Chronic Nonspecific Diarrhea Research Articles

Etiology of chronic diarrhea.

With worldwide use of oral rehydration solutions, the treatment of acute diarrhea does not pose much of a problem. However, chronic diarrhea is still harmful, especially for the growth and development status of the children. Between January 1993 to December 1996, patients who suffered from chronic diarrhea for more than one month duration and admitted to Dr. Sami Ulus Children's Hospital were evaluated for epidemiological and etiologic factors. Seventy consecutive patients were evaluated. The mean age was 40.8 months and 52% were males. Malnutrition was detected in 80% of cases. Etiologic factors included celiac disease 30%, cow milk allergy 17%, bacterial and parasitic factors 26%, cystic fibrosis 10% and postinfectious gastroenteritis 10%. Eosinophilic gastroenteritis, chronic nonspecific diarrhea, pseudo-obstruction, neurofibromatosis and inflammatory bowel disease were rarely detected. Celiac disease and cow milk allergy were implicated as the most common causes of chronic diarrhea. The vicious cycle of faulty nutrition, malnutrition and infection and postinfectious enteropathy were also significant factors in the etiology of chronic diarrhea. It may be considered that cow milk protein prick test, sweat test, immunologic tests and mucosal biopsies should be performed for the definite diagnosis of chronic diarrhea.

4 Nutritional management in diarrhoeal disease

Adequate nutritional intervention in diarrhoeal disease in children is crucial in obtaining optimal control of a disorder that may become life-threatening. During recent years, important advances have been made in our understanding of the pathophysiology of diarrhoeal states, in the formulation of oral rehydration solutions and in the role of micro- and macronutrients in diarrhoeal disorders. This chapter outlines some of the relevant concepts in the pathophysiology of diarrhoeal disease and provides a rationale for nutritional intervention. Guidelines for nutritional management in the settings of acute-onset diarrhoea, post-enteritis protracted diarrhoea and chronic non-specific diarrhoea are provided, mostly based on controlled clinical trials and meta-analyses of evidence-based medicine.

Chronic non‐specific diarrhoea in childhood: how often is it iatrogenic?

Epidemiological data, the appropriateness of the medical approach, the effectiveness of unrestricted diet and the subsequent course of chronic non‐specific diarrhoea (CNSD) were evaluated in 20 children, mean age at diagnosis 4.7 y, and mean duration of diarrhoea 24 months. A mean of 2.4 previous hospital admissions and a mean of 2.5 diagnoses other than CNSD were recorded per child before admission. On admission, 14/20 were following an elimination diet and 8/20 had an inadequate caloric intake; 16/20 had a weight/height ratio below the 50th percentile. In all cases a normal diet prescribed during hospitalization improved the diarrhoea and increased weight. A telephone interview performed 5.6 y after discharge revealed that in 10/20 of the cases, the parents were disappointed with the unrestricted diet prescribed during hospitalization. Nevertheless they reported that CNSD stopped spontaneously in a mean time of 1.7 y.

Chronic non-specific diarrhoea in childhood: how often is it iatrogenic?

Epidemiological data, the appropriateness of the medical approach, the effectiveness of unrestricted diet and the subsequent course of chronic non-specific diarrhoea (CNSD) were evaluated in 20 children, mean age at diagnosis 4.7 y, and mean duration of diarrhoea 24 months. A mean of 2.4 previous hospital admissions and a mean of 2.5 diagnoses other than CNSD were recorded per child before admission. On admission, 14/20 were following an elimination diet and 8/20 had an inadequate caloric intake; 16/20 had a weight/height ratio below the 50th percentile. In all cases a normal diet prescribed during hospitalization improved the diarrhoea and increased weight. A telephone interview performed 5.6 y after discharge revealed that in 10/20 of the cases, the parents were disappointed with the unrestricted diet prescribed during hospitalization. Nevertheless they reported that CNSD stopped spontaneously in a mean time of 1.7 y.

Surface features of small-intestinal mucosa in childhood diarrheal disorders.

