Lactulose is... Physiological properties of lactulose. The composition of lactulose and the features of its effect on the state of the gastrointestinal tract What products contain lactulose

Do you know what lactulose is and why microflora “loves” it? We understand why lactulose is contained in Prebiosweet and how it will help you be slimmer and more active.

In the 30s. of the last century, in the process of searching for a remedy for the treatment of digestive diseases, scientists discovered a substance that, for its bifidogenic properties, received the name "bifidus factor". So called lactulose - a prebiotic that stimulates the growth and development of bifidobacteria and lactobacilli.

The microflora of the large intestine is diverse, but it is bifido- and lactobacilli that produce enzymes that activate the protective functions of the body. The enzymatic activity of microflora is comparable to the work of the liver, so the activity of intestinal bacteria is no less important for the body than the functions of other vital organs.

Lactulose has the highest level of prebioticity among bifidogenic substances and has a pronounced positive effect on the state of microflora.

Lactulose is obtained from milk. But, unlike the milk sugar lactose, which is broken down in the stomach and converted into energy by the body, lactulose is not fermented in the stomach, but in the intestines. Simply put, lactulose is food for beneficial colon bacteria. Thanks to good nutrition, the quality and quantity of lacto- and bifidobacteria increases, which is very important for our body.

Healthy microflora is:

• normal digestion;
• proper bowel function;
• synthesis of vitamins by the body;
• effective absorption of calcium, magnesium and other minerals by the body.

The properties of lactulose are due to its ability to heal the intestinal microflora. To combat the damaging effects of negative factors, such as malnutrition, stress and unfavorable environment, it is important that the intestines perform their functions correctly and help the body remove waste and harmful substances. It is with this task that lactulose helps to cope.

Large doses of lactulose syrup are used as a mild laxative. During the diet, it helps to fight constipation, which can occur due to a reduction in the amount of food and dietary fiber consumed. Lactulose can be used by people of any age, including pregnant women and infants.

In small doses, lactulose is added to foods to give them prebiotic properties. Children's dairy products, dietary cereals, bran, muesli with lactulose are produced.
Lactulose in a preventive dosage is contained in Prebiosweet sugar substitutes. They help control the amount of sugar and simple carbohydrates in the diet and promote proper digestion.

What is lactulose in milk and what is its use?

Over the past five years, one of the most important areas for the development of the dairy industry in the Republic of Belarus has been the production of not only tasty, but also healthy food, which is of particular importance in areas with unfavorable radiation conditions. To this end, the country has developed a large number of regulations for the production of food products with therapeutic and prophylactic properties, including dairy products. PUE "Kalinkovichi Dairy Plant" was no exception. For several years now, the enterprise has been producing functional products, enriched with various therapeutic and prophylactic additives, such as vitamins, calcium, bifidobacteria, lactulose and others, in parallel with “pure” dairy products.

According to the company's current policy in the field of quality and safety of products and goals to achieve it, the company's management annually adopts plans to expand and update the range of products, - said the chief technologist of the plant MP Prokopenko. -- The team is trying to keep up with the times and introduce modern types of dairy products, which are recommended both by the developers of regulatory documents and the country's Ministry of Health. Before mastering their production, the specialists of the enterprise conduct a deep analysis of their significance, presence and demand in the market. The properties and qualities of a particular additive are carefully studied at training seminars - both in our country and in countries near and far abroad. We are guided only by technical regulations (standards, specifications, recipes) for the production of products, agreed with the Ministry of Health and approved by the State Standard of the Republic of Belarus.

The significance and importance of this direction in the development of the dairy industry is supported and highly appreciated at all levels, not only in our country, but also in the Russian Federation. And it is no coincidence that in 2012 at the international forum "Dairy Industry" in Moscow, according to the results of assessing the quality and functional properties of sour cream enriched with lactulose, produced by the Kalinkovichi Dairy Plant, it was recognized by tasters of a high professional level as the best among the "whales" of the dairy industry and was awarded the highest award of the competition - Grand Prix, which means a lot and speaks for itself.

