The Daytime Breath Hydrogen Profile in Children with Abdominal Symptoms and Diarrhoea

ABSTRACT. The daytime breath hydrogen profile (DBHP) enables the study of breath hydrogen (BH) excretion in children under normal dietary and environmental circumstances. We studied the DBHP in 43 children with abdominal pain and (or) diarrhoea in order to evaluate its use in the detection of carbohydrate malabsorption (CHM). The results were compared to those of the lactose BH test. The DBHP was abnormal in 16 patients (37%), 8 of whom also had an abnormal lactose BH test. Five other patients with an abnormal lactose BH test had a normal DBHP. In 7 out of 10 children with an abnormal DBHP, the recorded abdominal symptoms coincided with a sharp increase in BH excretion. Abnormal DBHPs were most frequently found in children with functional abdominal complaints and with giardiasis. Our findings indicate that CHM is more frequently encountered in children with abdominal symptoms than can be detected by the lactose BH test. The DBHP offers new possibilities in the investigation of gastrointestinal conditions by correlating the symptoms directly to the effect induced by CHM.     

Lactose malabsorption during gastroenteritis, assessed by the hydrogen breath test

Thirty-eight infants and young children with gastroenteritis were investigated for lactose malabsorption. Each of them was given an oral lactose load of either 0.5 g/kg or 2 g/kg after which breath hydrogen excretion was measured, and each was observed to see if he had clinical symptoms of lactose intolerance. Only one patient, given 2 g/kg lactose, had clinical intolerance. His breath hydrogen excretion however was negative. Three of 18 patients given 0.5 g/kg lactose had positive breath hydrogen tests. None of these was symptomatic. Lactose intolerance in gastroenteritis was rare in our study, and the hydrogen breath test was not an appropriate technique for detecting it.     

Beta-galactosidase tablets in the treatment of lactose intolerance in pediatrics

Lactose-intolerant children manifest diminished or nonexistent intestinal lactase activity, resulting in flatulence, abdominal pain, and diarrhea. To assess the hydrolytic capability of lactase-containing tablets taken immediately before oral lactose challenge, we studied 18 children previously identified as being lactose intolerant and having no underlying organic gastrointestinal disease. Subjects had a mean (+/- SEM) age of 11.4 +/- 3.4 years; 72% were male. At time of the study, lactase-containing tablets or placebo tablets were ingested (double-blind) immediately before drinking a solution of lactose. Breath samples were obtained for hydrogen analysis at 30-minute intervals during a 2-hour period, and clinical symptoms were monitored. In lactose-intolerant patients, hydrogen production was significantly greater following placebo (maximum hydrogen excretion, approximately 60 ppm) compared with lactase-containing tablets (maximum hydrogen excretion, 7 ppm). Increased hydrogen production was associated with clinical symptoms including abdominal pain (89% of subjects following placebo ingestion), bloating (83%), diarrhea (61%), and flatulence (44%). These results indicate, therefore, that coingestion of lactose and lactase-containing tablets significantly reduces both breath hydrogen excretion and clinical symptoms associated with lactose intolerance.     

Ineffectiveness of breath methane excretion as a diagnostic test for lactose malabsorption

BACKGROUND: In clinical and field conditions, breath gas analysis has been widely used in evaluating carbohydrate digestion. A field study was performed to determine the prevalence of lactose malabsorption in Myanmar children and to evaluate the possibility of using breath methane excretion to indicate lactose malabsorption in a field situation. METHODS: The study population consisted of 118 children aged 1 to 12 years. A hydrogen breath test after a lactose meal (2 g/kg, maximum 50 g) was used as a standard test. RESULTS: Lactose malabsorption was detected in 16.7% of children aged 1 to 2.9 years, with the prevalence increasing with age from 40.5% of those aged 3 to 5.9 years to 88.5% of those aged 6 to 8.9 years and reaching 91.7% in those aged 9 to 11.9 years. Lactose malabsorption was more prevalent when children were weaned before 4 months of age (87.2 vs. 41.1%; p < 0.01). Compared with lactose-tolerant children, those with lactose malabsorption had significantly higher concentrations of breath hydrogen excretion 60 minutes after the lactose test meal. Breath methane excretion was also significantly higher in samples at 120 minutes in children with lactose malabsorption. Breath methane excretion of greater than or equal to 2 parts per million at 180 minutes as a diagnostic test for lactose malabsorption had a sensitivity of 61.5% and a specificity of 84.6%. CONCLUSION: The breath methane test for lactose malabsorption has a lower sensitivity and specificity than the breath hydrogen test and therefore does not replace the lactose breath hydrogen test.     

