Small-bowel bacterial overgrowth in children with chronic diarrhea, abdominal pain, or both

doi:10.1016/S0022-3476(96)70390-6

The Journal of Pediatrics

Volume 128, Issue 2, February 1996, Pages 203-207

https://doi.org/10.1016/S0022-3476(96)70390-6 Get rights and content

Abstract

OBJECTIVE: To evaluate the frequency of small-bowel bacterial overgrowth (SBBO) as a cause of chronic digestive symptoms in a large cohort of children, using the glucose breath hydrogen test (BHT). DESIGN: Patients were 53 children (aged 2 months to 12 years) with chronic diarrhea, abdominal pain, or both. Diagnosis of SBBO was defined with a BHT by a change in H₂ concentration of 10 ppm H₂ or more in expired air after an oral glucose load. Patients with a positive BHT result were included in group 1 and treated with a combination of colistin and metronidazole for 10 days; a second BHT was performed 1 month later. Group 2 comprised patients with a negative BHT result. Group 3 (n = 15) was a control group of healthy subjects, and group 4 (n = 6) a comparison group of subjects with bacteriologically documented SBBO. RESULTS: Eighteen patients (34%) had a positive BHT result and 35 a negative result. The BHT results were comparable in groups 1 and 4 and in groups 2 and 3, respectively. Fasting H₂ levels were higher in group 1 than in groups 2 (p <0.001) and 3 (p <0.01). In group 1, children were younger than in group 2 (1 ± 1 year vs 3.9 ± 3 years; p <0.001) and diarrhea was frequent (83%), but 17% of patients had abdominal pain alone. Fetid stools (p <0.01), mucus in stools (p <0.01), and flatulence (p <0.05) were more frequent in group 1 than in group 2. Antibiotic treatment of children in group 1 led to a rapid disappearance of symptoms and normalization of BHT results. CONCLUSION: SBBO appears to be a frequent cause of chronic digestive symptoms in children, especially before the age of 2 years. The BHT provides a simple and noninvasive method of detecting it. The recognition of SBBO in children leads to effective treatment. (J PEDIATR 1996;128:203-7)

Section snippets

Patients

Patients were 53 children (aged 2 months to 12 years) referred for study of chronic diarrhea or abdominal pain during a 10-month period. Chronic diarrhea was defined according to age: more than one liquid stool after each meal before age 6 months and more than three loose stools daily in older children, for more than 1 month. Abdominal pain was considered chronic when it occurred at least 3 days a week for more than 1 month. Abdominal pain was identified in infants by mothers reporting intense

RESULTS

Eighteen patients (34%) had a positive BHT result (group 1); 35 patients (66%) had a negative result (group 2). Clinical data in the four groups are reported in Table I. Children in group 1 were younger than in group 2 (p <0.001), 89% of patients of group 1 being less than 2 years of age. Results of bacterial cultures and parasitologic examination of stools were negative in the children in group 1, except for Clostridium spp. in one. In group 2, bacterial cultures and parasitologic examination

DISCUSSION

Our data confirm that SBBO may be a common cause of chronic digestive symptoms in children, as suggested by previous reports,12, 13, 14, 15 even in the absence of predisposing conditions. SBBO might be especially frequent in children with chronic diarrhea, abdominal pain, or both, before the age of 2 years.

Because of the lack of microbiologic cultures of small bowel aspirate, the criterion used for a diagnosis of SBBO (i.e., a positive BHT result) might be considered controversial. However,

Acknowledgements

We are grateful to Pierre Bougnères for his work on the manuscript.