All additives used to enrich dairy products not only do not change the natural structure of milk and milk products, but also enhance their useful properties, the chief technologist emphasized. Enriched dairy products are useful and relevant for both adults and children: their constant use has a positive effect on the overall resistance of the body, protecting it from infections and increasing immunity. Lactulose is the most studied prebiotic of all known prebiotics, and the enrichment of a food product with lactulose at the rate of 2 g to the daily norm of the product endows it with numerous functional properties: intestinal digestion is activated, absorption of minerals increases, vitamin synthesis is stimulated, local immunity and anti-cancer protection are provided, etc. This , in fact, nothing more than the restoration of their natural "benefit" and biological expediency. For the first time more than 50 years ago, the lactulose molecule was found in human milk. Assumptions about the bifidogenic effect of lactulose - actively stimulating the growth and development of intestinal microflora - have been proven by numerous clinical studies. Since the discovery of lactulose, hundreds of scientific papers and monographs have been published in the field of pediatrics, gastroenterology and related sciences on its beneficial effect on physiological processes in the human body. Many are already familiar with lactulose - it is found both in the composition of medicines and in food products for preventive and health nutrition, but in much lower dosages. Lactulose is included in the list of essential drugs in the Republic of Belarus, the Russian Federation and many other countries.

For comparison, I would like to give the amount of lactulose in milk (which is indicated on the label on the milk package) and, for example, in the children's drug Prelax, which is sold in pharmacies (indicated in the annotation for the drug). And the ratio is: max. 0.25 g in 100 ml of milk enriched with lactulose versus 67 g in 100 ml of Prelax, i.e. 268 times more!!!”, states MP Prokopenko MP Prokopenko. -- fortified products are in great demand among buyers who care about their health and the health of their families - more than 15 tons of milk and 5 tons of enriched kefir daily produced by our production under the brand name "Kalinka" found its buyer in the market of the city, district and the whole Gomel areas.

At the same time, N.A. Kiselyov, General Director of Felicata Holding (manufacturer of prebiotic food ingredients for food fortification) emphasized that Belarusian products can compete with global manufacturers in terms of their benefits and quality:

Dairy plants in Belarus are traditionally considered to be producers of high-quality, healthy and tasty products, which can be safely called modern, as Belarusian producers keep up with the times. Take, for example, the expansion of the range of production through the introduction of functional food products enriched with biologically active substances, including lactulose, vitamins, minerals, and so on. In Russia, we consider dairy and other food products produced in the Republic of Belarus to be much better and tastier than what is produced in our country. The wide popularity of Belarusian grocery stores in Russia is proof of this. Belarusian manufacturers, firstly, comply with the highest production quality standards laid down back in the days of the USSR, and secondly, they do it at home, for themselves, since the main consumers of Belarusian-made products are Belarusians and Russians themselves. In terms of quality and usefulness, Belarusian dairy products, in our opinion, can compete not only with Russian-made goods, but with world leaders.

For example, in Japan, one of the ten countries with the highest life expectancy, lactulose was included in the "gold list" of foods that improve the health of the nation, back in 1992. In the wake of government support, manufacturers launched lactulose-enriched products on the market, and to this day, the Japanese company Morinaga Milk Industry Co. produces several types of dairy products containing lactulose and are popular not only in Japan, but also in France, Germany and other countries. By the way, such enriched foods are shown not only to children, but are also recommended for the nutrition of an aging population, which also needs additional resources to maintain the proper functioning of the digestive tract.

In Europe, lactulose as a fortifying food additive was registered in 2010, but even before that, lactulose-containing formulas for baby food were produced in some European countries. Belarusian manufacturers started producing products with lactulose in 2003, and in 2006, by the Decree of the President of the Republic of Belarus, the program "Children of Belarus" was approved, which has a sub-program "Children's food". Within the framework of the subprogram, recipes for preventive food products, such as semi-finished meat products, dairy products, chocolate, etc., enriched with lactulose, were developed. Since 2006, products with lactulose have been produced at more than 50 enterprises, in 2013 - more than 20, including 14 dairies and combines. It turns out that Belarus can not only be compared with Japan and Europe in terms of the degree of innovativeness of food production, but it can also be argued that Belarusian manufacturers have gone further technologically by introducing enrichment methods in other areas of the food industry. Speaking about the need to add lactulose to the food of the adult healthy population, it must be remembered that modern people, due to their eating habits and the abundance of refined (purified) foods, receive an insufficient amount of dietary fiber (fiber) necessary to maintain the proper form of intestinal microflora. Lactulose belongs to the class of prebiotics, the same dietary fibers that serve as food for bifidobacteria and lactobacilli, living in symbiosis with the human body and helping it to function properly.

