Volume 97, Issue 1
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



The lactulose mannitol (LM) dual sugar permeability test is the most commonly used test of environmental enteropathy in developing countries. However, there is a large but conflicting literature on its association with enteric infection and host nutritional status. We conducted a longitudinal cohort using a single field protocol and comparable laboratory procedures to examine intestinal permeability in multiple, geographically diverse pediatric populations. Using a previously published systematic review to guide the selection of factors potentially associated with LM test results, we examined the relationships between these factors and mucosal breach, represented by percent lactulose excretion; absorptive area, represented by percent mannitol excretion; and gut barrier function, represented by the L/M ratio. A total of 6,602 LM tests were conducted in 1,980 children at 3, 6, 9, and 15 months old; percent lactulose excretion, percent mannitol excretion, and the L/M ratio were expressed as age- and sex-specific normalized values using the Brazil cohort as the reference population. Among the factors considered, recent severe diarrhea, lower socioeconomic status, and recent asymptomatic enteropathogen infections were associated with decreased percent mannitol excretion and higher L/M ratios. Poorer concurrent weight-for-age, infection, and recent breastfeeding were associated with increased percent lactulose excretion and increased L/M ratios. Our results support previously reported associations between the L/M ratio and factors related to child nutritional status and enteropathogen exposure. These results were remarkably consistent across sites and support the hypothesis that the frequency of these exposures in communities living in poverty leads to alterations in gut barrier function.

[open-access] This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Article metrics loading...

Loading full text...

Full text loading...