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Although the true prevalence of small intestinal bacterial overgrowth in the general population remains unclear, there is an increased understanding that it is not uncommon among patients with gastrointestinal-related illnesses. If remained untreated, intestinal bacterial overgrowth can negatively affect a person’s health. The most common symptoms include bloating, abdominal pain, flatulence, halitosis, constipation, and diarrhea. Other serious clinical presentations may include chronic weight loss and malnutrition. A few treatment strategies have been investigated for intestinal bacterial overgrowth. Use of oral antimicrobial agents is found to be more effective than placebo. Most regimens are also well-tolerated by patients. Antimicrobial regimens can be categorized as nonabsorbable, such as rifaximin, versus absorbable agents, such as metronidazole. Although nonabsorbable drugs may have fewer systemic side effects, they also appear less effective than some absorbable agents in treating bacterial overgrowth in a blind-loop. The general treatment duration is between 7 and 10 days.
Long-term health-related quality of life of patients with pediatric onset intestinal failure
2015, Journal of Pediatric Surgery
Citation Excerpt :
Intestinal bacterial overgrowth is a common complication of IF and may cause diarrhea, bowel distension, and frequent abdominal pain. To treat bacterial overgrowth rotating oral antibiotics can be used empirically [4,22]. Among our IF patients, however, use of antibiotics was unrelated to the frequency of pain.
Despite improved survival rates of patients with pediatric intestinal failure (IF), data on health-related quality of life (HRQoL) of IF patients are still scarce. We hypothesized that I) continued parenteral nutrition, underlying intestinal motility disorder, abdominal pain and problematic bowel function would be associated with poorer HRQoL and higher parental stress levels, and II) the time intervals since the latest bowel operation, the latest episode of sepsis, and the latest inpatient care episode would be associated with better HRQoL and lower parental stress.
Patients with pediatric onset IF and their parents answered questionnaires on HRQoL, parental stress, and bowel-related symptoms. Clinical data were gathered by chart review. Controls matched for age and sex were randomly chosen by the Population Register Centre of Finland.
Thirty-six (73%) IF patients participated at a median age of 9 years. Overall HRQoL was similar to healthy peers, and frequent abdominal pain was the only factor associated with poorer HRQoL. Abdominal pain and stool frequency > 3 times per day were associated with higher levels of parental stress, whereas longer time intervals since the latest bowel operation or hospitalization were associated with lower parental stress levels.
Long-term HRQoL of pediatric IF patients is comparable to that of healthy peers. Time often eases parental stress, but frequent abdominal pain presents a challenge to the well-being of some patients and requires medical attention.
A double-blind placebo-controlled randomized trial on probiotics in small bowel bacterial overgrowth in children treated with omeprazole
2013, Jornal de Pediatria
Citation Excerpt :
The results suggest a placebo-effect of the PPI, since 18/70 were not compliant; only four reported no significant improvement, all of which in the non-compliant group. A cohort study by Boissieu et al. in 53 children, aged between 2 months and 12 years, with complaints of chronic diarrhea, abdominal pain, or both, reported SBBO as a frequent cause (34%), especially before the age of 2 years.22 Scarpellini et al. reported the prevalence of SBBO to be as high as 65% in children aged 3 to 16 years with irritable bowel syndrome (IBS).23
To evaluate the incidence of small bowel bacterial overgrowth (SBBO) in children treated with omeprazole, and to test whether probiotics influence the incidence.
A double-blinded, placebo-controlled trial was performed in 70 children treated orally during four weeks with 20 mg omeprazole per day. Lactobacillus rhamnosus R0011 (1.9 × 10⁹ cfu) and Lactobacillus acidophillus R0052 (0.1 × 10⁹ cfu) were simultaneously given daily to 36 subjects (probiotic group), while 34 subjects received placebo (placebo group). The diagnosis of SBBO was based on the development of suggestive symptoms, in combination with a positive glucose breath test.
After one month of proton pump inhibitor (PPI) treatment, 30% (21/70) had a positive breath test suggesting SBBO; of these 62% were symptomatic. Five children developed SBBO-like symptoms, but had a negative breath test; and 44 (63%) were symptom free and had a negative breath test. There was no difference in the incidence of positive breath tests in the probiotic versus the placebo group (33% vs 26.5%; p = 0.13).
Since symptoms suggesting SBBO developed in 26% of PPI-treated children, and since the glucose breath test was abnormal in 72% of these, this side-effect should be more frequently considered. The probiotic tested did not decrease the risk to develop SBBO.
Avaliar a incidência de SBID em crianças tratadas com omeprazol e testar se os probióticos influenciam essa incidência.
Um ensaio duplo-cego controlado por placebo foi realizado em 70 crianças tratadas oralmente, durante 4 semanas, com 20 mg de omeprazol por dia. Desses, 36 indivíduos receberam diária e simultaneamente Lactobacillus rhamnosus R0011 (1,9 × 10⁹ cfu) e Lactobacillus acidophillus R0052 (0,1 × 10⁹ cfu) (grupo probiótico), enquanto 34 receberam placebo (grupo placebo). O diagnóstico de SBID teve como base o desenvolvimento de sintomas sugestivos em combinação com um teste respiratório com glicose positivo.
Após um mês de tratamento com IBP, 30% (21/70) apresentaram um teste respiratório positivo sugerindo SBID; desses, 62% foram sintomáticos. Cinco crianças desenvolveram sintomas parecidos com os de SBID, mas apresentaram um teste respiratório negativo; 44 (63%) não apresentavam sintomas e tiveram teste respiratório negativo. Não houve diferença na incidência de testes respiratórios positivos no grupo probiótico em comparação ao grupo placebo (33% em comparação a 26,5%; p: 0,13).
Como houve sintomas sugestivos de SBID em 26% das crianças tratadas com IBP e o teste respiratório com glicose deu resultados anormais em 72% delas, esse efeito colateral deve ser levado em consideração com mais frequência. O probiótico testado não reduziu o risco de desenvolver SBID.
Short- and long-term effects of a lactose-restricted diet and probiotics in children with chronic abdominal pain: A retrospective study
2012, Complementary Therapies in Clinical Practice
Citation Excerpt :
However, this is an invasive method. The H2 breath test is a non-invasive alternative with good sensitivity and specificity, respectively 75–93% and 78–100%.19–21 In this study we chose to use a lactose H2 breath test.
To determine the short- and long-term effect of treatment in children with chronic abdominal pain (CAP).
A database with the results of H₂ breath test of children with CAP was created. All children with an abnormal test result were included and classified as small intestinal bacterial overgrowth (SIBO) or lactose intolerant (LTI). SIBO was treated with probiotics and LTI with a lactose-restricted diet. CAP was evaluated 5 months and 15 months after the test.
37 children (41%) were included. 17 LTI children (94%) improved after 5 months and 11 children (61%) after 15 months (P < 0.05). Seven SIBO children improved after 5 months and 4 children after 15 months. In the combination group all 4 children improved after 5 months and 3 children after 15 months.
Children with CAP caused by LTI or SIBO had less CAP after 5 months. This positive effect persists only in half of the children.

