Power" (56)
Challenge Yourself, Join the Pinoy Fitness 21K Challenge 2018
For those who want to level up in their running or those who just want to challenge their limits, a good race to join is none other than the Pinoy Fitness 21K Challenge which is happening on November 18, 2018 at the, SM By the Bay, SM Mall of Asia. Continue reading "Challenge Yourself, Join the Pinoy Fitness 21K Challenge 2018" (44)
Hello Kitty Run Manila 2018, Filinvest Alabang
The Hello Kitty Run Manila is making a second run in a different venue this year. The run will be held at Filinvest Alabang on September 30, 2018. Fans of Hello Kitty characters who are also into fun run would surely be excited for this fun run, Continue reading "Hello Kitty Run Manila 2018, Filinvest Alabang" (424)
SMDC Run 2018 race report and more
My second half-marathon for this year was at the SMDC Run 2018 which happened, obviously at the SM MOA grounds. From what I heard yesterday, this is the 4th year of the said running event. And it also happens to be my first time to join the said event. SMDC Run 2018 was organized by Leadpack and Takbo.ph and of course, SMDC. Continue reading "SMDC Run 2018 race report and more" (1034)
Running is Good for your Health
Running is good for your health. Plain and simple. The more you run, the healthier you become. Of course, don't forget to supplement that with proper nutrition. And by nutrition, you have so many options. You can either go clean and green, balanced and yet non-restrictive, LCHF, and the list goes on. Well, I'm not a nutritionist so I'm not going to tell which nutrition mode is the best for you. It's your body, so only you can determine which one suits you.
Now going back to the health benefits of running. You'll be surprised that there's a dearth of information available online. All you have to do is to Google it.
But if you've got no time and you want to find out the health benefits of running, here are 35 amazing health benefits of running.
Amazing right? Are those enough reasons to get you into running? (647)
PSE Bull Run 2018 race report and experience
And just like that, my first running event for 2018 happened last Sunday at the PSE Bull Run 2018. The event was held at the Bonifacio Global City, which I prefer more than the SM Mall of Asia Grounds. I joined the 25K category which according to Eric, the eruption, had a total of 350 participants. Continue reading "PSE Bull Run 2018 race report and experience" (849)
PSE Bull Run 2018 is on!, January 14, 2018, BGC
Same as last year, my first running event for 2018 will be the PSE Bull Run. Happening on January 14, 2018 at the Bonifacio Global City, the 13th iteration of this run is being organized by Runrio. Continue reading "PSE Bull Run 2018 is on!, January 14, 2018, BGC" (906)
7-Eleven Run 2018 is on February 8, Ready to Run 42K at the Skyway in 4 Hours?
As early as now, one of the most-awaited running event for 2018 was already announced. This is the 7-11 Run which will be held on February 8, 2018 in Filinvest City, Alabang. Of course, you don't need to be told that this is also know as the Skyway run. Continue reading "7-Eleven Run 2018 is on February 8, Ready to Run 42K at the Skyway in 4 Hours?" (1694)
Pinoy Fitness 21K Sub-2:30 Challenge Experience
This is a rather late post since it's been a week since this year's Pinoy Fitness 21K Challenge was held in SM MOA. But for documentation purposes, I'm posting this anyway. So, after three years of joining the PF 21K Sub-2 Challenge, I decided to step back this year and joined the sub-2:30 instead. It was a good decision especially since I have not been joining running events this year. My last first and only 21K foot race this year was sometime in February. Continue reading "Pinoy Fitness 21K Sub-2:30 Challenge Experience" (820)
Salomon X-Trail Run 2017 is on July 23, 2017
Watch out for details, this coming Friday, 23 June 2017! (2012)


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It was funny when it was just a problem for teenagers or recent college grads: looking for a job to get experience, but every job requires experience to hire you. It stopped being funny right around 2008. Today, as I drove past a newly foreclosed house not far from me, I was reminded that the joke is getting really old.
The catch-22 is alive and well. Companies expect more of job candidates because…well…because they can. The growing expectation is that a new hire should already have the tools and competencies they need to hit the ground running. Training? That's expensive, time intensive, and so 2002.
Candidly, I'd hoped that bridging a list of competencies to a plan for training would feel more rewarding than it did. This meant a return to the more familiar ground of writing learning objectives and deciding what can be learned verses what should be incumbent or even inherent. Because let's face it, if you're applying to star at a dinner theater, you know you need to be able to carry a tune.
But what about the other stuff? Maybe you can sing but you struggle a bit in the dance department. During the interview you'll say you're a fast learner. Don't waste your breath. Someone else will get the job.
I take a dim view of applying competency models to training for a reason: I just don't see it happening very much. When there is a new product or system to be learned, yes, there will be training. There will be training on company minutiae. There will be sensitivity and sexual harassment training. These things are givens like death and taxes. But increasingly, skills, knowledge and abilities are expected to be part of the new hire's fabric. Welcome aboard. Now adapt what you already know to thrive or you will drown here.
I hoped to find something to cheer me up on the subject. Nope. These are the words of a Ph.D. who does competency model consulting:
I ask the reader how difficult it would be to make someone smarter, a better planner, more interpersonally skilled, or change their motivations. How about the last time you saw an incompetent person enter a training program and leave competent? Training can improve a skill slightly, but there is almost no published data whatsoever to support the claim that training will significantly change behavior or fix a hiring mistake.
In other words, competency models for hiring? Yes. For training? No.
I wonder how many companies have taken his advice. I wonder how many good people didn't get the job because they lacked one competency that is supposedly untrainable.