Today, lactulose is widely used in the food and pharmaceutical fields. For more than half a century, this substance has been used to prevent and treat various disorders and disorders of the stomach and intestines. Lactulose is also used in the detection of dysbacteriosis and liver diseases.

Foods rich in lactulose:

General characteristics of lactulose

Lactulose is a prebiotic necessary for the full functioning of the organs of the gastrointestinal tract. Lactulose is a white, odorless powder, highly soluble in water. For the first time in 1929, lactulose was obtained by Hudson and Montgomery by heat treatment of lactose with an alkaline solution.

And in 1948, an Austrian pediatrician, concerned about the frequent cases of dysbacteriosis in "artificial" infants, made a discovery. He discovered in the composition of human milk a substance that promotes the growth of beneficial intestinal microflora. This substance turned out to be lactulose.

The composition of the lactulose molecule includes galactose and fructose. Artificially, lactulose is obtained from milk sugar. This is a rather laborious process - deep processing of milk. Today, lactulose is quite often used for the production of dietary supplements, as well as in pharmacology as part of laxatives and agents that improve the intestinal microflora.

Daily requirement for lactulose

Numerous experiments have established the following: the optimal use of lactulose is 3-4 g daily. As a result, the number of bifidobacteria in the intestines, which are extremely useful for the body, increases 5 times, while the number of Escherichia coli decreases 100 times. Lactulose significantly improves the intestinal microflora and increases the body's defenses.

The need for lactulose increases:

• with various disorders of the intestines (for example, with chronic constipation);
• with "contamination" of the intestinal microflora;
• with violations of the gastrointestinal tract;
• to stimulate and improve the work and functions of the liver;
• with high cholesterol;
• in metabolic disorders.

The need for lactulose decreases with:

• increased acidity of gastric juice;
• low intestinal pH;

Digestibility of lactulose

The assimilation of this substance has a fairly good indicator. Lactulose is broken down by the action of enzymes to the formation of simple organic acids: lactic, acetic, butyric and others.

Useful properties of lactulose, their effect on the body

Perhaps the main advantage and main property of lactulose is the ability to suppress harmful bacteria. An indisputable property, confirmed by experts, is the ability of lactulose to rid the body of toxic substances and harmful enzymes, such as ammonia, skatole, nitroreductase. Often used as a laxative.

Thanks to lactulose, calcium is better absorbed, which significantly increases bone strength.

Reducing disorders and disorders of the intestines is one of the important conditions for human health. A sufficient content of lactulose in the human body contributes to the full functioning of the intestines by improving the microflora.

Another useful property of lactulose is its anticarcinogenic effect. Lactulose has proven itself well as a prophylactic against colon cancer. Lactulose is necessary to stimulate the growth of healthy microflora.

Interaction with other elements

Lactulose interacts in the body with trace elements - calcium, magnesium, zinc, iron. Interacts with cholesterol, bile acids.

At the same time, indicators of cholesterol in the blood are normalized, and the synthesis of bile acids is also optimized. In addition, the absorption of magnesium, zinc, calcium and iron improves.

Factors affecting the content of lactulose in the body:

Lactulose is not produced in our body, and comes to us with food. To maintain a normal level of lactulose in the body, a complete balanced diet and nutrition, which include products containing it, is sufficient.

In addition, today there is a huge selection of medications containing lactulose. Most often, such drugs have a minimum number of contraindications and are approved for use from birth.

Lactulose for beauty and health

This substance is included in the list of food additives that increase human immunity, improve metabolic processes in the body. Lactulose promotes the rapid absorption of calcium. As you know, calcium contributes to the proper and healthy growth of hair, nails, teeth. Accordingly, the use of products containing lactulose has a great effect on the appearance and internal sensations.

Lactulose syrup contains (per 100 ml) 66.7 g of active ingredient + auxiliary element - water.

Also, the drug is produced in the form of a syrup containing 10 g lactulose , 1.65 g galactose and 0.9 g lactose in 15 ml of medicine.

Release form

The drug is produced in the form of a clear yellow syrup in bottles of 15, 200, 240 or 1000 ml.

pharmachologic effect

Laxative .

