An ESPGHAN Position Paper on the Use of Breath Testing in Paediatric Gastroenterology

Abstract

Objectives: Given a lack of a systematic approach to the use of breath testing in paediatric patients, the aim of this position paper is to provide expert guidance regarding the indications for its use and practical considerations to optimise its utility and safety. Methods: Nine clinical questions regarding methodology, interpretation, and specific indications of breath testing and treatment of carbohydrate malabsorption were addressed by members of the Gastroenterology Committee (GIC) of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN). A systematic literature search was performed from 1983 to 2020 using PubMed, the MEDLINE and Cochrane Database of Systematic Reviews. Grading of Recommendations, Assessment, Development, and Evaluation was applied to evaluate the outcomes. During a consensus meeting, all recommendations were discussed and finalised. In the absence of evidence from randomised controlled trials, recommendations reflect the expert opinion of the authors. Results: A total of 22 recommendations were voted on using the nominal voting technique. At first, recommendations on prerequisites and preparation for as well as on interpretation of breath tests are given. Then, recommendations on the usefulness of H2-lactose breath testing, H2-fructose breath testing as well as of breath tests for other types of carbohydrate malabsorption are provided. Furthermore, breath testing is recommended to diagnose small intestinal bacterial overgrowth (SIBO), to control for success of Helicobacter pylori eradication therapy and to diagnose and monitor therapy of exocrine pancreatic insufficiency, but not to estimate oro-caecal transit time (OCTT) or to diagnose and follow-up on celiac disease. Conclusions: Breath tests are frequently used in paediatric gastroenterology mainly assessing carbohydrate malabsorption, but also in the diagnosis of small intestinal overgrowth, fat malabsorption, H. pylori infection as well as for measuring gastrointestinal transit times. Interpretation of the results can be challenging and in addition, pertinent symptoms should be considered to evaluate clinical tolerance.

Traditional and Modern Diagnostic Approaches in Diagnosing Pediatric Helicobacter pylori Infection

“…Another major advantage of this test over serology or stool antigen is that it can be used in patients with a history of gastrectomy or those who recently received antibiotics or proton pump inhibitors [ 88 ] ( Table 1 ). Nevertheless, the European Society of Pediatrics Gastroenterology Hepatology and Nutrition (ESPGHAN) recommends to wait at least 2 weeks after proton pump inhibitors and 4 weeks after antibiotics before performing this test in practice [ 85 ].…”

“…False-positive results are uncommon, but they can occur in patients with a very recent history of endoscopy with a biopsy associated with gastrectomy or a significant alkalization of the gastric pH, but they can also be noticed when urea is hydrolyzed by other urease containing bacteria within the oral cavity or the stomach [ 90 ]. Therefore, the most recent ESPGHAN guideline stated that toothbrushing before the test in children might inactivate oropharyngeal bacteria, preventing false-positive results caused by this bacterial community [ 85 ]. The same effect was proven in the case of mouthwash with 1% chlorhexidine before taking this test [ 91 ], but its use in children remains controversial [ 85 ].…”

“…Therefore, the most recent ESPGHAN guideline stated that toothbrushing before the test in children might inactivate oropharyngeal bacteria, preventing false-positive results caused by this bacterial community [ 85 ]. The same effect was proven in the case of mouthwash with 1% chlorhexidine before taking this test [ 91 ], but its use in children remains controversial [ 85 ]. False-negative results are even less common than false-positive ones and are usually related to external factors such as method errors [ 54 ].…”

“…Thus, four samples should be collected from the patient after a digestive rest of at least 6 h: two before urea and two after urea ingestion. In fact, the current pediatric guidelines indicated that fastening periods are optimal at 8-12 h for children and at 4-6 h for infants younger than 6 months [85]. After collecting the first two samples in tubes or bags, the patient will receive a 'test mass' followed by a solution containing 13 C-labeled urea mixed with water.…”

Critical Steps for Human Gut Exfoliome RNA Profiling Analysis Using Non-Invasive Stool Samples

“…Non-invasive imaging techniques such as ultrasound, magnetic resonance, or PET-magnetic resonance could also be used to study intestinal morphology [17]. Intestinal permeability is performed by tests such as the analysis of alpha-1-antitrypsin to detect protein malabsorption or lactulose/mannitol oral-charged and the expired hydrogen test to detect carbohydrate malabsorption [18]. Gut inflammation could be studied by biomarkers such as fecal calprotectin, although that marker still presents some limitations [19].…”