The pathophysiology of diarrhea, especially in the otherwise healthy child, is still poorly understood. The aim of this study was to use the scanning electron microscope (SEM) to examine the surface of the jejunal mucosa of children with chronic nonspecific diarrhea (CNSD) (n = 9) and to compare the findings with specimens obtained from children with (n = 21) and without (n = 11) other gastrointestinal diseases. Light microscopy of the specimens from children with CNSD was normal. However, SEM showed the presence of bacterial colonization with predominantly coccoid organisms in 100% of cases. This colonization was associated with loss of glycocalyx and clumping of the microvilli. The children with celiac disease (n = 9) all showed characteristic appearances with light microscopy, but only one had bacterial colonization on SEM. The surface features of specimens from children with other gastrointestinal disorders (food intolerance, postenteritis syndrome, protracted diarrhea of infancy, and immune deficiency states) were very similar to those from the CNSD group. Bacteria were visible on 89% of specimens, and in half of these cases the organisms were bacilli. SEM of specimens from children with no gastrointestinal disease (ages 11-107 months) suggested an increased density of villi/unit area with advancing age. Bacteria were present in only two cases and did not include bacilli. The findings suggest that bacterial colonization of the surface of the small intestine is common in children with several gastrointestinal diseases and may play a part in their pathogenesis. Routine SEM examination of jejunal biopsies provides information not available from standard light microscopy, which may be relevant to the treatment of children with chronic diarrhea.

CHRONIC NONSPECIFIC DIARRHEA OF CHILDHOOD: Pathophysiology and Management

Chronic nonspecific diarrhea, or toddler's diarrhea, is a frequently encountered disorder of defecation in otherwise healthy children. Although the precise pathophysiology remains to be elucidated, evidence suggests that toddler's diarrhea primarily is a gut motility disorder, modulated by dietary factors. Although the role of low-fat diets has since long been established, the liberal consumption of fruit juices and soft drinks is considered an equally important factor. Normalization of the child's diet, especially with regard to fat, fiber, fluids, and fruit juices, usually suffices to attain resolution of the diarrhea.

Evaluation of 13CO 2 breath tests for the detection of fructose malabsorption

Breath hydrogen (H 2) studies have made clear that small intestinal absorption of fructose is limited, especially in toddlers. Malabsorption of fructose may be a cause of recurrent abdominal pain and chronic nonspecific diarrhea (toddler's diarrhea). Fructose absorption is facilitated by equimolar doses of glucose and, as we have found, amino acids (especially L-alanine); the mechanism underlying this effect remains unclear. To study fructose absorption in a more direct way, we combined breath H 2 studies with breath 13CO 2 studies. Gastric emptying was studied by using L-glycine-1- 13C in 4 children from 12.1 to 16.0 years of age. After 25 gm of fructose and 27.5 gm of glucose, when given together, gastric emptying was significantly ( p < 0.05) slower than with either sugar alone. In a second series of experiments, 5 children from 12.0 to 15.9 years of age were tested with 25 gm of fructose, alone and with equimolar doses of glucose and L-alanine, and 4 younger children from 3.1 to 6.1 years of age were tested with 2 gm/kg (max 37.5 gm) fructose, alone or with an equimolar dose of L-alanine. All fructose solutions were enriched with 15 mg of D-fructose- 13C-6. In all 9 children, fructose was malabsorbed as judged by breath H 2 increases ≥ 20 ppm, and the addition of glucose or L-alanine resulted in significantly lower breath H 2 increases ( p <- 0.005 for glucose, p <- 0.001 for alanine). In contrast, the addition of alanine or glucose did not change the pattern of breath 13CO 2 excretion in the 5 older children, whereas in the 4 younger children (with relatively higher doses), L-alanine addition resulted in significantly lower increases in breath 13CO 2. In the latter group, for each time point, breath H 2 and 13CO 2 concentrations after fructose were compared with those after fructose plus L-alanine; in 20 out of 24 points, both H 2 and 13CO 2 were higher after fructose. These results suggest that 13CO 2 not only originated from the oxidation of absorbed substrate but also, at least in part, from colonic bacterial metabolism. For the detection or fructose malabsorption—as opposed to, for instance, lactose—the 13CO 2 breath test seems to be of limited value.

Fluid intake and industrial processing in apple juice induced chronic non-specific diarrhoea.

