European Journal of Pediatrics

, Volume 178, Issue 9, pp 1395–1403 | Cite as

Fructose malabsorption in asymptomatic children and in patients with functional chronic abdominal pain: a prospective comparative study

  • Oihana Martínez-AzconaEmail author
  • Ana Moreno-Álvarez
  • Teresa Seoane-Pillado
  • Inés Niño-Grueiro
  • Ana Ramiro-Comesaña
  • María Menéndez-Riera
  • Marta Pérez-Domínguez
  • Alfonso Solar-Boga
  • Rosaura Leis-Trabazo
Original Article


The objective of this prospective cohort study was to compare fructose malabsorption in patients with functional chronic abdominal pain and in healthy children. The sample was divided into two groups: asymptomatic children and pain-predominant functional gastrointestinal disorders according to the Rome IV criteria. All children were tested for fructose malabsorption by a standardized breath hydrogen test. Hydrogen and methane were measured and the test was presumed positive when it exceeded 20 ppm above baseline. If positive, patients were given a low-fructose diet and the response was evaluated. One hundred five children were included (34 healthy children, 71 with functional chronic abdominal pain), with similar demographic characteristics in both groups (35.2% male, age 9.5 ± 2.8 years). Hydrogen levels in breath were tested through a hydrogen test for fructose demonstrating malabsorption in 58.8% of healthy children (95%CI 40.8%–76.8%) and in 40.8% of children with chronic abdominal pain (95%CI 28.7%–53.0%), removing those who had bacterial overgrowth. Twenty-one of 31 patients with symptoms and a positive test (72.4%) reported an improvement on a low-fructose diet.

Conclusion: Fructose malabsorption is more common in asymptomatic children than in patients with chronic abdominal pain. Better standardized test conditions are necessary to improve accuracy of diagnosis before using this test in clinical practice.

What is Known:

Although fructose malabsorption is believed to be related with chronic abdominal pain, high-quality evidence is lacking.

Concerns have raised regarding the use of breath hydrogen test for fructose malabsorption in children with chronic abdominal pain.

What is New:

Fructose malabsorption is not more common in children with pain-predominant functional gastrointestinal disorders than in asymptomatic children.

Improvement in symptoms with low-fructose diet may indicate that, although patients with pain-predominant functional gastrointestinal disorders did not have a higher percentage of malabsorption, they had greater fructose intolerance.


Chronic abdominal pain Rome IV Fructose malabsorption Fructose intolerance Low-fructose diet 



Breath hydrogen test


Chronic abdominal pain


Confidence interval


Authors’ contributions

Oihana Martinez Azcona: acquisition, analysis and interpretation of data, redaction of the manuscript.

Ana Moreno Álvarez: design of the work, acquisition and interpretation of data, redaction and review of the manuscript.

Teresa Seoane Pillado: design of the work, statistical analysis, review of the manuscript.

Inés Niño Grueiro: acquisition and analysis of data, review of the manuscript.

Ana Ramiro Comesaña: acquisition and analysis of data, review of the manuscript.

María Menéndez Riera: acquisition and analysis of data, review of the manuscript.

Marta Pérez Domínguez: acquisition and analysis of data, review of the manuscript.

Alfonso Solar Boga: design of the work, redaction and review of the manuscript.

Rosaura Leis Trabazo: design of the work, review of the manuscript.

