Fluid intake and industrial processing in apple juice induced chronic non-specific diarrhoea.

Dietary factors have been shown to contribute to the occurrence or persistence of chronic non-specific diarrhoea (CNSD). Among these are low dietary fat, high fluid consumption, and the consumption of apple juice. Prompted by the clinical impression that freshly pressed and unprocessed (''cloudy'') apple juice was less likely to induce diarrhoea than normal, enzymatically processed (''clear'') apple juice, both juices were compared in terms of carbohydrate malabsorption, gastric emptying, and effects on defecation patterns. Clear and cloudy apple juice differ in their fibre and non-absorbable monosaccharide and oligosaccharide contents. Ten healthy children aged 3.6 to 5.9 years ingested 10 ml/kg of clear and cloudy apple juice; in five of them it was enriched with 40 mg of [1-13C]-glycine. Clear apple juice resulted in increased (> or = 20 ppm) breath hydrogen excretion in 8/10, compared with 5/10 after cloudy apple juice; peak breath hydrogen was higher in the clear apple juice group (35 (4) and 18 (3) ppm, respectively). Gastric emptying as determined by means of labelled breath carbon dioxide (13CO2) excretion was similar with both juices. In a four week crossover clinical trial 12 children, formerly diagnosed as having CNSD, were given extra clear fluids (excluding fruit juices; > or = 50% over basal consumption), clear apple juice, or cloudy apple juice, for five day periods. Extra fluids and cloudy apple juice did not influence stool frequency and consistency compared with the basal period. In contrast, clear apple juice significantly promoted diarrhoea. It is suggested that, in addition to fructose, the increased availability of non-absorbable monosaccharides and oligosaccharides as a result of the enzymatic processing of apple pulp is an important aetiological factor in apple juice induced CNSD.     

Apple juice,fructose, and chronic nonspecific diarrhoea

Apple juice contains fructose and sorbitol, substances that have been shown to be incompletely absorbed by most people. As this might have clinical consequences, especially in young children, we investigated the absorption of the carbohydrate content of apple juice in apple juice consuming toddlers with chronic nonspecific diarrhoea as compared to controls, using the breath hydrogen (H₂) test. Incomplete absorption of the carbohydrates from 250 ml of apple juice, as indicated by a maximum breath H₂ increase of 20 parts per million (ppm), was found in all nine patients (mean ±SEM 57±8 ppm), and in five out of eight controls (22±7 ppm) (P<0.01). Six patients were retested with apple juice enriched with glucose, which is known to improve fructose absorption. The maximum breath H₂ increase as well as the area under the breath H₂ curve decreased significantly. It was thus estimated that fructose accounted for 80% of the incomplete absorption and sorbitol for 20%. Elimination of apple juice from the diets of the nine patients resulted in normalisation of both the frequency and the consistency of the stools. Incomplete absorption of the carbohydrates, particularly fructose, from apple juice seems to be quite common, and may contribute to chronic diarrhoea in young children.Abbreviations H₂ hydrogen - ppm parts per million     

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.     

Consequences of incomplete carbohydrate absorption from fruit juice consumption in infants.

BACKGROUND: Most infants consume fruit juices by 6 months of age. However, fruit juices containing sorbitol may be associated with carbohydrate malabsorption without clinical symptoms. We hypothesized that increased physical activity and metabolic rate may be associated with carbohydrate malabsorption. METHODS: Physical activity and metabolic rate were determined in 14 healthy infants ([mean +/- SD] age, 5.1 +/- 0.8 months; weight, 7.8 +/- 1.1 kg; length, 67 +/- 4.2 cm; and body fat, 26% +/- 5%) for 3 hours in a respiratory chamber. Seven were fed pear juice, and the other 7 were fed white grape juice (120 mL) after a 2-hour fast. Pear juice contains sorbitol and a high fructose-glucose ratio, whereas white grape juice is sorbitol free and has a low fructose-glucose ratio. Carbohydrate absorption was determined by breath hydrogen gas analysis. The study was double-blinded. RESULTS: When compared with the infants without carbohydrate malabsorption (peak breath hydrogen level < 20 ppm above baseline), 5 of the 7 infants fed pear juice and 2 of the 7 infants fed white grape juice exhibited carbohydrate malabsorption (peak breath hydrogen level > or = 20 ppm above baseline; P < .01). These infants also exhibited both increased physical activity (P < .001) and metabolic rate (P < .05) after juice consumption in comparison with infants with normal carbohydrate absorption. When grouped according to the type of juice consumed, only infants fed pear juice exhibited increases in physical activity (P < .01). CONCLUSIONS: Carbohydrate malabsorption is associated with increased physical activity and metabolic rate in infants. Most of the infants who had carbohydrate malabsorption consumed pear juice. Therefore, fruit juices containing sorbitol and high levels of fructose may not be optimal for young infants.     