  1. Denno DM, VanBuskirk K, Nelson ZC, Musser CA, Hay Burgess DC, Tarr PI, , 2014. Use of the lactulose to mannitol ratio to evaluate childhood environmental enteric dysfunction: a systematic review. Clin Infect Dis 59 (Suppl 4): S213S219.[Crossref]
  2. Linnankoski J, Makela J, Palmberg J, Mauriala T, Vedin C, Ungell A, Lazorova L, Artursson P, Urtti A, Yliperttula M, , 2010. Paracellular porosity and pore size of the human intestinal epithelium in tissue and cell culture models. J Pharm Sci 99: 42154227.[Crossref]
  3. Bjarnason I, Macpherson A, Hollander D, , 1995. Intestinal permeability: an overview. Gastroenterology 108: 15661581.[Crossref]
  4. Hossain MI, Nahar B, Hamadani JD, Ahmed T, Roy AK, Brown KH, , 2010. Intestinal mucosal permeability of severely underweight and nonmalnourished Bangladeshi children and effects of nutritional rehabilitation. J Pediatr Gastroenterol Nutr 51: 638644.[Crossref]
  5. Weisz AJ, Manary MJ, Stephenson K, Agapova S, Manary FG, Thakwalakwa C, Shulman RJ, Manary MJ, , 2012. Abnormal gut integrity is associated with reduced linear growth in rural Malawian children. J Pediatr Gastroenterol Nutr 55: 747750.[Crossref]
  6. Menzies IS, Zuckerman MJ, Nukajam WS, Somasundaram SG, Murphy B, Jenkins AP, Crane RS, Gregory GG, Avenue A, , 1999. Geography of intestinal permeability and absorption. Gut 44: 483489.[Crossref]
  7. Faubion W, Camilleri M, Murray J, Kelly P, Kosek M, Enders F, Larson J, Boe G, Dyer R, Singh R, , 2016. Improving the detection of environmental enteric dysfunction: a lactulose, rhamnose assay of intestinal permeability in children aged under 5 years exposed to poor sanitation and hygiene. BMJ Public Heal 2: e00006.
  8. Barboza MS, Jr Silva TM, Guerrant RL, Lima AA, , 1999. Measurement of intestinal permeability using mannitol and lactulose in children with diarrheal diseases. Braz J Med Biol Res 32: 14991504.[Crossref]
  9. Behrens RH, Lunn PG, Northrop-Clewes C, Hanlon PW, Neale G, , 1987. Factors affecting the integrety of the intestinal mucosa of Gambian children. Am J Clin Nutr 45: 14331441.
  10. Filteau SM, Rollins NC, Coutsoudis A, Sullivan KR, Willumsen JF, Tomkins AM, , 2001. The effect of antenatal vitamin A and beta-carotene supplementation on gut integrity of infants of HIV-infected South African women. J Pediatr Gastroenterol Nutr 32: 464470.[Crossref]
  11. Goto K, Chew F, Torun B, Peerson JM, Brown K, , 1999. Epidemiology of altered intestinal permeability to lactulose and mannitol in Guatemalan infants. J Pediatr Gastroenterol Nutr 1999: 282290.[Crossref]
  12. Kukuruzovic RH, Haase A, Dunn K, Bright A, Brewster DR, , 1999. Intestinal permeability and diarrhoeal disease in Aboriginal Australians. Arch Dis Child 81: 304308.[Crossref]
  13. Roy S, Behrens R, Haider R, Akramuzzaman S, Mahalanabis D, Wahed M, Tomkins A, , 1992. Impact of zinc supplementation on intestinal permeability in Bangladeshi children with acute diarrhoea and persistent diarrhoea syndrome. J Pediatr Gastroenterol Nutr 15: 289296.[Crossref]
  14. Jalonen T, Isolauri E, Heyman M, Crain-Denoyelle AM, Sillanaukee P, Koivula T, , 1991. Increased beta-lactoglobulin absorption during rotavirus enteritis in infants: relationship to sugar permeability. Pediatr Res 30: 290293.[Crossref]
  15. Noone C, Menzies IS, Banatvala JE, Scopes JW, , 1986. Intestinal permeability and lactose hydrolysis in human rotaviral gastroenteritis assessed simultaneously by non‐invasive differential sugar permeation. Eur J Clin Invest 16: 217225.[Crossref]
  16. Alam A, Sarker S, Wahed M, Khatun M, Rahaman M, , 1994. Enteric protein loss and intestinal permeability changes in children during acute shigellosis and after recovery: effect of zinc supplementation. Gut 35: 17071711.[Crossref]
  17. Raj SM, Sein KT, Anuar AK, Mustaffa BE, , 1996. Effect of intestinal helminthiasis on intestinal permeability of early primary schoolchildren. Trans R Soc Trop Med Hyg 90: 666669.[Crossref]
  18. Campbell DI, McPhail G, Lunn PG, Elia M, Jeffries DJ, , 2004. Intestinal inflammation measured by fecal neopterin in Gambian children with enteropathy: association with growth failure, Giardia lamblia, and intestinal permeability. J Pediatr Gastroenterol Nutr 39: 153.[Crossref]
