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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
Gryboski JD. Diarrhea from dietetic candies. N Engl J Med
1966;29:718.
George DE. Chronic diarrhea in infants and children. AFT
Practical Therapeutics 1984;29:280-8.
Babb RR. Coffee, sugars, and chronic diarrhea. Postgrad Med
1984;75:82-7.
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.
Hyams JS. Sorbitol intolerance: an unappreciated cause of
functional gastrointestinal complaints. Gastroenterology
1983;84:30-3.
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