Menu ENN Search

Carbohydrate malabsorption in acutely malnourished children and infants: A systematic review

Summary of research*

Location: Global

What we know: Diarrhoea is commonly associated with SAM; carbohydrate malabsorption may be a contributing factor.

What this article adds: A recent systematic review finds a consistently reported reduced capacity for carbohydrate absorption in severely malnourished children. Evidence is lacking on the extent of malabsorption, the impact on clinical outcomes and the relationship with infections. Malabsorption of monosaccharides and disaccharides is common (most observed is lactose malabsorption); this has implications for current SAM treatment since therapeutic products tend to be high in carbohydrates. Intervention studies are needed to determine whether different therapeutic food carbohydrate profiles affect outcomes of SAM complicated by carbohydrate malabsorption, and how.

Severe acute malnutrition (SAM) accounts for approximately one million child deaths per year. SAM is associated with multiple co-morbidities that may contribute to an increased risk of death, a prominent one being diarrhoea. A common cause of diarrhoea in developing countries is enteric infection, which, when associated with underlying malnutrition, can lead to villous blunting and, as a result, impaired carbohydrate absorption. In turn, significant decreases in carbohydrate absorption can lead to severe osmotic diarrhoea. To inform future modification of therapeutic feeds, it is necessary to determine the prevalence of carbohydrate malabsorption and to understand the possible impact of carbohydrate malabsorption on the recovery of malnourished children. This systematic review aims to evaluate the research to determine the extent to which carbohydrate malabsorption occurs in children with SAM, to find out what types of carbohydrate are malabsorbed, and to find out if carbohydrate malabsorption in children with SAM is associated with osmotic diarrhoea.

A comprehensive literature search was performed in PubMed and Embase and reference lists of selected articles were further screened for additional relevant publications. All observational and controlled intervention studies involving children with SAM in which direct or indirect measures of carbohydrate absorption were analysed were eligible for inclusion. A total of 20 articles were selected for this review.  

Some of the included studies performed dynamic tests of carbohydrate absorption in children with malnutrition. The most common technique was blood glucose rise after carbohydrate tolerance tests using a glucose response curve after an oral carbohydrate load. For an oral tolerance test, generally 2g of carbohydrate per kilogram of body weight dissolved in a 10% solution was given orally after a six-hour fast and capillary blood was then sampled every 30 minutes for two hours. If the blood glucose rises less than 30mg/100ml after oral carbohydrate is administered, intolerance is considered likely; increments of less than 20mg/100ml are considered diagnostic of malabsorption. When compared with controls, children with SAM showed a decline in the average maximum glucose rise. Other studies compared malnourished children before and after treatment. One study (Viteri et al, 1973) reporting a significant improvement in carbohydrate absorption after treatment and another (James, 1972) showing no significant improvement after treatment in lactose or sucrose absorption.

Other studies, instead of comparing treated subjects with control subjects, investigated plasma glucose increments in children with SAM to indicate malabsorption after administration of a carbohydrate load. Rothman et al (1980) showed that glucose increments in eight of 12 children with SAM fell below the cut-off value of 20mg/100ml, while increments in the remaining four were less than 30mg/100ml. These findings indicate that carbohydrate malabsorption is prevalent in children with SAM. Comparison of absorption of different types of carbohydrates was also done in several studies, which revealed that lactose intolerance is a concern for children with SAM. One study in particular looked at lactose malabsorption in different types of SAM and found that the proportion of children with lactose malabsorption was highest in those with kwashiorkor, second highest in those with marasmic kwashiorkor, and lowest in those with marasmus (James, 1972).

Some studies measured faecal pH and output of water and carbohydrate as markers of carbohydrate malabsorption. A pH of less than 5.5 (normal pH values range between 7 and 7.5) and the presence of reducing substances in the faeces are indicative of carbohydrate intolerance and malabsorption as a result of villous atrophy. A higher mean stool weight and a higher lactic acid content are also consistent with carbohydrate malabsorption. Reduced faecal pH was observed in children with SAM compared with controls in the studies that conducted carbohydrate tolerance tests, although the average pH was still more than 5.5 in all malnourished cohorts studied. Four studies demonstrated a significant reduction in mean stool weight in children on a disaccharide-free diet compared with children on a lactose-containing diet. For example, Maclean and Graham (1975) demonstrated that children with SAM on a low-lactose diet had a mean stool weight nearly three times lower than that of convalescent children. Overall, the data from faecal examination in included studies suggests the prevalence of carbohydrate malabsorption in children with SAM, as determined by increased mean stool mass, the presence of reducing substances, and an acidic faecal pH.