  19. Goto R, Mascie-Taylor CGN, Lunn PG, , 2008. Impact of intestinal permeability, inflammation status and parasitic infections on infant growth faltering in rural Bangladesh. Br J Nutr 101: 15091516.[Crossref]
  20. Lin A, Arnold BF, Afreen S, Goto R, Huda TMN, Haque R, Raqib R, Unicomb L, Ahmed T, Colford JM, Luby SP, , 2013. Household environmental conditions are associated with enteropathy and impaired growth in rural Bangladesh. Am J Trop Med Hyg 89: 130137.[Crossref]
  21. Wessells KR, Hess SY, Rouamba N, Ouédraogo ZP, Kellogg M, Goto R, Duggan C, Ouédraogo J-B, Brown KH, , 2013. Associations between intestinal mucosal function and changes in plasma zinc concentration following zinc supplementation. J Pediatr Gastroenterol Nutr 57: 348355.[Crossref]
  22. Lee GO, Kosek P, Lima AA, Singh R, Peñataro Yori P, Paredes Olortegui M, Lamsam J, Oliveira D, Guerrant RL, Kosek M, , 2014. The lactulose:mannitol diagnostic test by HPLC and LC-MSMS platforms: considerations for field studies of intestinal barrier function and environmental enteropathy. J Pediatr Gastroenterol Nutr 59: 544550.[Crossref]
  23. MAL-ED Network Investigators, 2014. The MAL-ED study: a multinational and multidisciplinary approach to understand the relationship between enteric pathogens, malnutrition, gut physiology, physical growth, cognitive development, and immune responses in infants and children up to 2 years of. Clin Infect Dis 59 (Suppl 4): S193S206.
  24. Kosek M, Haque R, Lima A, Babji S, Shrestha S, Quereshi S, Amidou S, Mduma E, Lee G, Yori P, Guerrant R, Bhutta Z, Lang D, Gratz J, Gottleib M, , 2012. Fecal markers of intestinal inflammation and permeability associated with the subsequent acquisition of linear growth deficits in infants. Am J Trop Med Hyg 88: e2125.
  25. Kosek M, Guerrant RL, Kang G, Bhutta Z, Yori PP, Gratz J, Gottlieb M, Lang D, Lee G, Haque R, Mason CJ, Ahmed T, Lima A, Petri WA, Houpt E, Olortegui MP, Seidman JC, Mduma E, Samie A, Babji S, , 2014. Assessment of environmental enteropathy in the MAL-ED cohort study: theoretical and analytic framework. Clin Infect Dis 59 (Suppl 4): S239S247.[Crossref]
  26. Caulfield LE, Bose A, Chandyo RK, Nesamvuni C, De Moraes ML, Turab A, Patil C, Mahfuz M, Ambikapathi R, Ahmed T, Network TM, , 2014. Infant feeding practices, dietary adequacy, and micronutrient status measures in the MAL-ED study. Clin Infect Dis 59 (Suppl 4): 248254.[Crossref]
  27. Richard SA, Barrett LJ, Guerrant RL, Checkley W, Miller MA, The MAL-ED Network Investigators, 2014. Disease surveillance methods used in the 8-site MAL-ED cohort study. Clin Infect Dis 59 ( Suppl 4 ): S220S224.[Crossref]
  28. Kosek M, Lee GO, Guerrant RL, Rashidul Haque GK, Ahmed T, Bessong P, Ali A, Mduma E, Yori PP, Faubion W, Lima A, Olortegui MP, Mason C, Babji S, Singh R, Gottlieb M, the MAL-ED Network, 2017. Age and sex normalization of intestinal permeability measures for improved assessment of permeability in infancy and early childhood: results from the MAL-ED study. J Pediatr Gastroenterol Nutr doi:10.1097/MPG.0000000000001610.
  29. World Health Organization, 2006. Child Growth Standards. Methods and Development: Length/height-for-Age, Weight-for-Age, Weight-for-Length, Weight-for-Height and Body Mass Index-for-Age. Geneva, Switzerland: World Health Organization.
  30. Psaki SR, Seidman JC, Miller M, Gottlieb M, Bhutta ZA, Ahmed T, Ahmed AMS, Bessong P, John SM, Kang G, Kosek M, Lima A, , 2014. Measuring socioeconomic status in multicountry studies: results from the eight-country MAL-ED study. Popul Health Metr 12: 111.[Crossref]
  31. Rogawski ET, Platts-Mills JA, Seidman JC, John S, Mahfuz M, Ulak M, Shrestha S, Soofi SB, Yori PP, Duma E, Svensen E, Ahmed T, Lima AAM, Bhutta Z, Kosek M, Lang D, Gottlieb M, Kang G, Bessong P, Houpt ER, Guerrant RL, , 2017. Use of antibiotics in children younger than two years in eight countries: a prospective cohort study. Bull World Heal Organ 95: 4961.[Crossref]
  32. Patil CL, Turab A, Ambikapathi R, Nesamvuni C, Chandyo RK, Bose A, Islam MM, Ahmed AS, Olorteguii MP, de Moraes ML, Caulfield LE, , 2015. Early interruption of exclusive breastfeeding: results from the eight-country MAL-ED study. J Health Popul Nutr 34: 110.[Crossref]
  33. Labbok M, Krasovek K, , 1990. Toward consistency in breastfeeding definitions. Stud Fam Plann 221: 226230.[Crossref]