Pharmacodynamics and pharmacokinetics

What Lactulose ? Lactulose - it's synthetic disaccharide 6-galoctoside-fructose . The substance enters the large intestine, where its reactions occur. Low molecular weight organic acids formed as a result of this process, significantly reduce pH environment. This process contributes to the removal from the body slag , and rapid evacuation of feces.

Preparations lactulose have a mild, but rather intense laxative effect, which does not require additional intake of a large amount of liquid. The medicine increases osmotic intra-intestinal pressure , intensifies peristalsis , fluid is retained in the intestinal cavity and softening of the stool occurs.

Thanks to the reduction pH and the emergence of a more acidic environment in the intestines can now multiply lactobacilli and bifidumbacteria who use lactulose as a nutrient substrate . Quantity pathogenic microorganisms and decaying will decrease significantly. Toxic substances such as ammonia , salt heavy metals , radionuclides faster excreted from the body.

In the digestive system there is no specific, splitting lactulose , so the substance freely penetrates into the large intestine. The drug undergoes reactions metabolism with lactobacillus and bifidumbacterium . Main - lactic acid and others org. acids .

Indications for use

Preparations with this active ingredient are usually prescribed:

• with chronic;
• as part of complex treatment hepatic encephalopathy ;
• with digestive disorders;
• at salmonellosis ;
• pregnant and lactating women;
• infants older than 1.5 months who are bottle-fed;
• elderly people with indigestion;
• after resection of hemorrhoids .

Contraindications

The drug is contraindicated in case of its components and in case of galactosemia .

Galactosemia - what is this? This is a hereditary disease, accompanied by a lag in development, both mental and physical, accumulation galactose in .

Side effects

The first doses of the drug may be accompanied by bloating , increased and discomfort (symptoms disappear after 2 days). Rarely disappeared in patients, observed nausea and vomit .

Instructions for use Lactulose (Method and dosage)

The dosage of the drug is selected individually, after consultation with the doctor.

It is best to drink the medicine during meals, in the morning.

At acute intestinal infection caused by salmonella , appoint 15 ml, 3 times a day. The duration of admission is 10-12 days. It is necessary to drink 2-3 courses with a break in a week. During the passage of the third course, take 30 ml, 3 times a day.

Instructions for Lactulose syrup for children

The syrup can be diluted with water or juice.

For children from 7 to 14 years old, first appoint 15 ml of syrup, then 10 ml per day.

At the age of 6 years, take 5-10 ml of the drug.

Syrup for newborns (from six months to 1 year) is recommended to prescribe at a dosage of 5 ml per day.

Overdose

Occurs with an overdose. Which goes away on its own after a while. There may also be an increase in side effects.

Interaction

If you combine the drug with a wide range of action, then the effectiveness of the drug is reduced.

The medicine lowers pH of intestinal microflora , which may delay the release of active ingredients from enteric-coated products.

Terms of sale

The drug is approved for non-prescription dispensing from pharmacies.

Lactulose(lat. lactulose) - laxative drug, prebiotic.

Chemical compound: 4-O-beta-D-Galactopyranosyl-D-fructose. Empirical formula C 12 H 22 O 11 .

Lactulose - international non-proprietary name (INN) of the medicinal product. According to the pharmacological index, lactulose belongs to the group "Laxatives". According to ATC - to the group "Osmotic laxatives" and has the code A06AD11.

Lactulose is an odorless white crystalline substance, highly soluble in water. It is a product of deep milk processing and is produced from milk sugar lactose. Lactulose belongs to the class of oligosaccharides, a subclass of disaccharides: its molecule consists of residues of galactose and fructose.

Lactulose is a prebiotic , that is, she:

• is not broken down by digestive enzymes and is not absorbed in the stomach and small intestine and reaches the large intestine unchanged
• selectively stimulates the growth and development of the microflora of the colon - bifidobacteria, lactobacilli and similar ones