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Tom Izzo is the Greatest Coach in NCAA Tourney History, And Math Proves It
I never took any stats classes, because, uh...radio. But I can tell you who's at the top of a list - and when it comes to the best coaches in college basketball, during the NCAA tournament - the guy at the top is Tom Izzo. And that's not just my opinion - that's proven by math.
Somebody at the fivethirtyeight.com website figured it all out. Since 1985, the Spartans have performed MUCH better than their seedings say they should have.
Here's the story, so you can show your friends from down the road at the "Harvard of the Midwest".
Banana Don and Stephanie McCoy amuse and thrill you every weekday morning from 5:30 –10AM on the radio at 100.7 WITL.
Banana Don can be reached via email at firstname.lastname@example.com and on Twitter at @WITLBananaDon and @WITLFM. Also, Facebook friend Banana Don and Stephanie at Facebook.com/BananaStephanie and Facebook.com/WITLFM.


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Image: Finborough Theatre
Written in 1905, Break of Noon is a semi-autobiographical romance, based on Paul Claudel's own real love affair with a married woman, and his experiences as French consul in China.
A modern French classic, it is a unique poetic and symbolist manifesto, in verse, on the human frailty of ambivalence and the conflicts and contradictions between physical love and spiritual faith.
Break of Noon was banned from the stage by Claudel himself for forty three years (following a recommendation from his priest during confession), until his friend, famous actor and director Jean-Louis Barrault, after he'd successfully created the epic Soulier de Satin, convinced him to allow him to produce the play in 1948.
Barrault's production, in French, for the famous Renaud-Barrault Company was seen in London in 1951.
It was revived at the Comédie Francaise as recently as 2007.
"Noon at the sun. Noon at the centre of our lives."
Set in Hong Kong and China at the turn of the 20th century, against the backdrop of the age of Empire and the first whispers of revolt and decolonisation, Break of Noon follows the inner journeys of four people who together depict all the multifaceted faces of Love.
Ysé is at the centre of a romantic entanglement with three men: De Ciz, her unstable husband who is obsessed with business and will do anything to open new trade markets in the East; Mesa, devoted to his Catholic faith, but who was rejected for the priesthood and feels abandoned by God; and Amalric, a fortune-seeking explorer, and Ysé's old flame, who seems to be pushing Ysé into other men's arms, whilst still hoping she will return to him one day …
Social media & info
London SW10 9ED
Performance days & times
Sunday ‑ 7‑30pm
Monday ‑ 7‑30pm
Author: Paul Claudel
Director: David Furlong
Production: Exchange Theatre in association with Neil McPherson for the Finborough Theatre


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Thanks BzzzAgent!


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5th World Congress of Dermoscopy (WCD) – 2018
Official website
Welcome Letter
Dear friends and colleagues,
It is our great pleasure to welcome you to the official website of the 5th World Congress of Dermoscopy, which will be held in Thessaloniki, Greece from 14 to 16 June 2018.
In close collaboration with the International Dermoscopy Society, we are putting our best efforts to ensure that the 5th World Congress of Dermoscopy will be a global scientific celebration, bringing together all passionate dermoscopists around the globe, from inspiring teachers and experienced clinicians to young researchers and residents.
The on-line registration is already open and you can take advantage of the very reduced fee, which will be valid until the the 31st of March 2017.
Our website, as well as our facebook and twitter pages, will be fully active during all the time period until June 2018, so you can keep yourself updated on latest news about the Congress.
In the land where the history of the modern science began, we invite you to join a journey to the future of diagnosis in Dermatology.
Looking forward to meeting you in Thessaloniki!
Aimilios Lallas
Congress General Secretary
Secretary of International Dermoscopy Society
CommitteesNO INFORMATION
SupportNO INFORMATION
Program 1
Organizers 2
SpeakersNO INFORMATION
Exhibitors and sponsorsNO INFORMATION
Media partnersNO INFORMATION
Venue 1
Thessaloniki Concert Hall
Greece, 546 46, Thessaloniki, Odos 25 Martiou & Paralia
website: www.tch.gr


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I pass Everest in my PC, motherboard work on an ASRock P45X3 motherboard? Surfing the net and but would this make that big a difference? Thanks Doesn'ta small headphone amplifier.I'm wondering ifmight be my motherboard.
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