  34. Houpt E, Gratz J, Kosek M, Zaidi AKM, Qureshi S, Kang G, Babji S, Mason C, Bodhidatta L, Samie A, Bessong P, Barrett L, Lima A, Havt A, Haque R, Mondal D, Taniuchi M, Stroup S, Mcgrath M, Lang D, MAL-ED Network Investigators, 2014. Microbiologic methods utilized in the MAL-ED cohort study. Clin Infect Dis 59 (Suppl 4): S225S232.[Crossref]
  35. Platts-Mills JA, Babji S, Bodhidatta L, Gratz J, Haque R, Sami A, Havt A, McCormick BJ, McGrath M, Olortegui MP, Qureshi S, Shakoor Sadia, Mondal D, Lima IF, Hariraju D, Rayamajhi BB, Lang D, Kabir F, Yori PP, Mufamadi B, Amour C, Carreon JD, Richard S, Bhutta Z, Lang D, Bessong P, Mduma E, Ahmed T, Lima AA, Mason CJ, Zaidi AK, Kosek M, Richard L Guerrant, Gottlieb M, Miller M, Kang G, Houpt ER, MAL-ED Network Investigators, 2015. Pathogen-specific burdens of community diarrhoea in developing countries (MAL-ED): a multisite birth cohort study. Lancet Glob Health 3: e564e575.[Crossref]
  36. Burnham KP, Anderson DR, , 2003. Model Selection and Multimodel Inference: A Practical Information-Theoretic Approach. New York, NY: Springer Science and Business Media.
  37. Stolwijk AM, Straatman H, Zielhuis GA, , 1999. Studying seasonality by using sine and cosine functions in regression analysis. J Epidemiol Community Health 53: 235238.[Crossref]
  38. Royston P, Ambler G, Sauerbrei W, , 1999. The use of fractional polynomials to model continuous risk variables in epidemiology. Int J Epidemiol 28: 964.[Crossref]
  39. Ambikapathi R, Kosek MN, Lee GO, Mahopo C, Patil CL, Maciel BL, Turab A, Islam MM, Ulak M, Bose A, Paredes Olortegui M, Pendergast LL, Murray-Kolb LE, Lang D, McCormick BJJ, Caulfield LE, , 2016. How multiple episodes of exclusive breastfeeding impact estimates of exclusive breastfeeding duration: report from the eight-site MAL-ED birth cohort study. Matern Child Nutr 1: 117.
  40. Catassi C, Bonucci A, Coppa G, Giorgi P, , 1995. Intestinal permeability changes during the first month: effect of natural versus artificial feeding. J Pediatr Gastroenterol Nutr 21: 383386.[Crossref]
  41. Shulman RJ, Schanler RJ, Lau C, Margaret Heitkemper C-NO, Smith EO, , 1998. Early feeding, antenatal glucocorticoids, and human milk decrease intestinal permeability in preterm infants. Pediatr Res 44: 519523.[Crossref]
  42. Taylor SN, Basile LA, Ebeling M, Wagner CL, , 2009. Intestinal permeability in preterm infants by feeding type: mother's milk versus formula. Breastfeed Med 4: 1115.[Crossref]
  43. De Segura AG, Escuder D, Montilla A, Bustos G, Pallás C, Fernández L, Corzo N, Rodríguez JM, , 2012. Heating-induced bacteriological and biochemical modifications in human donor milk after holder pasteurisation. J Pediatr Gastroenterol Nutr 54: 197203.[Crossref]
  44. Indrio F, Riezzo G, Raimondi F, Bisceglia M, Cavallo L, Francavilla R, , 2008. The effects of probiotics on feeding tolerance, bowel habits, and gastrointestinal motility in preterm newborns. J Pediatr 152: 801806.[Crossref]
  45. The MAL-ED Network Investigators, 2017. Causal Pathways of Environmental Enteropathy Evaluated in a Multicentre Birth Cohort Study (MAL-ED). EBioMedicine (in press).
  46. Campbell DI, McPhail G, Lunn PG, Elia M, Jeffries DJ, , 2004. Intestinal inflammation measured by fecal neopterin in Gambian children with enteropathy: association with growth failure, Giardia lamblia, and intestinal permeability. J Pediatr Gastroenterol Nutr 39: 153.[Crossref]
  47. Rogawski ET, Bartelt LA, Platts-Mills JA, Seidman JC, Samie A, Havt A, Babji S, Trigoso DR, Qureshi S, Shakoor S, Mduma E, Lima AAM, Kang G, Kosek MN, Bessong PO, MAL-ED Network Investigators, 2017. Causes and consequences of Giardia infection in the first two years of life in the MAL-ED birth cohort. J Pediatric Infect Dis Soc (In press).
  48. Kelly P, Besa E, Zyambo K, Louis-Auguste J, Lees J, Banda T, Soko R, Banda R, Amadi B, Watson A, , 2016. Endomicroscopic and transcriptomic analysis of impaired barrier function and malabsorption in environmental enteropathy. PLoS Negl Trop Dis 10: e0004600.[Crossref]

Data & Media loading...

Supplementary Data

Supplemental Figure and Table

  • Received : 23 Oct 2016
  • Accepted : 31 Jan 2017

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error