Recurrent Abdominal Pain in Children: Lactose and Sucrose Intolerance, A Prospective Study

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Received for publication Sept 18, 1978; accepted Nov 6, 1978. Reprint requests to (W.M.L.) Department ofPediatrics, Division

ofGastroenterology, University ofCalifornia School of Medicine, San Francisco, CA 94143.

PEDIATRICS Vol. 64 No. 1 July 1979 43

Recurrent

Abdominal

Pain

in Children:

Lactose

and

Sucrose

Intolerance,

A Prospective

Study

William M. Liebman, MD

From the Department of Pediatrics, Division of Gastroenterology, University of California School of Medicine, San Francisco

ABSTRACT. Thirty-eight consecutive children with re-current abdominal pain underwent lactose tolerance tests;

28 of these were also given sucrose tolerance tests. Ab-doniinal pain and abnormal lactose tolerance tests were noted in 1 1 of 38, while none of the 28 had an abnormal

sucrose tolerance test; however, 1 had abdominal pain. Elimination diet for 4 weeks produced significant or total pain relief in 10 of 1 1 (lactose free) and 0 of 1 children (sucrose free). Lactose intolerance seems to play a con-tributory role in recurrent abdominal pain in children, while sucrose intolerance does not. Pediatrics 64:43-45,

1979; abdominal pain, lactose, sucrose, intolerance.

Recurrent abdominal pain (RAP) is a common, troublesome, and enigmatic problem in children. The incidence of these recurrent attacks of abdom-inal pain over a period, three months or longer, has

been found to be 9% to 15% in the general pediatric population.’’ The etiology of this problem remains ill-defined. Organic factors, eg, peptic ulcer disease, urinary tract infections, have been implicated in the minority of cases, 6% to 20%, while psychogenic factors have been most frequently mentioned as triggering such attacks of pain. The present study attempts to clarify prospectively the potential role of lactose and sucrose intolerance in children with RAP.

MATERIALS AND METHODS

Subjects

Group I-Children with RAP. Thirty-eight

con-secutive children, 20 boys and 18 girls, 5 to 14.5

years of age (mean age 8.8 years), with RAP of no apparent etiology were evaluated (Table 1). De-tailed histories, particularly dietary intake, and physical examinations were performed in all pa-tients. Laboratory and radiotogic studies, including complete blood count, urinalysis, sedimentation

rate, serum transaminases, creatinine, urine amy-lase/creatinine clearance ratio, upper gastrointes-tinal (UGI) series (38), barium enema (24), and intravenous pyelogram (21) were normal. In se-lected patients when clinically indicated (13), fiber-optic upper endoscopy was performed and was un-remarkable.

Group 11-Children without RAP. Twenty-nine

children, 18 boys and 1 1 girls, 3 to 15 years of age (mean age 7.4 years), including 14 children with other gastrointestinal problems, eg, constipation, and 15 normal children were evaluated during the same time period (Table 2). Informed consent was obtained for all patients.

Lactose, Sucrose Tolerance Tests

All patients ingested nothing for four to six hours before each test. The disaccharide, lactose (38) or sucrose (28), was administered orally as a 10% so-lution in a dose of 2 gm/kg of body weight, maxi-mum 50 gm. Serum glucose was measured at 0, 30, 60, 90, and 120 minutes after ingestion orally. The number and nature of stools, presence or absence of reducing substances by Ctinitest determination, and symptomatology were recorded for 24 hours after completion of all tests.4 Disaccharide intoler-ance (malabsorption) was considered present if the increase in serum glucose was less than 20 mg/100 ml above base line. In addition, the presence of symptomatotogy was correlated with abnormal val-ues and/or the stool number, consistency, and pres-ence or not of reducing substances.