The other indirect method used for assessing carbohydrate absorption is the measurement of metabolic enzymes, namely lactase, sucrose and maltase in jejunal mucosal biopsy samples. Mucosal disaccharidases, specifically, are essential for disaccharide absorption. Different studies observed reduced levels of disaccharides in malnourished children. James (1972) further illustrated a rise in disaccharidase levels after treatment of both children with moderately acute malnutrition and children with SAM. In another study, two children with SAM showed normal lactase, sucrose and maltase activities; one child with SAM had low sucrose and maltase activities and borderline low lactase activity, and eight children with SAM had low lactase and sucrose activities, six of whom also has low maltase activity.

Measurement of anthropometric markers can be indirectly related to carbohydrate malabsorption and is harder to control for influencing factors. A study conducted in a cohort of 20 male children with SAM indicated that, despite the increased incidence of diarrhoea in the cohort on a lactose-containing diet compared with the cohort on a lactose-free diet, both cohorts recovered well and in a similar fashion with regard to anthropometric characteristics (Prinsloo et al, 1969). In contrast, two studies showed a decreased weight gain in children on a lactose-free diet. In one study in 20 malnourished children placed on a semi-elemental diet containing glucose and maltodextrin as the carbohydrates, the average weight gain after 21 days was 420g, while in the 18 malnourished children on the cow’s milk-based diet, the average weight gain after 21 days was 110g (Eichenberger et al, 1984).

This review finds a consistently reported reduced capacity for carbohydrate absorption in severely malnourished children. The extent of carbohydrate malabsorption, the impact of malabsorption on severe diarrhoea, dehydration and other adverse clinical outcomes, and the relationship between malabsorption and infection are unclear owing to the lack of conclusive studies. Most of the observational studies reviewed by the authors suggested a prevalence of lactose malabsorption and an increase in diarrhoea and reduced weight gain in children on a lactose-containing diet. The consistent observation of malabsorption of both monosaccharides and disaccharides could have profound implications for current treatment of severe malnutrition, since the therapeutic foods in most treatment protocols have a relatively high carbohydrate content. Additional well-designed intervention studies are needed to determine whether outcomes of SAM complicated by carbohydrate malabsorption could be improved by altering the carbohydrate/lactose content of therapeutic feeds and to explain the precise mechanisms involved.


Eichenberger JR, Hadorn B, Schmidt BJ. A semi-elemental diet with low osmolarity and high content of hydrolyzed lactalbumin in the treatment of acute diarrhea in malnourished children. Arq Gastroenterol. 1984;21:130–135.

James WP. Comparison of three methods used in assessment of carbohydrate absorption in malnourished children. Arch Dis Child. 1972;47:531–536.

MacLean WC Jr and Graham GC. Evaluation of a low-lactose nutritional supplement in malnourished children. J Am Diet Assoc. 1975;67:558–564.

Prinsloo JG, Wittmann W, Pretorius PJ, et al. Effect of different sugars on diarrhoea of acute kwashiorkor. Arch Dis Child. 1969;44:593–599.

Rothman D, Habte D, Latham M. The effect of lactose on diarrhoea in the treatment of kwashiorkor. J Trop Pediatr. 1980;26:193–197.

Viteri FE, Flores JM, Alvarado J, et al. Intestinal malabsorption in malnourished children before and during recovery. Relation between severity of protein deficiency and the malabsorption process. Am J Dig Dis. 1973;18:201–211.


*Kvissberg, MA; Dalvi, PS; Kerac, M; Voskuijl, W; Berkley, JA; Priebe, MG; Bandsma, RH (2015) Carbohydrate malabsorption in acutely malnourished children and infants: A systematic review. Nutrition reviews. ISSN 0029-6643 DOI: 10.1093/nutrit/nuv058


More like this

en-net: Lactose Intolerance

What are the messages on IYCF regarding the feeding guidance for Lactose intolerance baby? How should they select and prepare food from natural sources? Dear Michael Thank...

en-net: use of lactose free formula milk in F-75

I am a pediatric consultant managing Malnutrition in inpatient and outpatient setting.We prepare and use F-75 by non-cooking recipe in our hospital, which is causing osmotic...