Lactulose is the only laxative effective and safe drug in all age groups approved for use in pediatric practice . The most important feature of lactulose is its prebiotic effect. Prebiotics are partially or completely indigestible food components that selectively stimulate the growth and / or metabolism of one or more groups of microorganisms living in the large intestine, ensuring the normal composition of the intestinal microbiocenosis. From a biochemical point of view, this group of nutrients includes polysaccharides and some oligo- and disaccharides. For microorganisms, they are vital components of their nutrition, sources of energy and plastic material. As prebiotics, dietary fiber, oligosaccharides, lactose and lactulose are the most well studied. As a result of microbial metabolism of prebiotics in the colon, lactic acid, short-chain fatty acids, carbon dioxide, hydrogen, and water are formed. Carbon dioxide is largely converted into acetate, hydrogen is absorbed and excreted through the lungs, and organic acids are utilized by the macroorganism, and their importance for humans can hardly be overestimated. Lactulose, by stimulating the growth of normal intestinal microflora, helps to maintain anti-infective protection, in particular against shigella, salmonella, yersinia and rotaviruses. When children are artificially fed with a milk formula containing 1.2 g / 100 kcal of lactulose at a ratio of lactose to protein of 2.5: 1, an almost pure culture of bifidobacteria is formed in the intestine, and the acidity of the intestinal contents decreases (Belmer S.V. et al.) .

The dose of lactulose is selected individually, starting with 5 ml 1 time per day. In the absence of effect, the dose is gradually increased (by 5 ml every 3-4 days) until the desired effect is obtained. Conventionally, the maximum dose in children under 5 years old is 30 ml per day, in children 6-12 years old - 40-50 ml per day, in children over 12 years old and adults - 60 ml per day. The multiplicity of reception can be 1-2 (rarely 3) times a day. The course of lactulose is prescribed for 1–2 months, and if necessary, for a longer period. The drug is canceled gradually under the control of the frequency and consistency of the stool (Belmer S.V. and others).

Lactulose, due to its unique properties, is rightfully considered the gold standard of laxatives. She, like other osmotic drugs, is able to retain water in the intestinal lumen, in proportion to the number of its molecules. Lactulose is not metabolized or absorbed in the small intestine, since brush border enzymes cannot hydrolyze the bond between galactose and fructose molecules, and it reaches the large intestine almost unchanged. Here, under the influence of bacterial enzymes, lactulose breaks down with the formation of short-chain fatty acids (lactic, acetic, propionic and butyric). These organic acids may be absorbed or remain in the intestinal lumen. In the latter case, there is a decrease in pH (increased acidity of feces). Possessing a pronounced osmotic activity, organic acids stimulate the obligate excretion of water throughout the colon, which does not allow the mucous membrane to absorb the products of the enzymatic decomposition of lactulose. As a result of an increase in intraluminal pressure caused by water retention and an increase in chyme volume, the peristaltic reflex is initiated and coordinated motor activity is stimulated, which leads to an acceleration of intestinal transit. An additional mechanism for stimulating peristalsis is an increase in the volume of intra-intestinal contents due to an increase in the biomass of bifidobacteria and lactobacilli, the growth of which is stimulated by the products of enzymatic hydrolysis of lactulose. This phenomenon develops much later than the main effects, but makes a significant contribution to the development of the overall laxative effect. Enzymatic processes lead to the formation of gas (10 g of lactulose - 1 liter of hydrogen and carbon dioxide), most of which is absorbed into the bloodstream and excreted with exhaled air. In some patients, the remainder of this gas can cause bloating. Flatulence is almost the only side effect of lactulose. In some patients, it can develop on the 3-4th day from the start of lactulose intake and, as a rule, disappears on its own. In persistent cases, to eliminate flatulence, the dose of lactulose should be reduced. In order to prevent the development of flatulence, a gradual increase in the dose of lactulose from the minimum to the most effective can be recommended. It should also be remembered that exceeding the daily dose of lactulose (more than 100 g) can lead to severe diarrhea. Standard doses of lactulose have a mild laxative effect due to lower, compared to other laxatives of this class, osmotic activity and suppression of water reabsorption in the colon (Pasechnikov V.V.). D.).

Unlike most laxatives, when taking laxatives with an osmotic effect (lactulose and macrogol), there is no irritation of the chemoreceptors of the mucous membrane and its damage even with prolonged use of the drugs. The high efficacy of lactulose and macrogol and the absence of serious adverse reactions make these drugs most preferred laxatives, used in the treatment of chronic constipation (Roytberg G.E., Strutynsky A.V. Internal diseases. Digestive system. M.: MEDpress-inform, 2007).

Osmotic laxatives based on lactulose and macrogol are often considered as second-line drugs for the treatment of constipation of any type, which are recommended when non-drug methods and dietary fiber are ineffective (Shulpekova Yu.O.).