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44 RECURRENT ABDOMINAL PAIN IN CHILDREN TABLE 1. Group I-Disaccharide Intolerance and

Recurrent Abdominal Pain

Ethnic Group Lactose Tolerance Sucrose Tolerance

Test (n = 38) Test (n = 28)

Normal Abnormal Normal Abnormal

Caucasian 23 4 21 0

Black 2 5 5 0

Hispanic 2 1 1 0

Oriental 0 1 1 0

TABLE 2. Group Il-Disaccharide Tolerance in Normal Children and Those with Other Gastrointestinal Problems

Ethnic Group Lactose Tolerance Sucrose Tolerance

Test (n = 29) Test (n = 29)

Normal Abnormal Normal Abnormal

Caucasian 24 0 24 0

Black 0 1 1 0

Hispanic 3 0 3 0

Oriental 1 0 1 0

Diet

Lactose-free or sucrose-free diets were used by 11 patients with abnormal lactose tolerance tests, six with normal lactose tolerance tests but with

symp-tomatology, and by one with symptomatology only (sucrose). In each patient, the diet was maintained for four weeks, and a daily clinical record was maintained by each patient, including symptoma-tology, stool number, and character. Data were analyzed by Student’s t test.

RESULTS

No significant differences in intake of lactose-containing foods, eg, milk (glasses per day) or su-crose-containing foods, eg, cereals (bowls per day), were noted in absorbers versus malabsorbers (P> .05). The frequency of pain was not significantly different in absorbers versus malabsorbers (9.8 ver-sus 10.6 attacks per week, P > .05), as was the number of (2.1 versus 2.7 attacks per day, P > .05) or character of stools daily. The average duration of RAP was not significantly different in absorbers versus malabsorbers (9.8 versus 10.3 months, P> .05).

Group I

Of 38 children tested, 1 1 had a positive (abnor-mat) lactose intolerance test. Symptomatically, ab-dominal cramps were observed in all (11/11), while increased stool number was present in 8/11, and the presence of reducing substances 1+ or more, in 8/11. However, six of 27 children with normal lac-tose tolerance tests had abdominal cramps, too, while only one had increased stool number and

presence of reducing substances. Of 28 children

tested, none had a positive sucrose tolerance test, although one patient did have abdominal cramps, but stools negative for reducing substances (Table 1).

Dietary elimination (lactose-free) produced sig-nificant (P > .05) or total relief of pain in 10/11 malabsorbers and 0/6 nonmalabsorbers. A sucrose-free diet did not produce pain relief in the one patient who was symptomatic during the oral tol-erance test. At least one-year follow-up of all pa-tients revealed the same except for one lactose malabsorber (1/10) who was no longer having sig-nificant pain relief on a lactose-free diet.

Group II

Of 29 children tested, one had an abnormal (pos-itive) lactose tolerance test, but none an abnormal sucrose tolerance test. The one lactose malabsorber had abdominal cramps during the test, while none with normal sucrose tolerance tests had

symptom-atology.

Dietary elimination (lactose) did not produce any change in the one malabsorber’s underlying prob-lem, constipation.

DISCUSSION

RAP as a major, singular symptom usually occurs in children, 3 to 14 years of age, most frequently between 5 to 10 years of age.’’ As previously men-tioned 9% to 15% of the general pediatric population is affected, and the incidence of organic disease has been estimated as 6% to 20% in most series.’ ‘ The role of lactose specifically in RAP had been inves-tigated in only a few series, including Bayless and Huang5 and Barr et

,

who reported a contribut-ing frequency of more than 25% using breath

hy-drogen analysis. In addition, Barr et al” used an

elimination diet, lactose-free (four weeks) , to con-firm the contributory role of disaccharide intoler-ance. The present study has also confirmed a sig-nificant frequency of and probably symptomatic contribution of lactose intolerance, specifically 11/ 38 patients, including 4/27 who were white.

Lactose-free dietary treatment for four weeks produced significant or total relief of RAP in 10/1 1 children

(malabsorbers). Conversely, sucrose intolerance by oral tolerance tests could not be confirmed in any of 28 children tested. One patient who had a normal tolerance test but was clinically symptomatic

dur-ing the test had no relief during the use of a sucrose-free diet for four weeks.