Incomplete intestinal absorption of fructose.

Intestinal D-fructose absorption in 31 children was investigated using measurements of breath hydrogen. Twenty five children had no abdominal symptoms and six had functional bowel disorders. After ingestion of fructose (2 g/kg bodyweight), 22 children (71%) showed a breath hydrogen increase of more than 10 ppm over basal values, indicating incomplete absorption: the increase averaged 53 ppm, range 12 to 250 ppm. Four of these children experienced abdominal symptoms. Three of the six children with bowel disorders showed incomplete absorption. Seven children were tested again with an equal amount of glucose, and in three of them also of galactose, added to the fructose. The mean maximum breath hydrogen increases were 5 and 10 ppm, respectively, compared with 103 ppm after fructose alone. In one boy several tests were performed with various sugars; fructose was the only sugar incompletely absorbed, and the effect of glucose on fructose absorption was shown to be dependent on the amount added. It is concluded that children have a limited absorptive capacity for fructose. We speculate that the enhancing effect of glucose and galactose on fructose absorption may be due to activation of the fructose carrier. Apple juice in particular contains fructose in excess of glucose and could lead to abdominal symptoms in susceptible children.     

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.     

Fructose breath hydrogen tests in infants with chronic non-specific diarrhoea

Clear fluids high in fructose (e.g., apple juice) have been incriminated for symptoms of chronic non-specific diarrhoea (CNSD), in particular in children 1–4 years of age. H₂ breath tests were performed, after ingestion of fructose (1 g/kg), in 15 patients referred with CNSD and 35 controls. All 15 CNSD children (100%) had breath peak H₂ of 20 ppm versus 49% of the 35 controls (P=0.0005). Median peak H₂ in CNSD (90 ppm, range 31–136) was significantly higher than in controls (20 ppm, range 1–139) (P<0.001). Orocoecal transit time in children with positive tests was similar in both groups. Similary, median H₂ increases during the test period had the same distribution. We demonstrated fructose malabsorption in CNSD, but found a great overlap with the control group. Our results strongly discourage the use of fructose breath H₂ tests in children suspected of CNSD. A positive test has no diagnostic value and a negative test has no clinical implications.Conclusion For clinical practice, we suggest a dietary history and a trial of appropriate measures in infants with chronic nonspecific diarrhoea, instead of performing the fructose H₂ breath test.     

Incomplete carbohydrate absorption from fruit juice consumption after acute diarrhea

We carried out a double-blind, randomized study in 60 children with acute diarrhea to determine their capacity to tolerate commonly consumed fruit juices. Feedings of juice with high fructose/glucose ratios and sorbitol resulted in incomplete carbohydrate absorption and recurrence of diarrhea during the phase immediately after improvement of the illness.     

Irritable bowel syndrome and nonspecific diarrhea in infancy and childhood--relationship with juice carbohydrate malabsorption