Dietary factors have been shown to contribute to the occurrence or persistence of chronic non-specific diarrhoea (CNSD). Among these are low dietary fat, high fluid consumption, and the consumption of apple juice. Prompted by the clinical impression that freshly pressed and unprocessed ('cloudy') apple juice was less likely to induce diarrhoea than normal, enzymatically processed ('clear') apple juice, both juices were compared in terms of carbohydrate malabsorption, gastric emptying, and effects on defecation patterns. Clear and cloudy apple juice differ in their fibre and non-absorbable monosaccharide and oligosaccharide contents. Ten healthy children aged 3.6 to 5.9 years ingested 10 ml/kg of clear and cloudy apple juice; in five of them it was enriched with 40 mg of [1-13C]-glycine. Clear apple juice resulted in increased (> or = 20 ppm) breath hydrogen excretion in 8/10, compared with 5/10 after cloudy apple juice; peak breath hydrogen was higher in the clear apple juice group (35 (4) and 18 (3) ppm, respectively). Gastric emptying as determined by means of labelled breath carbon dioxide (13CO2) excretion was similar with both juices. In a four week crossover clinical trial 12 children, formerly diagnosed as having CNSD, were given extra clear fluids (excluding fruit juices; > or = 50% over basal consumption), clear apple juice, or cloudy apple juice, for five day periods. Extra fluids and cloudy apple juice did not influence stool frequency and consistency compared with the basal period. In contrast, clear apple juice significantly promoted diarrhoea. It is suggested that, in addition to fructose, the increased availability of non-absorbable monosaccharides and oligosaccharides as a result of the enzymatic processing of apple pulp is an important aetiological factor in apple juice induced CNSD.

Fructose breath hydrogen tests in infants with chronic non-specific diarrhoea

Fructose breath hydrogen tests in infants with chronic non-specific diarrhoea

Fructose breath hydrogen tests in infants with chronic non-specific diarrhoea.

Clear fluids high in fructose (e.g., apple juice) have been incriminated for symptoms of chronic non-specific diarrhoea (CNSD), in particular in children 1-4 years of age. H2 breath tests were performed, after ingestion of fructose (1 g/kg), in 15 patients referred with CNSD and 35 controls. All 15 CNSD children (100%) had breath peak H2 of > or = 20 ppm versus 49% of the 35 controls (P = 0.0005). Median peak H2 in CNSD (90 ppm, range 31-136) was significantly higher than in controls (20 ppm, range 1-139) (P < 0.001). Orocoecal transit time in children with positive tests was similar in both groups. Similarly, median H2 increases during the test period had the same distribution. We demonstrated fructose malabsorption in CNSD, but found a great overlap with the control group. Our results strongly discourage the use of fructose breath H2 tests in children suspected of CNSD. A positive test has no diagnostic value and a negative test has no clinical implications. For clinical practice, we suggest a dietary history and a trial of appropriate measures in infants with chronic nonspecific diarrhoea, instead of performing the fructose H2 breath test.

Oral IgA treatment of chronic non-specific diarrhoea in infants and children

Oral IgA treatment of chronic non-specific diarrhoea in infants and children

Investigation of chronic diarrhoea

Chronic diarrhoea may be best defined as a parental perception of persistently increased looseness and frequency of stools, as this is the problem which presents itself to the paediatrician. A knowledge of the normal patterns of bowel action in children is essential to enable the paediatrician to decide whether true diarrhoea is present. In the infant, up to one bowel action per feed may be regarded as normal, and the consistency may often be semi-liquid. This is particularly so in breast fed infants who tend to have softer, more frequent, less malodorous, and more acidic stools than their bottle-fed counterparts. In the older child, four or more loose stools per day may be considered to be abnormal, though less frequent and markedly loose stools may also be abnormal. At this point, it is convenient to differentiate the problem into one of the following clinical entities: (4 (b) (cl spurious diarrhoea resulting from chronic constipation with overflow incontinence; protracted diarrhoea, associated with failure to thrive or other symptoms; chronic non-specific diarrhoea of infancy or childhood, associated with good growth (often called toddler diarrhoea).