Lactose Malabsorption and Giardiasis in Basotho School Children

ABSTRACT. The prevalence of primary, adult-type, lactose malabsorption was assessed by means of the hydrogen breath test after intake of 360 ml of full cream milk (∼18 g lactose) in 96 randomly selected Basotho school children, aged 5–15 years. Of 86 children who did not have diarrhoea in the previous week 82 (85 %) were lactose malabsorbers, while 4 (5 %) could not be classified because of undetectable hydrogen excretion. Milk intolerance presenting as diarrhoea was significantly ( p <0.01) more common in children who associated previous abdominal complaints with milk intake and/or did not like milk. A negative hydrogen breath test was significantly ( p <0.05) more often observed in children who had diarrhoea in the previous week. Giardia was present in 18 (19 %) of 93 children. The incidence of giardiasis did not correlate with the presence of lactose malabsorption in children without diarrhoea in the previous week. However, milk intolerance presenting as diarrhoea was significantly ( p <0.05) more common in children with giardiasis. The findings support the use of physiological quantities of milk in Basotho school children.     

Bacterial contamination of the small intestine as an important cause of chronic diarrhea and abdominal pain: diagnosis by breath hydrogen test

Unsuspected bacterial contamination of the small intestine was indicated by breath hydrogen testing in nine patients aged 2 to 34 months during physical examinations for chronic diarrhea and abdominal pain. Elevated bacterial counts of questionable significance were found in duodenal aspirates before and after antibiotic treatment. There was no evidence of bile salt deconjugation or structural changes in the small intestine by light or electron microscopy. This may indicate that the site of colonization is distal to the biopsy site. Breath testing indicated lactose malabsorption in all patients, and four of five patients tested also malabsorbed sucrose. Duodenal disaccharidase levels in all patients were within the normal ranges, but in eight patients the lactase-sucrase ratio was greatly elevated (0.80 +/- 0.36; normal less than 0.45). Dietary restriction alone did not cause complete cessation of symptoms, whereas all patients responded dramatically to oral antibiotic therapy. When patients were well, the lactase-sucrase ratio had returned to normal in those tested, and all nine had normal lactose and lactulose breath hydrogen tests. Unsuspected bacterial contamination of the small intestine, which is easily detected using the breath hydrogen test, may be more commonly associated with chronic diarrhea in children than has been previously realized. In such cases, therapy should be directed at removing the contamination.     

Fructose malabsorption and dysfunctional gastrointestinal manifestations]

BACKGROUND: Individuals with impaired intestinal absorption of fructose may exhibit recurrent abdominal discomfort after the ingestion of fructose-containing foods. We report on patients with this disorder in whom the diagnosis was made by the fructose hydrogen breath test. METHODS: We investigated 293 patients with recurrent abdominal pain, meteorism or diarrhea in connection with the ingestion of fruits, apple juice or soft drinks. Mixed expired air was collected before and at 30 minute intervals after a fructose load and analysed thereafter by a hydrogen sensitive electrochemical cell. Incomplete absorption of fructose was defined as a peak rise in breath hydrogen of > 20 ppm. RESULTS: 108 out of 293 patients showed an abnormal peak rise after fructose (mean 71.8 ppm, SD 31.4). This malabsorption of fructose was associated with clinical symptoms in 79 of them. Sensitivity and specificity of the fructose hydrogen breath test were 98 or 86 per cent respectively. 19 patients with an abnormal breath test and symptoms following fructose were reexamined after a load with equimolar concentrations of glucose and fructose. Hydrogen breath test was normal in all of them, none developed abdominal discomfort. CONCLUSION: A considerable number of individuals suffer from dysfunctional gastrointestinal problems due to fructose malabsorption. The fructose hydrogen breath test is a simple, sensitive and noninvasive method for the diagnosis for this disorder. Possible means of treatment are dietary fructose restriction or a modification of the diet in which fructose-containing foods are exchanged for those with equal concentrations of glucose and fructose.     

Breath hydrogen test and sucrase isomaltase deficiency.

Sucrose breath hydrogen tests were performed on 7 children with proved sucrase isomaltase deficiency. All children had raised breath hydrogen excretion. The amount of hydrogen produced and symptoms experienced increased with increasing sucrose loads. The sucrose breath hydrogen test appears to be a reliable indicator of sucrose malabsorption in sucrase isomaltase deficiency.     