Lactose intolerance and malabsorbed carbohydrate present in some fruitjuice may trigger symptoms commonly seen in irritable bowel syndrome. In a two-site study, 28 subjects 9 months to 18 years old (mean 6.9 +/- 5.9 years) with significant intake of apple juice or pear nectar (> 6 oz a day) with the diagnoses of irritable bowel syndrome, functional abdominal pain, or chronic nonspecific diarrhea were recruited. Breath hydrogen tolerance tests utilizing lactose, sucrose, and apple juice in the amount they typically consumed were positive in 32%, 0%, and 50%, respectively. Subjects were asked to refrain from the ingestion ofjuice for 1 month: 13 of the 28 (46%) subjects improved while 15 (54%) showed no change in their symptoms. In fact, none consuming 6 to 12 oz of apple or pear juice daily improved, 27% of those consuming 12 to 16 oz improved, and 91% of those consuming > 16 oz improved (P < 0.02). Subjects were then given comparable amounts of white grape juice for 1 year. The initial symptoms did not recur in any of the subjects who initially responded to the juice-free diet. Of the 15 subjects who did not respond to the juice-free diet, seven became asymptomatic. Overall, 20 subjects (71%) were asymptomatic, and eight (29%) had no change in their symptoms. Some individuals with irritable bowel syndrome have their symptoms based on their malabsorption of carbohydrates present in apple juice and pear nectar and may improve with adequate choices of fruit juice such as changing to white grape juice.     

Nuclear transit study in children with chronic faecal soiling after Hirschsprung disease (HSCR) surgery has revealed a group with rapid proximal colonic treatment and possible adverse reactions to food

Background/purpose

Long-term problems with faecal incontinence occur in up to 50 % of patients after pull-through for Hirschsprung disease (HSCR). The cause often remains unknown, leading to empirical treatments. Using nuclear transit study, we found some patients surprisingly had rapid proximal colonic transit, suspicious of occult diarrhoea. We aimed to assess whether these patients had unrecognized adverse reactions to food.

Methods

Patients (n = 10, all males, 9.6 year; 4.25–15.5 years) with persistent faecal incontinence following pull-through for HSCR referred to the senior author and after exclusion of anatomical defects, underwent nuclear transit studies. Most (8) subsequently underwent breath hydrogen tests for sugar malabsorption and were tested for adverse reactions to food. Exclusion diets for protein allergens, lactose or fructose were then trialed.

Results

Of the 10 patients with rapid intestinal transit proven on nuclear transit study, breath hydrogen tests for fructose and/or lactose malabsorption were done in 8, and were positive in 7/8 patients. Exclusion diets contributed to either resolution or improvement in faecal incontinence in 9/10 patients.

Conclusions

Rapid transit in the proximal, ganglionated colon may be present in children with faecal incontinence following pull-through for HSCR, possibly secondary to adverse reactions to food. This study suggests that children with post-operative soiling may benefit from a transit study and hydrogen breath tests to diagnose adverse reactions to food caused by sugar malabsorption.

     

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.     

In vitro hydrogen production by enteric bacteria cultured from children with small bowel bacterial overgrowth.

Lactulose breath hydrogen test and Enterotest string test were carried out simultaneously on 19 children 3-5 years old. Bacteria isolated from the jejunal fluid in upper small intestines of these children were incubated with lactulose at neutral pH. Anaerobes were present in all but one child, and in 15 children they were present in numbers greater than 5 log10 organisms per ml. Most of these bacteria did not produce hydrogen in vitro. Hydrogen production (greater than 100 ppm) was observed with the following bacteria: Bacteroides (5%), clostridia (8%), anaerobic corynebacteria (5%), Escherichia coli (67%), Lactobacillus (8%), Staphylococcus (8%), and Streptococcus (9%). The following bacteria did not produce hydrogen in vitro: Actinobacter, Actinomyces, anaerobic cocci, Bifidobacterium, Fusobacterium, micrococci, Neisseria, Sarcina, and Veillonella. This study suggests that in the diagnosis of small bowel bacterial overgrowth using lactulose breath hydrogen test, it is important to consider that patients with a flat breath hydrogen response to a carbohydrate challenge during the first 60 min may be infected with enteric bacteria which are not capable of producing H2.     