Due to the ability to bind water, the synthetic disaccharide lactulose, like other osmotic laxatives, increases stool mass, softens the consistency and accelerates the movement of chyme through the colon. However, lactulose induces flatulence and bloating . Moreover, the intestinal microflora adapts to the daily intake of non-absorbable sugars. This circumstance reduces the effectiveness of lactulose during long-term treatment and also forces you to constantly increase its dose to achieve the effect (Makhov V.M., Beresneva L.A.).

Lactulose contributes to the appearance of imbalance short chain fatty acids in the colon: it stimulates the production of acetic acid to the detriment of butyric and propionic (Ardatskaya M.D.).

Lactulose is the drug of choice for the treatment of constipation in the elderly. 30–100 ml/day Its advantage lies in the fact that it does not require additional fluid intake, does not lead to addiction, is not absorbed (it can be prescribed for diabetes mellitus), does not cause electrolyte disturbances, and is effective in liver diseases (Zvenigorodskaya L.A., Samsonova N.G. .).

Professional Medical Publications concerning issues of impact lactulose on the gastrointestinal tract:

• Belmer S.V., Gasilina T.V., Khavkin A.I., Eiberman A.S. Functional disorders of the digestive system in children. M., RSMU, 2005.–36 p.

• Pasechnikov V.D. Functional constipation due to delayed transit of intestinal contents // Farmateka. - 2003. - No. 10. - p. 16–23.

• Zvenigorodskaya L.A., Samsonova N.G. Chronic ischemic disease of the digestive system: clinical picture, diagnosis, treatment. Consilium Medicum. -2008. -№ 2. General issues of gastroenterology.


• Babayan M.L. The use of lactulose in pediatric practice // BC. Mother and child. Pediatrics. 2011. No. 22. pp. 1380–1383.

Indications for use:

• chronic constipation
• hepatic encephalopathy
• salmonellosis, except for generalized forms
• digestive disorders in infants and children under 10 years of age associated with putrefactive processes as a result of food poisoning

• Adults. As a laxative, adults are usually prescribed 1-3 tablespoons of syrup per day for 3 days. Further, as part of maintenance therapy, take 2-5 teaspoons per day. For liver diseases - 2-3 tablespoons 3 times a day
• Children. 1-3 teaspoons per day.

The use of lactulose during pregnancy. FDA risk category for the fetus when taking pregnant lactulose: B (animal studies did not reveal the risk of negative effects of lactulose on the fetus, there were no adequate studies in pregnant women).

Contraindications:

• hypersensitivity to lactulose
• galactosemia (a hereditary disease characterized by the accumulation of galactose in the blood and a lag in physical and mental development)

At overdose possible diarrhea, pain in the abdomen. In this case, the drug should be discontinued.

Special instructions:

• lactulose is used with caution in patients with diabetes mellitus (especially in the treatment of hepatic encephalopathy) and with lactose intolerance
• stop taking lactulose if diarrhea occurs
• with gastrocardial syndrome, doses are increased gradually, in order to avoid flatulence; flatulence usually disappears on its own after 2-3 days of treatment
• it is unacceptable to prescribe lactulose for abdominal pain, nausea and vomiting
• in the treatment of higher doses for more than 6 months, it is necessary to regularly monitor the level of electrolytes in the serum
• if constipation persists when taking lactulose for several days or after stopping the drug, constipation reappears, you should consult a doctor

Trade names of medicines, in which lactulose is the active ingredient: Dufalac, Lactulose Poli, Lizalak, Normaze, Portlak, Romfalac.

As a prebiotic, lactulose is included in the following prebiotic products : "Bio-Max" (milk, fermented milk products), baby milk with lactulose "Agusha", "Ladybug" (fermented milk products), "For Health" (milk, fermented milk products), "Obninsky" (fermented milk products), " Tallinn "(kefir).

In addition, lactulose is the basis of a number of dietary supplements and is used in some drugs as an excipient (Bifiform and others).

The following medicinal products containing lactulose are registered in the USA: Constulose, Kristalose, Chronulac, Cephulac, Constilac, Cholac, Duphalac, Evalose, Heptalac, Enulose, Generlac.

By order of the Government of the Russian Federation dated December 30, 2009 No. 2135-r, lactulose (syrup) is included in