Lactase deficiency among Malaysian children with recurrent abdominal pain

OBJECTIVES: To determine the prevalence of lactase deficiency among Malaysian children with recurrent abdominal pain and to describe their clinical characteristics. METHODOLOGY: Twenty-four children referred consecutively to the University of Malaya Medical Centre who fulfilled Apley's criteria (at least three episodes of abdominal pain severe enough to affect normal activity over a period longer than 3 months) were tested for lactase deficiency using a pocket breath test analyser (BreatH2 meter; Europa Scientific, Cheshire, England). Lactulose was used to check for hydrogen-producing capacity. RESULTS: There were 14 males and 10 females in the study, consisting of five Malays, 14 Chinese and five Indians. Mean age was 9.9 years. Seventeen of the 24 children (70.8%) with recurrent abdominal pain who underwent the breath hydrogen test had a positive result. In those with a negative result, subsequent lactulose administration resulted in a positive rise in breath hydrogen. None of the 24 children developed abdominal pain during the test. All the Indian subjects, 71.4% of the Chinese subjects and 40% of the Malay subjects with recurrent abdominal pain had lactase deficiency. The proportion of boys and girls with lactase deficiency was similar (71.4 vs 70.0%, respectively). There was no significant difference between lactase sufficient and deficient children with recurrent abdominal pain with regard to sex, age, ethnic group and clinical features. Following a lactose-free diet, none of the children in the breath hydrogen positive and negative groups reported any appreciable difference in pain symptoms. CONCLUSIONS: The prevalence of lactase deficiency among this group of Malaysian children with recurrent abdominal pain was high, but lactase deficiency did not appear to play an important role in causing the symptoms.     

Lactose absorption and malabsorption in healthy Italian children: do the quantity of malabsorbed sugar and the small bowel transit time play roles in symptom production?

Using breath hydrogen analysis after an oral lactose load (2 g/kg; maximum 50 g), we investigated the prevalence of lactose malabsorption in 61 healthy Italian children aged 6-13 years. We also examined the relationship between symptoms and small bowel transit time and the degree of sugar malabsorption. Three of 61 subjects produced no H2 after both lactose and lactulose load and thus were eliminated at the outset. Lactose malabsorption was defined as excretion of greater than 20 ppm H2. Lactose intolerance was classified as mild (colicky pain, flatulence, abdominal distension, borborygmi) or severe (diarrhea). The frequency of lactose malabsorption in the children aged 6-8 years (group I) was 25%; in the children aged 8-11 years (group II), it was 35%, and in the children aged 11-13 years (group III) 56%. The differences in frequency between the first and the third groups were significant (p = 0.05). Three of 20 (15%) in group I, two of 20 (10%) in group II, and three of 18 (17%) in group III were classified not only as lactose malabsorbing, but also as lactose intolerant, with symptoms during and after the test. We found no difference in the small bowel transit times or in the quantities of malabsorbed lactose in symptomatic and asymptomatic malabsorbing subjects. Other factors that may play a role in symptom production are discussed.     

The status of lactose absorption in Hong Kong Chinese children

Lactose malabsorption was investigated in 169 Chinese children aged between two and 16 years using the breath hydrogen test. The challenge was either lactose solution (1 g/kg) or cow's milk (10 ml/kg). Overall, 68% of the children showed a significant increase in breath hydrogen following the lactose challenge while only 17% showed an increase after the cow's milk challenge and 13% after both challenges. The number of malabsorbers increased significantly (p less than 0.001) with age and no associated gastrointestinal symptoms or signs were found in any of the children following the challenges, suggesting a gradual and partial loss of intestinal lactase activity. We conclude that the prevalence of lactose malabsorption in Hong Kong children is very high using the standard lactose tolerance test but when a more realistic amount of lactose and a natural medium such as a glass of milk is used as the challenge, the number of malabsorbers becomes small and clinically insignificant.     

Carbohydrate malabsorption following fruit juice ingestion in young children

We performed breath hydrogen analyses in 13 healthy children (9 to 36 months of age) and seven children (14 to 27 months of age) with chronic nonspecific diarrhea after they had ingested pear, grape, and apple juices and a 2% sorbitol solution. Excess breath H2 excretion was found in virtually all study subjects following the ingestion of either pear juice (with approximately 2% sorbitol content) or the 2% sorbitol solution, in approximately 50% of those ingesting apple juice (0.5% sorbitol), and in 25% of those ingesting grape juice (no sorbitol) (P less than .001, analysis of variance). No differences were noted between the healthy children and those with chronic nonspecific diarrhea. Forty percent of all study subjects in whom excess breath hydrogen excretion occurred also had diarrhea and abdominal cramping. Carbohydrate malabsorption appears to be frequent following the ingestion of common fruit juices and in some children may be associated with nonspecific gastrointestinal symptoms.     