Effect of orange and apple juices on iron absorption in children

OBJECTIVE: To measure iron absorption in children from meals containing apple juice or orange juice so as to determine if iron absorption will be greater with orange juice because of its higher ascorbic acid content than apple juice, a noncitrus fruit juice that US children reportedly prefer. DESIGN: On 2 successive days, children consumed identical meals that included apple juice on one day and orange juice on the other, in random order. The meals were labeled with iron-57 on one day and iron-58 on the other. Iron absorption was measured from red blood cell incorporation of the iron stable isotopes 14 days later. SETTING: Nutrition research institute in a major metropolitan medical center. PATIENTS: A total of 25 healthy children, 3 to 6 years of age, were recruited, of whom 21 (11 male and 10 female) completed the study.Intervention Identical meals served with orange juice and apple juice were given on consecutive days, in a balanced randomized design. MAIN OUTCOME MEASURES: Iron absorption measured by established stable isotope methods. RESULTS: Median iron absorption from the meal ingested with apple juice was 7.17% (mean +/- SD, 9.48% +/- 9.68%). Median iron absorption from the meal ingested with orange juice was 7.78% (9.80% +/- 6.66%; P =.44). Iron absorption from the meal that included apple juice was significantly correlated with serum ferritin concentration (P =.02); iron absorption from the meal that included orange juice tended to correlate with serum transferrin receptor concentration (P =.051). CONCLUSIONS: As children absorb iron well from a meal that includes either orange or apple juice, a preference for apple juice does not pose a concern with regard to the prospect of iron-deficiency anemia, which remains a significant health problem in the United States.     

Relationship between urinary and blood glucose in diabetic children.

The relationship of urine glucose concentration with 'average' blood glucose concentration for the corresponding period was investigated in 10 juvenile diabetics during the performance of 15 inpatient metabolic profiles. 0% glucosuria was associated with 'average' blood glucose concentrations less than 6.4 mmol/l (less than 115 mg/100ml), 2% glycosuria with concentrations greater than 8.6 mmol/l (greater than 154 mg/100ml), and over 5% glycosuria with concentrations greater than 11.3 mmol/l (greater than 204 mg/100ml). Urinary glucose loss was large (greater than 278 mmol; greater than 5g) when the 'average' blood glucose was greater than 11.1 mmol/l (greater than 200 mg/100ml). Because many diabetics have blood glucose concentrations up to 11.1 mmol/l, it is advantageous if glucosuria up to 5% is detectable by routine home urine tests. The 2-drop Clinitest method detects glycosuria up to 5% without significant loss of accuracy and is recommended in preference to the 5-drop method.     

Fruit juice consumption and the prevalence of obesity and short stature in german preschool children: results of the DONALD Study. Dortmund Nutritional and Anthropometrical Longitudinally Designed.

BACKGROUND: In recent years, a possible association between excessive consumption of fruit juice (> or =12 fl oz per day) and short stature and/or obesity has been discussed. The association among the consumption of fruit juice, anthropometric indices, and the overall diet was examined during a 3-year period in a sample of healthy preschool children participating in the Dortmund Nutritional and Anthropometrical Longitudinally Designed (DONALD) Study. METHODS: Two hundred five children were examined annually at the ages of 3, 4, and 5 years. Dietary intake was calculated from 3-day weighed diet records. Height was measured using a stadiometer. Weight was measured using an electronic scale. RESULTS: Five children consumed excessive fruit juice continually in all three records, 10 children in two records, and 23 children in one record. None of the five children with repeatedly excessive fruit juice consumption was obese or short. Growth velocity, body mass index, and height standard deviation score were not correlated with fruit juice consumption. Consumption of fruit juice was inversely correlated with the consumption of all other beverages and the total consumption of all other food. The intake of protein, fat, and carbohydrates of children consuming excessive fruit juice was closer to the international dietary preventive guidelines than the intake of children consuming low amounts of fruit juice. CONCLUSIONS: In the study sample, even repeatedly excessive fruit juice consumption had no influence on anthropometric indices. The results do not justify a general warning or a general promotion regarding high fruit juice consumption in preschool children's diets.     

