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Outbreak of Diarrhea Linked to Dietetic Candies -- New Hampshire

A 13-year-old girl was treated at a Milford, New Hampshire, hospital emergency room April 30, 1984, for acute abdominal pain and diarrhea. Induced vomiting yielded partially digested pieces of a hard candy. The New Hampshire Poison Center notified the Epidemiology Office, New Hampshire Division of Public Health Services, that candy possibly caused the illness.

Investigation disclosed that, earlier that day, eight neighborhood playmates, ages 5-13 years (mean 9 years), had experienced abdominal cramps, urgency in defecation, and two to six loose bowel movements each, H to 1H hours after eating three to 16 pieces of a dietetic candy per child. There was no known common exposure to other food, drink, or toxic substance. Only the 13-year-old girl received medical attention; the other seven children recovered spontaneously within 2-3 hours after the illness began. Each of three additional playmates who ate one piece of candy and four who ate no candy did not become ill. The attack rate for children who had eaten any of the candy was 8/12 (67%); it was 8/9 (89%) for children who had eaten three or more pieces.

The candies, purchased locally, had been manufactured in Pennsylvania and are one of a number of dietetic candy products distributed widely for the past 6 years to retailers throughout the United States and to countries overseas. The candies in this outbreak each contained approximately 3 grams of sorbitol as a sweetener. Sorbitol, a hexahydric sugar alcohol, acts as an osmotic laxative. The candies were purchased in bulk and individually wrapped. The wrappers carried no ingredient information and no warning of adverse effects if eaten in excess. A survey of a number of sorbitol-containing dietetic products on the market in New Hampshire revealed instances of inadequate and inaccurate labeling. Reported by R Lipin, MD, Milford, New Hampshire Poison Center, Hanover, Epidemiology Office, New Hampshire Div of Public Health Svcs; Div of Field Svcs, Epidemiology Program Office, Investigations Section, Special Studies Br, Chronic Diseases Div, Center for Environmental Health, CDC.

Editorial Note

Editorial Note: Sorbitol has been responsible for both acute and chronic diarrheal illnesses in adults and children (1-3). In a normal adult, after a 35-gram oral dose, levels of sorbitol in blood remain undetectable, and serum glucose remains unchanged (4). Ingestion of 10 grams of sorbitol caused bloating and flatulance in most of seven volunteers in one study. Twenty grams caused more severe symptons of cramping and diarrhea (5). In children, the dose of sorbitol required to produce gastrointestinal symptoms is markedly less than in adults. Sorbitol ingestion has not been associated with harmful effects other than diarrhea and gastrointestinal discomfort. In unexplained cases of acute or chronic diarrhea, a careful dietary history should be obtained, with careful attention to the possible ingestion of sorbitol.

References

  1. Gryboski JD. Diarrhea from dietetic candies. N Engl J Med 1966;29:718.

  2. George DE. Chronic diarrhea in infants and children. AFT Practical Therapeutics 1984;29:280-8.

  3. Babb RR. Coffee, sugars, and chronic diarrhea. Postgrad Med 1984;75:82-7.

  4. World Health Organization. Food additives. Miscellaneous: sorbitol. Toxicological evaluation of some food additivies including anticaking agents, antimicrobials, antioxidants, emulsifiers and thickening agents. Geneva, Switzerland: World Health Organization, 1974;498-504.

  5. Hyams JS. Sorbitol intolerance: an unappreciated cause of functional gastrointestinal complaints. Gastroenterology 1983;84:30-3.

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