Delayed complete functional lactase sufficiency in breast-fed infants

Colonic fermentation of unabsorbed lactose was evaluated by measuring breath hydrogen (BH2) after a regular feeding in 17 white, normal, exclusively breast-fed infants 4-5 weeks of age. Interval breath samples were collected with a specially modified face mask and analyzed by gas chromatography for H2 and CO2 concentrations. Five infants (29%) produced 20 ppm or more of H2, four of whom underwent repeated testing. Three infants stopped producing over 20 ppm of H2 as they grew older. On a repeat evaluation, one of these three infants had levels over 20 ppm when other foods were introduced into his diet. The other continued to have elevated BH2 when weaned. Stools of infants with elevated BH2 levels had no detectable glucose, and pH was over 5.5. Weight-for-age of infants with elevated BH2 was at or above the 75th percentile. BH2 levels, normalized for the amount of breast milk ingested, fell significantly with age. These results show that complete small bowel absorption of lactose from breast milk does not occur in all white, normal, term, appropriate-for-gestational-age infants in the first months of life. The absence of glucose in the stool and the normal stool pH suggest that the unabsorbed lactose that produced H2 can be degraded in the colon.     

Lactase insufficiency revisited

The definition of "insufficient" small bowel lactase activity varies greatly among authors. The present study is aimed at redefining lactase insufficiency by comparing intestinal lactase activity and results of the lactose breath hydrogen test. Primary "insufficient" lactase activity was considered to be present when a child with a normal small bowel histology showed lactose malabsorption as measured by the lactose breath hydrogen test. The lactase activity of 22 "normal" children ranged from 0.77 to 4.57 U/g wet weight, while five children showed primary lactase insufficiency as defined above. Small bowel lactase activity in the latter patients was less than 0.74 U/g wet weight. Sucrase and maltase activities were similar in both groups of patients. We conclude that children with a normal small bowel histology should be considered to have primary lactase insufficiency when small bowel lactase activity is below 0.75 U/g wet weight.     

Late-onset hypolactasia in Hong Kong school children.

Three hundred and twenty Chinese school children aged between 6 and 19 years from six schools in Hong Kong were tested for their lactose digestion status. After an overnight fast, the children were challenged with cow's milk, 5 ml/kg bodyweight (i.e. lactose approximately 0.25 g/kg). Malabsorption was assessed by measuring hydrogen concentration from end-expiratory breath samples taken in duplicate before and at 90 and 180 minutes after the challenge. On average, 10% of the children showed an increase in breath hydrogen excretion within 3 h after the challenge, indicating malabsorption of lactose. None of the children complained of gastro-intestinal symptoms or showed any clinical sign of intolerance to the milk. The number of malabsorbers increased significantly (p less than 0.001) with age, starting at about 3% at the age of 8 and reaching about 27% at the age of 18 years. The sharpest rise occurred between 14 and 15 years. It is concluded that, despite the high prevalence of hypolactasia, Hong Kong Chinese children can consume normal amounts of milk without developing any untoward clinical symptom or sign.     

Lactose malabsorption and recurrent abdominal pain in Italian children

The role of lactose malabsorption (LM) was investigated in 32 children (mean age 8.13 +/- 2.46 years) with recurrent abdominal pain (RAP). LM was detected in 75% of them by a lactose breath hydrogen test (LBHT) after a 2-g/kg (max 50-g) load. Of the 18 malabsorbers who participated in a 3-month lactose-free diet (LFD), 14 were judged "improved" and reported lower pain frequency (p less than 0.001). The malabsorbers who improved versus the not improved had comparable past lactose ingestion but were distinguishable on the basis of their lactose absorption capacity (0.36 vs. 0.81 g/kg; p less than 0.01), as subsequently determined by multiple LBHTs with 25-, 12.5-, and 6-g loads. The ratio between past lactose ingestion and lactose absorption was 1.89 in the improved and 0.55 in the not improved groups (p less than 0.01), retrospectively indicating lactose as a possible cause of the symptoms in the improved group. The reintroduction of lactose in amounts not exceeding the absorption capacity into the diet of each malabsorber who had improved with LFD caused relapse in none of the 14 subjects monitored for 2-6 months. In conclusion, LM seems an important cause of symptoms in Italian children with RAP. Assessment of the lactose absorption threshold of each subject of LBHTs provides a basis for reintroduction of "calibrated" amounts of lactose-containing foods (e.g., milk) into the diet.     