Malabsorption of modified food starch (acetylated distarch phosphate) in normal infants and in 8-24-month-old toddlers with non-specific diarrhea, as influenced by sorbitol and fructose

Acetylated distarch phosphate (ADiSP) is a modified starch used in some baby foods. The bioavailability of ADiSP and a native (unmodified) starch was evaluated in 20 normal infants and 21 toddlers aged 8-24 mo with chronic non-specific diarrhea. Formulae contained 8% native or 8% modified waxy maize starch. No infant or toddler consuming Formula N (native starch) had elevated peak breath hydrogen levels (20 ppm or greater), stools clinically positive for reducing substances (0.75% or greater) or loose stools. Fourteen infants received formula M (modified starch): 2 had elevated breath hydrogen, 1 had positive stools and another had loose stools. Of the 21 toddlers fed formula M, 2 had elevated breath hydrogen, but none had positive stools or loose stools. Formula NS (native starch with 2% sorbitol) had little effect on breath hydrogen in the infants but significantly increased it in the toddlers. Formula NS produced loose stools in 2 toddlers but no clinically positive stools in any infant or toddler. Formula MS (modified starch with 2% sorbitol) elevated breath hydrogen in 3 infants and 8 toddlers, and produced positive stools in 2 infants and 2 toddlers, and loose stools in 4 infants and 7 toddlers. Formula MSF (modified starch with 2% sorbitol and 5% fructose) elevated breath hydrogen in 7 infants and 10 toddlers, positive stools in 7 infants and 6 toddlers, and loose stools or diarrhea in 7 infants and 11 toddlers.

Conclusion: ADiSP modified starch can increase breath hydrogen and produce loose stools. Sorbitol and fructose aggravate the malabsorption, in some cases leading to frank diarrhea.     

Fructose breath hydrogen tests.

Fructose absorption was studied by the breath hydrogen test in 114 healthy children aged 0.1-6 years, given either 2 g/kg or 1 g/kg of fructose. All 57 children given 2 g/kg had peak breath hydrogen excretions > or = 20 ppm. At 1 g/kg only 25/57 (44%) showed incomplete absorption and the percentage incompletely absorbing fructose and the peak breath hydrogen value were significantly higher in children aged 1-3 years. Interestingly, this age distribution correlates with that of toddler diarrhoea.     

Fructose breath hydrogen tests

Fructose absorption was studied by the breath hydrogen test in 114 healthy children aged 0.1-6 years, given either 2 g/kg or 1 g/kg of fructose. All 57 children given 2 g/kg had peak breath hydrogen excretions > or = 20 ppm. At 1 g/kg only 25/57 (44%) showed incomplete absorption and the percentage incompletely absorbing fructose and the peak breath hydrogen value were significantly higher in children aged 1-3 years. Interestingly, this age distribution correlates with that of toddler diarrhoea.     

The effective use of acai juice,blueberry juice and pineapple juice as negative contrast agents for magnetic resonance cholangiopancreatography in children

Magnetic resonance cholangiopancreatography (MRCP) is commonly performed in the evaluation of known or suspected pancreaticobiliary disease in children. The administration of a negative oral contrast agent can improve the quality of the examination without significant additional cost. We describe our experience with certain brands of acai juice, blueberry juice and pineapple juice as negative oral contrast agents in children. We believe these fruit juices are safe, palatable and may improve MRCP image quality.     

GLUCOSE-GALACTOSE MALABSORPTION

In 2 children with glucose-galactose malabsorption the intermediate metabolism of hexoses was studied. The removal rate of injected glucose was slow when the diet of the children contained limited amounts of well absorbed carbohydrate (fructose). When sufficient fructose was given in the diet, the half-life of injected glucose was normal. A fast removal rate was seen when large amounts of carbohydrates had been administered prior to the intravenous GTT. The results of oral fructose tolerance tests varied with the pre-test diet in a similar manner. The fructosemia was small and independent of the diet, but the blood glucose concentration reacted in a way indicating decreased glucose tolerance if the diet contained little absorbable carbohydrate. This was evidently an unspecific effect of carbohydrate deprivation; in a control case, an infant with cystic fibrosis, initially malnourished, signs of decreased glucose tolerance were seen with an oral fructose tolerance test. In him, as well as in the patient with glucose-galactose malabsorption, the supranorma1 rise of blood glucose was abolished by dietary measures ensuring an ample supply of calories and carbohydrates. The intravenous galactose tolerance, tested in one of the patients, was probably normal at 13 months of age and certainly normal at 6 years of age. It is concluded that the observed abnormalities of the metabolism of glucose in patients with glucose-galactose malabsorption are unspecific for this disease and merely secondary to carbohydrate deprivation.