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Small-bowel bacterial overgrowth in children with chronic diarrhea, abdominal pain, or both☆,☆☆,★

Abstract

Section snippets

Patients

RESULTS

DISCUSSION

Acknowledgements

Gastroenterology

Gastroenterology

Gastroenterology

Am J Clin Nutr

Gastroenterology

Gastroenterology

Gastroenterology

Gastroenterology

Bacterial overgrowth

Am J Gastroenterol

Bacterial overgrowth of the gastrointestinal tract

Adv Intern Med

Diagnosis of bacterial overgrowth of the small intestine, comparison of the 14C-D-xylose breath test and jejunal cultures in 60 patients

Scand J Gastroenterol

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

J Pediatr Gastroenterol Nutr

A pattern of breath hydrogen excretion suggesting small bowel bacterial overgrowth in Burmese village children

J Pediatr Gastroenterol Nutr

Upper small intestinal microflora in diarrhea and malnutrition in Nigerian children

J Pediatr Gastroenterol Nutr

Intestinal microflora and bacterial overgrowth in early life

J Pediatr Gastroenterol Nutr

Bacterial microflora of the upper gastrointestinal tract in infants with protracted diarrhoea

Arch Dis Child

Chronic nonspecific diarrhea of infancy successfully treated with trimethoprim-sulfamethoxazole

Scand J Gastroenterol

Diagnosis of bacterial overgrowth of the small intestine, comparison of the ¹⁴C-D-xylose breath test and jejunal cultures in 60 patients