印度尼西亚儿童牛奶摄入与乳糖吸收不良之间的关系

目的 探讨3~12岁印度尼西亚儿童牛奶摄入与乳糖吸收不良之间的关系。 方法 该研究为横断面研究。研究对象为在印度尼西亚雅加达中部随机选取的营养状况良好的174名3~12岁健康儿童,包括72名3~5岁儿童和102名6~12岁儿童。 结果 3~5岁儿童乳糖吸收不良患病率为20.8%（15/72）,6~12岁儿童乳糖吸收不良患病率为35.3%（36/102）。牛奶或乳制品摄入与乳糖吸收不良之间无显著关联性（P>0.05）。在氢呼气试验中,51例乳糖吸收不良儿童主要表现为腹泻（62%）、腹痛（52%）和恶心（5%）。 结论 3~12岁印度尼西亚儿童牛奶摄入和乳糖吸收不良无关联,这提示遗传易感性可能比乳糖摄入的适应机制更重要。     

Breath hydrogen excretion in infants with colic.

Breath hydrogen excretion as an index of incomplete lactose absorption was measured in 118 healthy infants who were either breast fed or given a formula feed containing lactose, some of whom had colic. Infants with colic (n = 65) were selected on the basis of the mother''s report of a history of inconsolable crying lasting several hours each day. Infants in the control group (n = 53) were not reported to cry excessively by their mothers. Breath samples were collected using a face mask sampling device preprandially, and 90 and 150 minutes after the start of a feed. Normalised breath hydrogen concentrations were higher in the group with colic than in the control group at each time point. The median maximum breath hydrogen concentration in the colic group was 29 ppm, and in the control group 11 ppm. The percentage of infants with incomplete lactose absorption (breath hydrogen concentration more than 20 ppm) in the colic group was 62% compared with 32% in the control group. The clinical importance of the observed association between increased breath hydrogen excretion and infantile colic remains to be determined. Increased breath hydrogen excretion indicative of incomplete lactose absorption may be either a cause or an effect of colic in infants.     

DIAGNOSTIC VALUE OF SUCROSE TOLERANCE TEST IN CHILDREN EVALUATED BY BREATH HYDROGEN MEASUREMENT

Abstract. Douwes, A. C., Fernandes, J., Jongbloed, A. A. (Sophia Children's Hospital and Neonatal Unit, Academic Hospital of the Erasmus University, Rotterdam, The Netherlands). Diagnostic value of sucrose tolerance test in children, evaluated by breath hydrogen measurement. Acta Paediatr Scand, 69:79, 1980.—An oral sucrose tolerance test was performed in a group of 103 children, aged between 3 months and 15 years because of episodic diarrhea and/or abdominal pains. Sucrose malabsorption defined as an abnormal increase in expired hydrogen, was found in only 3 children who suffered from congenital sucrase-isomaltase deficiency. This 1% incidence of sucrose malabsorption was lower than the incidence of lactose malabsorption found in this group (33 %). Mean rise in blood glucose during the sucrose test was higher (3.4 ± 1.4 vs. 2.4 ± 1.2 mmol/l, p < 0.0001) and the occurrence of false flat blood glucose curves was lower (3% vs. 12.8%, p < 0.05) than during the lactose test. These findings are consistent with the higher sucrase activity in the small bowel mucosa compared to lactase. In contrast to the lactose tolerance test, sucrose tolerance test should not be used as a screening procedure for secondary disaccharidase deficiency in children     

Dumping Syndrome in Children

ABSTRACT. Dumping syndrome is rarely seen in children. We studied ten children with symptoms following various types of gastric surgery. All had abnormal blood glucose and breath hydrogen responses after oral glucose challenge, indicating reduction of both glucose tolerance and glucose absorption, as compared to controls. Glucose tolerance was best expressed as the difference between peak and subsequent lowest blood glucose level, the upper limit of normal (mean + 3 SD) being 5.9 mmol/l. In eight children with persisting symptoms we tested the effects of glucomannan, a highly hygroscopic tasteless fibre, on glucose tolerance and glucose absorption. Glucomannan significantly improved glucose tolerance, but did have no overall effect on glucose absorption. Four children tested glucomannan added to the main meals. Breath hydrogen excretion, as established with the daytime breath hydrogen profile, decreased significantly in two, but complaints increased in three children. Glucomannan does not appear to be suitable for the treatment of dumping syndrome in children as the side effects seem to overrule the beneficial effects.