Chronic Nonspecific Diarrhea of Childhood

Chronic Nonspecific Diarrhea of Childhood

Role of juice carbohydrate malabsorption in chronic nonspecific diarrhea in children

Role of juice carbohydrate malabsorption in chronic nonspecific diarrhea in children

Iron Absorption and Iron Deficiency in Infants and Children with Gastrointestinal Diseases

SummaryIron status, iron absorption, and intestinal blood loss were studied in 199 children undergoing diagnostic evaluation for suspected malabsorption. Evaluation of iron status included hematological indices, serum ferritin, and transferrin saturation. Iron absorption was assessed by the increment of serum iron after an oral iron load. Iron deficiency was common among patients affected by malabsorptive states, such as celiac disease (84%), cow's milk intolerance (76%), Crohn's disease (72%), and giardiasis (64%), whereas it was less common among patients with postinfectious enteritis (41%) and chronic nonspecific diarrhea (11%). Intestinal blood loss was seen only in patients with Crohn's disease and cow's milk intolerance, irrespective of iron nutritional status. On the other hand, iron malabsorption was very common, affecting 85–95% of the iron‐deficient patients in all diagnostic groups, except in chronic nonspecific diarrhea. Iron malabsorption was less common among patients with adequate iron nutritional status than in those with iron deficiency. Iron malabsorption appears to play a major role in the pathogenesis of iron deficiency in patients with malabsorption. The iron absorption test shows greater sensitivity as a screening test for upper intestinal malabsorption than the D‐xylose absorption test.

Iron absorption and iron deficiency in infants and children with gastrointestinal diseases.

Iron status, iron absorption, and intestinal blood loss were studied in 199 children undergoing diagnostic evaluation for suspected malabsorption. Evaluation of iron status included hematological indices, serum ferritin, and transferrin saturation. Iron absorption was assessed by the increment of serum iron after an oral iron load. Iron deficiency was common among patients affected by malabsorptive states, such as celiac disease (84%), cow's milk intolerance (76%), Crohn's disease (72%), and giardiasis (64%), whereas it was less common among patients with postinfectious enteritis (41%) and chronic nonspecific diarrhea (11%). Intestinal blood loss was seen only in patients with Crohn's disease and cow's milk intolerance, irrespective of iron nutritional status. On the other hand, iron malabsorption was very common, affecting 85-95% of the iron-deficient patients in all diagnostic groups, except in chronic nonspecific diarrhea. Iron malabsorption was less common among patients with adequate iron nutritional status than in those with iron deficiency. Iron malabsorption appears to play a major role in the pathogenesis of iron deficiency in patients with malabsorption. The iron absorption test shows greater sensitivity as a screening test for upper intestinal malabsorption than the D-xylose absorption test.

Clinical Application of a Simple HPLC Method for the Sugar Intestinal Permeability Test

SummaryA new high pressure liquid chromatography (HPLC) method has been used to measure urinary sugar levels for the intestinal permeability test with cellobiose and mannitol (C/M test). Urinary specimens have been prepared by simple filtration through a Millipore membrane. The method is highly sensitive (minimal detectable concentration of urinary sugars = 0.01 mg/ml) and reproducible (coefficient variation between samples = 0.47% for cellobiose and 0.25% for mannitol). By this method a C/M test has been performed in a large series of gastroenterological patients. High values of mean urinary C/M percentage recovery ratio (C/M%) were found in 30 children with active gluten‐sensitive enteropathy compared with controls (0.42 ± 0.66 versus 0.014 ± 0.005). In 44 treated celiacs and 34 children with chronic nonspecific diarrhea the mean C/M%s were 0.027 ± 0.018 and 0.021 ± 0.012, respectively. The results of this study confirm that the C/M test is a valuable investigation in the diagnostic studies of children with chronic diarrhea. The simple HPLC method described for the determination of urinary sugar levels should allow a wider diffusion of this test.

