Dietary exclusion of fructose and lactose after positive breath tests improved rapid‐transit constipation in children

Abstract

Declaration of conflict of interest: JH is the treating physician for the patients, and the questionnaire was sent to parents to assess the outcomes of treatment. The questionnaire was filled in online and was not anonymous. Data were deidentified for this study. KW and BS had no relationship to patients and analyzed deidentified data. Less than half of the patients returned questionnaires. Author contribution: KW collated and analyzed the data and wrote the first draft. CL, VP, and JW created the 'Google Poll' questionnaire and data collection link and collected data into an Excel file. JH cosupervised KW. He was the treating physician, organized the transit studies and breath tests and interpreted the results, advised the parents on what to exclude from their child's diet, and suggested they contact dietitians/nutritionists for support. He designed the questionnaire; organized the format with CL, VP, and JW; and sent the questionnaires out to patients. He designed the study and edited drafts. BS supervised KW, supervised data collection and analysis, supervised writing the first draft, and edited drafts. BS had full access to all data in the study and takes responsibility for the integrity of the data and accuracy of the analysis. AbstractAims: Exclusion of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) from the diet is effective in alleviating symptoms of irritable bowel syndrome (IBS) in adults. Rapid-transit constipation (RTC) is a recently discovered subset of chronic constipation and has been linked to food intolerance. The aim of this study was to audit the effect of specific FODMAP elimination diets in children with RTC. Methods: This was an audit of children presenting to a tertiary children's hospital surgeon with refractory chronic constipation who had rapid transit in the proximal colon on nuclear imaging; had hydrogen/methane breath tests for fructose, lactose, and/or sorbitol intolerance; and were advised to exclude positive sugar under clinical supervision. Patients filled in a questionnaire rating severity of constipation, abdominal pain, and pain on defecation with a visual analogue scale (VAS, 0 = none, 10 = high) and stool consistency for 6 months before and after dietary exclusion. Results: In responses from 29 children (5-15 years, 21 males), 70% eliminated fructose, and 40% eliminated lactose. There was a significant reduction in the severity of constipation (VAS mean AE SEM, pre 5.8 AE 0.5 vs post 3.3 AE 0.6, P < 0.0001), abdominal pain (5.1 AE 0.6 vs 2.8 AE 0.5, P = 0.0004), pain on defecation (5.8 AE 0.6 vs 2.6 AE 0.5, P < 0.0001), and increase in stool wetness (Bristol Stool Scale pre 3.3 AE 0.3 vs post 3.9 AE 0.2, P = 0.004). Conclusion: Children with RTC showed significant improvements in constipation and pain after excluding the sugar indicated by positive breath tests, suggesting that specific sugar-exclusion diets may have a role in the management of RTC in children.

How to manage irritable bowel syndrome in children

“…Proposed therapeutic interventions include single and/or comprehensive carbohydrate restriction with additional selective prebiotic and/or enzyme supplementation 30 . Dietary exclusion of fructose and lactose after positive breath tests was reported to improve rapid‐transit constipation in children 31 . However, no effect was found for a lactose‐free diet while fructose‐restricted diets were effective in 5/6 studies 32 .…”

“…In children with rapid‐transit constipation and a positive breath test upon fructose challenge, fructose exclusion results in improved constipation, abdominal pain, stool consistency and decreased laxative use 37 . Children with rapid‐transit constipation show significant improvement of constipation and pain after excluding the carbohydrate indicated by a positive breath test, suggesting that specific sugar‐exclusion diets may have a role in the management of rapid‐transit constipation 38 . There are only few trials with a FODMAP diet in children with recurrent functional abdominal pain disorders, with encouraging results on the efficacy particularly of fructose‐restricted diet 39 .…”

“…30 Dietary exclusion of fructose and lactose after positive breath tests was reported to improve rapid-transit constipation in children. 31 However, no effect was found for a lactose-free diet while fructoserestricted diets were effective in 5/6 studies. 32 Studies demonstrate that dietary elimination of fermentable carbohydrates, such as a low-FODMAP diet, reduces the severity of one or more GI symptoms in about 25% to 50% of paediatric patients, independent of the IBS subtype.…”

“…37 Children with rapid-transit constipation show significant improvement of constipation and pain after excluding the carbohydrate indicated by a positive breath test, suggesting that specific sugar-exclusion diets may have a role in the management of rapidtransit constipation. 38 There are only few trials with a FODMAP diet in children with recurrent functional abdominal pain disorders, with encouraging results on the efficacy particularly of fructoserestricted diet. 39 More research is needed to elucidate the relevance of a selective exclusion of fructans and fructose in children with chronic abdominal pain.…”

Paediatric constipation for general paediatricians: Review using a case‐based and evidence‐based approach

“…However, high fibre may be detrimental in children with STC due to weak propulsive action of the colon. Children with rapid transit constipation may have symptoms consistent with possible food intolerance52 Carrying out sugar‐specific dietary exclusions identified with the help of a breath analysis can help 63. (evidence level – low) Transcutaneous electrical stimulation – It is effective in treating children with STC, with long‐lasting effects 64.…”