Disaccharide intolerance, particularly lactose, is now considered to be a common condition that is present in a large proportion of the world’s popu-lation.”’ ‘ Lactose intolerance is an apparent genetic

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ARTICLES 45 trait, being found in more than 65% to 70% of black

Americans and American Indians, but only in 5% to

15% of white Americans of Northwestern, Euro-pean, or Scandinavian extraction.”” This inability to hydrolyze the disaccharide, lactose (or sucrose),

may result from a reduction in the activity of intes-tinal lactase (sucrase). Ingestion of the disaccharide

may result in gastrointestinal symptomatology, in-cluding abdominal distention and pain, flatus,

bor-borygmi, or The diagnosis of lactose or

sucrose malabsorption can be made with reasonable certainty, although indirectly, if the rise in blood glucose is less than 20 mg/100 ml after a tolerance test dose of 2 gm/kg of body weight, maximum 50 gm, and if accompanied by gastrointestinal symp-tomatology (intolerance) #{149}4,5,8,9,1 1 Alternate diagnos-tic, highly accurate, but indirect tests include

anal-ysis of breath for hydrogen after disaccharide feed-ing, increased when lactose is not hydrolyzed, reaches the colon and bacterial fermentation occurs (H2 produced).46’7” Use of tactose-1-’4C and anal-ysis of ‘4CO2 in breath has been quite limited in children, as has lactose-1-’3C.4 The direct method is that of intestinal mucosal biopsy and enzyme (di-saccharidase) assay.4”#{176}”2 Using breath hydrogen analysis, Barr et al recently demonstrated lactose malabsorption in 43% of children with RAP. Their study also suggested that milk ingestion, pain fre-quency, and symptom response to lactose were unreliable indicators of lactose malabsorption.’ Our

study has also demonstrated that lactose

intoler-ance is not infrequent in RAP and apparently

sig-nificantly contributes to symptomatotogy, irrespec-tive of ethnic background. However, in contrast to the study of Barr et al’ and others’#{176} oral tolerance tests and symptomatic response to an oral disac-charide load seem to reflect disaccharide malab-sorption accurately.

The present study has demonstrated that lactose intolerance (malabsorption) is present in 29% of

children with RAP and apparently plays a signifi-cant role in RAP, while sucrose intolerance does not seem to be an important or prevalent factor in children with RAP. In addition, oral tolerance tests do apparently reflect disaccharide malabsorption and symptomatology thereof (intolerance).

REFERENCES

1. Apley J: The Child with Abdominal Pain, ed 2,

Oxford, Blackwell Scientific Publications, 1975 2. Liebman WM: Recurrent abdominal pain in children:

A retrospective survey of 1 19 patients. Clin Pediatr

17:149, 1978

3. Stone RT, Barber GJ: Recurrent abdominal pain in childhood. Pediatrics 45:732, 1970

4. Newcomer AD: Disaccha.ridase deficiencies. Mayo Clin Proc 48: 648, 1973

5. Bayless TM, Huang 5-5: Recurrent abdominal pain due to milk and lactose intolerance in school-aged children. Pediatrics 47:1029, 1971

6. Barr RG, Watkins JB, Levine MD: Recurrent abdom-inal pain (RAP) of childhood due to lactose intoler-ance: A prospective study. Pediatr Res 12:429, 1978 7. Barr RG, Becker MD, Heymann PW, et al: Lactose

malabsorption abdominal pain and lactose ingestion in a multiethnic school population. Clin Res 74:1006, 1978

8. Bayless TM, Rothfeld B, Massa C, et al: Lactose and milk intolerance: Clinical implications. N EngI JMed 292:1156, 1975

9. Ransome-Kuti 0: Lactose intolerance-a review. Postgrad Med J 53 (suppl 2):73, 1977

10. Welsh JD: Isolated lactase deficiency in humans: Report on 100 patients. Medicine 49:257, 1970 11. AAP Committee on Nutrition. The practical

signifi-cance of lactose intolerance in children. Pediatrics

62:240, 1978

12. Levitt MD, Donaldson RM: Use ofrespiratory hydro-gen (H2) excretion to detect carbohydrate malabsorp-tion. J Lab Gun Med 75:937, 1970

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1979;64;43

Pediatrics

William M. Liebman

Prospective Study