Relationship Between Abdominal Symptoms and Fructose Ingestion in Children with Chronic Abdominal Pain

Abstract

BackgroundLimited valid data are available regarding the association of fructose-induced symptoms, fructose malabsorption, and clinical symptoms.AimTo develop a questionnaire for valid symptom assessment before and during a carbohydrate breath test and to correlate symptoms with fructose breath test results in children/adolescents with functional abdominal pain.MethodsA Likert-type questionnaire assessing symptoms considered relevant for hydrogen breath test in children was developed and underwent initial validation. Fructose malabsorption was determined by increased breath hydrogen in 82 pediatric patients with functional abdominal pain disorders; fructose-induced symptoms were quantified by symptom score ≥2 and relevant symptom increase over baseline. The results were correlated with clinical symptoms. The time course of symptoms during the breath test was assessed.ResultsThe questionnaire exhibited good psychometric properties in a standardized assessment of the severity of carbohydrate-related symptoms. A total of 40 % (n = 33) had malabsorption; symptoms were induced in 38 % (n = 31), but only 46 % (n = 15) with malabsorption were symptomatic. There was no significant correlation between fructose malabsorption and fructose-induced symptoms. Clinical symptoms correlated with symptoms evoked during the breath test (p < 0.001, r2 = 0.21) but not with malabsorption (NS). Malabsorbers did not differ from non-malabsorbers in terms of symptoms during breath test. Symptomatic patients had significantly higher pain and flatulence scores over the 9-h observation period (p < 0.01) than did nonsymptomatic patients; the meteorism score was higher after 90 min.ConclusionsFructose-induced symptoms but not fructose malabsorption are related to increased abdominal symptoms and have distinct timing patterns.

Roles of Lactose and Fructose Malabsorption and Dietary Outcomes in Children Presenting with Chronic Abdominal Pain

“…This represented the most frequent abnormality recorded in the medical screening of our study population. This observation is in line with other studies evaluating children with CAP or irritable bowel syndrome (IBS) that reported even higher rates of malabsorption detected by abnormal breath tests (Supplementary Tables S3 and S4) [8,21,[26][27][28][29][30]. Of note, patients in our cohort received diagnostic tests for carbohydrate malabsorption only if they reported abdominal pain associated with dietary intake.…”

“…Although carbohydrate malabsorption is frequently detected in children, which corresponds to our findings, symptom relief has not been achieved by elimination of the respective carbohydrate in several randomized controlled trials [29,37]. We report lower dietary response rates to lactose-free or fructose-restricted diet (24% and 18%, respectively) than other studies [8,10,21,28,30,35,38]. However, the best dietary response rates (81-95%) have been reported in patients diagnosed with lactose or fructose intolerance [9,30,38].…”

“…We administered a solution of 2 g of lactose per kilogram body weight up to a maximum of 50 g, which is within the upper dose range of 0.5 to 2 g/kg up to an absolute amount of 25 or 50 g used in pediatric studies ( Supplementary Table S3) [11,22,27,[29][30][31][32]. In the absence of a gold standard for fructose H 2 BT, we administered a fructose solution of 1 g per kilogram body weight up to a maximum of 25 g, which is within the dose range of 0.5 to 2 g/kg up to a maximum of 10 to 50 g used in recent pediatric studies ( Supplementary Table S4) [9,11,21,29,[33][34][35]. Of note, increasing the fructose load up to 1.4 g/kg body weight on average resulted in increases in hydrogen production and H 2 BT positivity [9].…”

“…The study done by Wirth et al might especially reflect the high placebo effect of dietary restrictions in patients with abdominal pain [37] and may explain the absent response toward DBPC carbohydrate provocation in H 2 BT positive patients [29]. Currently, insufficient evidence exists to recommend dietary restrictions involving lactose or fructose elimination or a long-term FODMAP diet, which may lead to nutritional deficits in children with CAP in general [14,21,41,42].…”

“…In order to investigate the causal relationship of lactose and fructose intolerance in CAP, we analyzed the presence of symptoms and the abnormal increase during H 2 BT as well as symptom relief during consumption of an elimination diet at the follow-up visit. H 2 BT was performed with 2 g/kg (maximum 50 g) of lactose or 1 g/kg of fructose (maximum 25 g) dissolved in water, which is comparable to quantities used in other studies (Supplementary Tables S3 and S4) [15,21]. After overnight fasting, the hydrogen concentration in exhaled air was measured before, and at 30, 60, 90, and 120 minutes after carbohydrate ingestion [22].…”