Clinical Application of a Simple HPLC Method for the Sugar Intestinal Permeability Test

A new high pressure liquid chromatography (HPLC) method has been used to measure urinary sugar levels for the intestinal permeability test with cellobiose and mannitol (C/M test). Urinary specimens have been prepared by simple filtration through a Millipore membrane. The method is highly sensitive (minimal detectable concentration of urinary sugars = 0.01 mg/ml) and reproducible (coefficient variation between samples = 0.47% for cellobiose and 0.25% for mannitol). By this method a C/M test has been performed in a large series of gastroenterological patients. High values of mean urinary C/M percentage recovery ratio (C/M%) were found in 30 children with active gluten-sensitive enteropathy compared with controls (0.42 +/- 0.66 versus 0.014 +/- 0.005). In 44 treated celiacs and 34 children with chronic nonspecific diarrhea the mean C/M%s were 0.027 +/- 0.018 and 0.021 +/- 0.012, respectively. The results of this study confirm that the C/M test is a valuable investigation in the diagnostic studies of children with chronic diarrhea. The simple HPLC method described for the determination of urinary sugar levels should allow a wider diffusion of this test.

Normal Energy Intake Range in Children with Chronic Nonspecific Diarrhea

SummaryAn increase in energy intake often occurs at weaning. The increase may be due partly to prompting by the caregiver to accelerate the child's weight gain and partly motivated by the palatability of common weaning foods. Increased food intakes initiated during weaning and continued into the second year of life may be associated with chronic, nonspecific diarrhea in selected children. An educational project was designed to reduce intakes augmented by either cause. Reductions were achieved by the regulation of energy‐dense foods in the child's diet and reliance on the child's appetite control to determine meal size. The educational intervention was applied prospectively under nonblinded, controlled conditions. Children, 1 to 2 years of age, with chronic nonspecific diarrhea were assigned randomly to either a treatment or control group. Compliance, food consumption, preprandial glycemia, and outdoor activities were reported by the children's mothers in four 7‐day diaries; symptoms related to the children's clinical condition and anthropometric and biochemical indices of nutritional status were noted at the beginning and end of a 7‐month period. Forty‐four of 53 children in the experimental group maintained compliance, and 44 of 47 children in the control group completed the follow‐up. Energy intake decreased significantly by almost one‐third in the experimental group. Growth, skinfold thickness measurements, and outdoor activities were similar between experimental and control groups over the 7‐month period. Diarrheal episodes occurred in 6, 1, and 2 children in the experimental group at 1.5, 3, and 7 months and in 22, 18, and 15 children in the control group, respectively (p &lt; 0.002). Twenty of 32 parameter of clinical status were more advantageous in the experimental group compared to 9 of 32 in the control group in a comparison of the mean values in the two groups at the final examination (p &lt; 0.05). Serum folate (p &lt; 0.001) also was significantly higher in the experimental group. The described intervention appeared to achieve lower energy intakes in a safe and reproducible manner. It may be a useful tool to prevent overeating and control signs and symptoms associated with chronic, nonspecific diarrhea.

Normal Energy Intake Range in Children with Chronic Nonspecific Diarrhea

An increase in energy intake often occurs at weaning. The increase may be due partly to prompting by the caregiver to accelerate the child's weight gain and partly motivated by the palatability of common weaning foods. Increased food intakes initiated during weaning and continued into the second year of life may be associated with chronic, nonspecific diarrhea in selected children. An educational project was designed to reduce intakes augmented by either cause. Reductions were achieved by the regulation of energy-dense foods in the child's diet and reliance on the child's appetite control to determine meal size. The educational intervention was applied prospectively under nonblinded, controlled conditions. Children, 1 to 2 years of age, with chronic nonspecific diarrhea were assigned randomly to either a treatment or control group. Compliance, food consumption, preprandial glycemia, and outdoor activities were reported by the children's mothers in four 7-day diaries; symptoms related to the children's clinical condition and anthropometric and biochemical indices of nutritional status were noted at the beginning and end of a 7-month period. Forty-four of 53 children in the experimental group maintained compliance, and 44 of 47 children in the control group completed the follow-up. Energy intake decreased significantly by almost one-third in the experimental group. Growth, skinfold thickness measurements, and outdoor activities were similar between experimental and control groups over the 7-month period. Diarrheal episodes occurred in 6, 1, and 2 children in the experimental group at 1.5, 3, and 7 months and in 22, 18, and 15 children in the control group, respectively (p less than 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)