FEX: Debate on the Management of Severe Malnutrition : A Response

By Professor Ann Ashworth, London School of Hygiene and Tropical Medicine Background Many individuals and organisations, including NGOs, have contributed to the improved...

en-net: Treatment of SAM and special cases

I'm writing this question on behalf of Dr. Huda, IRC in Yemen. Dr Huda wants to know if there is any adverse effect of using plumpy nut with a SAM patient who has sickle cell...

en-net: Use of half strength infant formula instead of F75 Formula

Hi All I am currently working as a Dietitian Advisor to the Samoan NHS. A current practice in the Paediatric ward for infants ranging from about 6 months to 2 years,...

FEX: NGOnut discussion summaries - ORS v Resomal, Lactose intolerance, and split peas

O.R.S OR RESOMAL Question Does anyone have any data documenting the superiority of a reduced sodium, higher potassium ORS over the standard WHO ORS? The few studies which we...

FEX: Kenya and Malawi: Intestinal disturbances and mortality in complex malnutrition cases

View this article as a pdf Lisez cet article en français ici This is a summary of the following paper: Wen B, Farooqui A, Bourden C et al. (2023) Intestinal...

FEX: Developing food supplements for moderately malnourished children: lessons learned from RUTF

Summary of research1 Location: Global What we know: RUTF is as effective as F100 in treating SAM, where weight gain is the recovery outcome. Food supplements for moderate...

en-net: inpatient SAM management

hi.. in Jordan, the CMAM program is integrated into primary healthcare...thus, only children with urgent complications are referred for secondary healthcare services. F-100...

en-net: Abdominal enlargement for SAM patients treated in ITC

Hi! we recently gathered In patient Therapeutic Care Centers in our Region who had been established for a year or more. They had case presentations and sharing of experiences....


What are the guidelines as pertaining when to give Albendazole to the new cases or admission of SAM in the OTP programs. Kenya Protocol says its given on the 1st Visit. other...

en-net: Lactose Intolerance

What the treatment for SAM child suffering lactose intolerance? And SAM child suffering both lactose intolerance and celiac disease ? Hello, Just a small precision: it is the...

FEX: Informal workshop on bioavailability of micronutrients in RUTF

Summary of workshop report1 Ready to use therapeutic foods (RUTFs) and ready to use supplementary foods (RUSFs) are two types of ready to use food (RUF) or more specifically,...

FEX: Postscript on local capacity building for treatment of severe malnutrition

Ann Ashworth Hill, Professor of Community Nutrition Public Health Nutrition Unit, London School Hygiene and Tropical Medicine International NGOs usually provide better...

FEX: Management of shigellosis in undernourished children

Tens of thousands of Rwandan refugees were believed to have died from dysentery in the Goma camps in 1994/95. Above Goma, Eastern Zaire Summary of published paper1 Acute...

en-net: Plumpy doz for chronic malnutrition prevention

After the release of the papers from Phuka and Adu-Afarwuah showing the possible effect of LNS in the prevention of chronic malnutrition, some organizations might be thinking...

FEX: Mitochondrial homeostasis and severe malnutrition

View this article as a pdf Lisez cet article en français ici This is a summary of the following paper: Ling C, Versloot C, Kvissberg M et al. (2023) Rebalancing of...

en-net: Probiotics and ORS

why are`nt probiotics used in management of diarrhoea in SAM?? is there any evidence or have there been any attempt to fortify ORS with probiottics?? See: reduced...

FEX: Impact evaluation of WASH in nutrition intervention on morbidity and acute malnutrition in Niger

View this article as a pdf Lisez cet article en français ici By SaïdouTamboura, Dr Moussa IssaLende and Lucia Pantella Tamboura Saïdou has worked in...

FEX: Development of a maternal service package for mothers of children with severe acute malnutrition admitted to nutrition rehabilitation centres in India

View this article as a pdf Lisez cet article en français ici By Vani Sethi, Praveen Kumar and Arjan De Wagt Vani Sethi PhD is a public health nutritionist in the...


Reference this page

Kvissberg, MA; Dalvi, PS; Kerac, M; Voskuijl, W; Berkley, JA; Priebe, MG; Bandsma, RH (). Carbohydrate malabsorption in acutely malnourished children and infants: A systematic review. Field Exchange 53, November 2016. p36.



Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.