Compliance with ethical standards

The study was conducted in accordance with the Declaration of Helsinki (7th revision), the Spanish regulations on observational studies (Order SAS 3470/2009), and Spanish personal data protection law (Law 15/ 1999). The study protocol was approved by the Ethics Committee of A Coruña, Spain. Parents or legal representatives of all patients gave written informed consent before inclusion, and patients over 12 years old also signed informed assent. All data were anonymized.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Casterton PL, Verbeke KA, Brouns F, Dammann KW (2012) Evaluation of sucromalt digestion in healthy children using breath hydrogen as a biomarker of carbohydrate malabsorption. Food Funct 3(4):410–413. CrossRefGoogle Scholar
  2. 2.
    Comité de Nutrición de la Asociación Española de Pediatría (2003) Consumo de zumos de frutas y de bebidas refrescantes por niños y adolescentes en España. Implicaciones para la salud de su mal uso y abuso. An Pediatr 58(6):584–593CrossRefGoogle Scholar
  3. 3.
    Däbritz J, Mühlbauer M, Domagk D, Voos N, Henneböhl G, Siemer ML, Foell D (2014) Significance of hydrogen breath tests in children with suspected carbohydrate malabsorption. BMC Pediatr 14:59. CrossRefGoogle Scholar
  4. 4.
    Di Lorenzo C, Youssef NN, Sigurdsson L, Scharff L, Griffiths J, Wald A (2001) Visceral hyperalgesia in children with functional abdominal pain. J Pediatr 139(6):838–843. CrossRefGoogle Scholar
  5. 5.
    Ebert K, Witt H (2016) Fructose malabsorption. Mol Cell Pediatr 3(1):10. CrossRefGoogle Scholar
  6. 6.
    Escobar MA Jr, Lustig D, Pflugeisen BM, Amoroso PJ, Sherif D, Saeed D, Shamdeen S, Tuider J, Abdullah B (2014) Fructose intolerance/malabsorption and recurrent abdominal pain in children. J Pediatr Gastroenterol Nutr 58(4):498–501. CrossRefGoogle Scholar
  7. 7.
    Frieling T, Kuhlbusch-Zicklam R, Kalde S, Heise J, Hülsdonk A, Kreysel C (2011) Fructose malabsorption: how much fructose can a healthy subject tolerate? Digestion. 84(4):269–272. CrossRefGoogle Scholar
  8. 8.
    Gasbarrini A, Corazza GR, Gasbarrini G, Montalto M, Di Stefano M, Basilisco G, Parodi A, Usai-Satta P, Vernia P, Anania C et al (2009) Methodology and indications of H2-breath testing in gastrointestinal diseases: the Rome consensus conference. Aliment Pharmacol Ther 29(Suppl 1):1–49. Google Scholar
  9. 9.
    Gibson PR, Newnham E, Barrett JS, Shepherd SJ, Muir JG (2007) Review article: fructose malabsorption and the bigger picture. Aliment Pharmacol Ther 25(4):349–363. CrossRefGoogle Scholar
  10. 10.
    Giteling MJ, Bierna-Zeinstra SM, Lisman-van Leeuwen Y, Passchier J, Berger MY (2011) Prognostic factors for persistence of chronic abdominal pain in children. J Pediatr Gastroenterol Nutr 52(2):154–161. CrossRefGoogle Scholar
  11. 11.
    Gomara RE, Halata MS, Newman LJ, Bostwick HE, Berezin SH, Cukaj L, See MC, Medow MS (2008) Fructose intolerance in children presenting with abdominal pain. J Pediatr Gastroenterol Nutr 47(3):303–308. CrossRefGoogle Scholar
  12. 12.
    Hammer V, Hammer K, Memaran N, Huber WD, Hammer K, Hammer J (2018) Relationship between abdominal symptoms and fructose ingestion in children with chronic abdominal pain. Dig Dis Sci 63(5):1270–1279. CrossRefGoogle Scholar
  13. 13.
    Helwig U, Koch AK, Koppka N, Holtmann S, Langhorst J (2019) The predictive value of the hydrogen breath test in the diagnosis of fructose malabsorption. Digestion. 99(2):140–147. CrossRefGoogle Scholar
  14. 14.
    Hoekstra JH, W van Kempen AAM, Bijl SB, Kneepkens CM (1993) Fructose breath hydrogen tests. Arch Dis Child 68(1):136–138CrossRefGoogle Scholar
  15. 15.
    Hyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, Van Tilburg M (2016) Childhood functional gastrointestinal disorders: child/ adolescent. Gastroenterology 150:1456–1468. CrossRefGoogle Scholar
  16. 16.
    J Jones HF, Butler RN, Moore DJ, Brooks DA (2013) Developmental changes and fructose absorption in children: effect on malabsorption testing and dietary management. Nutr Rev 71(5):300–309. CrossRefGoogle Scholar
  17. 17.
    Jones HF, Burt E, Dowling K, Davidson G, Brooks DA, Butler RN (2011) Effect of age on fructose malabsorption in children presenting with gastrointestinal symptoms. J Pediatr Gastroenterol Nutr 52(5):581–584. CrossRefGoogle Scholar
  18. 18.
    Kneepkens CM, Vonk RJ, Fernandes J (1984) Incomplete intestinal absorption of fructose. Arch Dis Child 59(8):735–738CrossRefGoogle Scholar
  19. 19.
    Lozinsky AC, Boé C, Palmero R, Fagundes-Neto U (2013) Fructose malabsorption in children with functional digestive disorders. Arq Gastroenterol 50(3):226–230. CrossRefGoogle Scholar
  20. 20.
    Maagaard L, Ankersen DV, Végh Z, Burisch J, Jensen L, Pedersen N, Munkholm P (2016) Follow-up of patients with functional bowel symptoms treated with a low FODMAP diet. World J Gastroenterol 22(15):4009–4019. CrossRefGoogle Scholar
  21. 21.
    Nucera G, Gabrielli M, Lupascu A, Lauritano EC, Santoliquido A, Cremonini F, Cammarota G, Tondi P, Pola P, Gasbarrini G, Gasbarrini A (2005) Abnormal breath tests to lactose, fructose and sorbitol in irritable bowel syndrome may be explained by small intestinal bacterial overgrowth. Aliment Pharmacol Ther 21(11):1391–1395. CrossRefGoogle Scholar
  22. 22.
    Rajilić-Stojanović M, Biagi E, Heilig HG, Kajander K, Kekkonen RA, Tims S, De Vos WM (2011) Global and deep molecular analysis of microbiota signatures in fecal samples from patients with irritable bowel syndrome. Gastroenterology 141(5):1792–1801. CrossRefGoogle Scholar
  23. 23.
    Rajindrajith S, Zeevenhooven J, Devanarayana NM, Crispus Perera BJ, Benninga MA (2018) Functional abdominal pain disorders in children. Expert Rev Gastroenterol Hepatol 12(4):369–390. CrossRefGoogle Scholar
  24. 24.
    Rao SSC, Attaluri A, Anderson L, Stumbo P (2007) Ability of the normal human small intestine to absorb fructose: evaluation by breath testing. Clin Gastroenterol Hepatol 5(8):959–963. CrossRefGoogle Scholar
  25. 25.
    Saps M, Pensabene L, Turco R, Staiano A, Cupuro D, Di Lorenzo C (2009) Rotavirus gastroenteritis: precursor of functional gastrointestinal disorders? J Pediatr Gastroenterol Nutr 49(5):580–583. CrossRefGoogle Scholar
  26. 26.
    Scarpato E, Kolacek S, Jojkic-Pavkov D, Konjik V, Zivkovic ER, Kostovski A, Zdraveska N, Altamimi E, Papadopoulou A, Karagiozoglou-lampoudi T et al (2018) Prevalence of functional gastrointestinal disorders in children and adolescents in the Mediterranean region of Europe. Clin Gastroenterol Hepatol 16(6):870–876. CrossRefGoogle Scholar
  27. 27.
    Siddiqui I, Ahmed S, Abid S (2016) Update on diagnostic value of breath test in gastrointestinal and liver diseases. World J Gastrointest Pathophysiol 7(3):256–265. CrossRefGoogle Scholar
  28. 28.
    Truswell AS, Seach JM, Thorbun AW (1988) Incomplete absorption of pure fructose in healthy subjects and the facilitating effect of glucose. Am J ClinNutr 48(6):1424–1430. Google Scholar
  29. 29.
    Tsampalieros A, Beauchamp J, Boland M, Mack DR (2008) Dietary fructose intolerance in children and adolescents. Arch Dis Child 93(12):1078. CrossRefGoogle Scholar
  30. 30.
    Wilder-Smith CH, Olesen SS, Materna A, Drewes AM (2019) Repeatability and effect of blinding of fructose breath tests in patients with functional gastrointestinal disorders. Neurogastroenterol Motil 31(2):e13497. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Oihana Martínez-Azcona
    • 1
    Email author
  • Ana Moreno-Álvarez
    • 2
  • Teresa Seoane-Pillado
    • 3
  • Inés Niño-Grueiro
    • 4
  • Ana Ramiro-Comesaña
    • 4
  • María Menéndez-Riera
    • 4
  • Marta Pérez-Domínguez
    • 4
  • Alfonso Solar-Boga
    • 2
  • Rosaura Leis-Trabazo
    • 5
  1. 1.Department of PediatricsComplexo Hospitalario Universitario A CoruñaA CoruñaSpain
  2. 2.Pediatric Gastroenterology, Hepatology and Nutrition Unit, Department of PediatricsComplexo Hospitalario Universitario A CoruñaA CoruñaSpain
  3. 3.Clinical Epidemiology and Biostatistics UnitComplexo Hospitalario Universitario A CoruñaA CoruñaSpain
  4. 4.University of Santiago de CompostelaSantiago de CompostelaSpain
  5. 5.Pediatric Gastroenterology, Hepatology and Nutrition Unit, Department of PediatricsComplexo Hospitalario Universitario Santiago de CompostelaSantiago de CompostelaSpain

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