Toddler diarrhoea and other conditions

Sonny KF ChongConsultant Paediatrician and

GastroenterologistQMHC, Epsom & St Helier NHS Trust.

15 May 2010 (Symposium St Anthony’s Hospital)

Normal Stool Pattern

• 0-6 months• Breast fed Once every 1-2 weeks to

about 12 times/day. pH =5.0• Formula fed 1 to 3 stools per day • (range 1-7) pH=7.0• 6 mo -1 yr 2 to 3 per day (range 1 to 7). After

1 yr Formed; like adult stools.

Definition of diarrhoea

• Excessive loss of water and electrolytes in stool.

• Question: what is excessive?

• “What one sees depends on where one stands”.

Diarrhoea

• A. Physician- faecal losses- illness (acute and /or chronic)

• B. Parent- true losses

• - stool pattern differs from normal

• - single watery stool - anxiety

• C. “Technical” = > 30 gms of stool/ kg/day

Definition

• Loose frequent foul smelling stools

• Without Failure to Thrive

• No organic pathology

• Commonest presentation

Major causes of chronic diarrhoea in small infants

• Milk and soy protein intolerance (CMPI Savihlati Arch Dis Child 1985)

• Protracted infectious enteritis (viral)

• Munchausen syndrome by proxy

• Hirschprung disease

• Autoimmune enteropathy

• Microvillus inclusion disease

• Congenital transport defects

• Nutrient malabsorption

• Intractable diarrhoea of infancy

Major causes of chronic diarrhoea in toddlers

• Irritable colon (chronic nonspecific diarrhoea)• Protracted viral enteritis• Coeliac disease • Giardiasis• Carbohydrate intolerance, and Sucrase isomaltase

deficiency• CIBD• Tumours (secretory diarrhoea)

Chronic diarrhoea in school-aged children

• Chronic Inflammatory bowel disease (Crohn disease, Ulcerative colitis)

• Primary acquired lactase deficiency (lactase levels fall between 3 to 5 years)

• Constipation with encopresis (chronic soiling occurs so frequently, unable to control, while most with true diarrhoea can usually control)

Toddler Diarrhoea

• Also known as Chronic non-specific diarrhoea• or Irritable bowel syndrome of childhood• Often preceded by infantile colic• May be associated with constipation• Self-limiting in 90% of cases• High incidence of functional bowel disorder

or IBS in parents

Toddler diarrhoea

• Initially, thought abnormalities of intestinal secretion or increase in prostaglandin.

• More likely, motility disorder with decreased postprandial transit time. Resultant delivery of undigested nutrients in colon (irritated colon). IBS variant (Davidson. J Pediatr 1966).

General Management of Chronic nonspecific diarrhoea of childhood.

• 1. Assure parents of benign nature.• 2. Emphasize “normal variation”• 3. “Clear by 39 months.” (Davidson et al 1966).• 4. Non-irritating diet (avoid all spicy, greasy

foods, and all caffeine-containing beverages). Fibre, fluid, fat, fruit (juice) avoidance. Kneepens, Hoekstra et al. Ped Clin NA 1996).

• 5. Medication: Loperamide (opiate analogue effect on gut motility).

Differential diagnosis

• Infection- exclude parasitic infestation (giardiasis, cryptosporidia).

• Osmotic diarrhoea and carbohydrate intolerance.

• Encopresis

• Drug induced

Differential diagnosis

• Coeliac disease

• Cystic fibrosis, exocrine pancreatic insufficiency (Shwachman syndrome)

• Dietary causes: Food Allergy( a pathologic immune mediated process to an offending antigen), Food intolerance (an abnormal physiologic response to an ingested food or additive)

Differential diagnosis

• Secretory diarrhoea: Factitious diarrhoea, Munchausen syndrome by proxy (toxin eg Magnesium)

• Rare causes: Zollinger-Ellison syndrome, Vernier-Morrison syndrome (VIPoma, gut secreting tumours).

Screening tests in diarrhoea

• Stool clinitest Carbohydrate Stool pH< 5.5 Malabsorption-usually

prox small bowel injury• Stool occult blood Inflammation, colonic• Stool (Wright’s) Inflammation, colonic

• Stool (Sudan stain) gross steatorrhea, pancreatic, or biliary

• Stool antitrypsin Protein losing enteropathy

• Serum carotene diffuse SB injury

Carbohydrate malabsorption

• Most common cause of Osmotic diarrhoea (“solute trap”) - Lactose intolerance:

• Secondary lactose intolerance following gastroenteritis (post GE enteropathy).

• Lactose Hydrogen breath test

• Carbohydrate intolerance: excessive intake of high carbohydrate beverages (fructose, sorbitol). Faecal Na low.

Osmotic diarrhoea

• Excessive fluid intake, with an unbalanced diet of low residue, high carbohydrate, low fat foods.

• Young children who drink 40 oz of juices.

• Sorbitol, nonabsorbable carbohydrate in pears, prunes, plums, sweet cherries; also especially sugar-free products, candy, and apple and pear juice, diabetic jams, sugar-free gum

Carbohydrate Malabsorption• Consider Sucrase-isomaltase (SI) deficiency

in Toddler diarrhoea with normal growth. • Older children and adolescents with Irritable

Bowel Syndrome (IBS) who 1) have histories dating to an early age. 2) have diarrhoea predominant IBS. 3) Resistant to usual dietary interventions or antispasmodic antimotility agents.

Congenital SI deficiency-diagnosis

• Stool reducing sugar >0.5%, stool pH 5-6.0, after hydrolysis with 0.1N HCl

• Sucrose breath hydrogen test

• UGI endoscopy and SB biopsy for disaccharidases (completely absent sucrase activity and reduced isomaltase activity to 10% of normal).

Sucrase-isomaltase deficiency

• Treatment

• Strict sucrose-free low starch diet.

• Reduce wheat and potatoes (high amylopectin content).

• Treat with baker’s yeast (saccharomyces cerevisiae) or concentrated yeast derived sucrase (Sucraid by Orphan Med, Minn).

Coeliac disease

• In Ireland, 1 in 600 births, while in N. America 1 in 6000.

• Serum anti-gliadin and anti-endomysial antibody highly sensitive and specific. More recently, tissue transglutaminase antibody.

• SB biopsy gold standard.

Giardia

• Closely mimics Chronic non-specific diarrhoea.

• Day care centres or crowded institutions.

• Secondary lactose intolerance.

• Stool exam 50% normal!

• String test or

• SB biopsy with duodenal aspirate

Drug-induced diarrhoea

• Antibiotics-alter bowel flora (penicillins, cephalosporins). Pseudomembranous colitis

• Prokinetic drugs- metoclopramide, cisapride, erythromycin, laxative abuse (Munchausen syndrome).

• Clostridium difficile. Treat with

metronidazole,vancomycin, lactobacillus GG.

Soiling/Encopresis

• Encopresis involuntary passage of loose stools. In the toddler or older child, often presents as diarrhoea and is almost always caused by severe constipation.

• Rectal exam or an abdominal KUB.

• If impacted, Fletcher’s enema

followed by a stool softener (mineral oil bid).

Food Hypersensitivity

• Incidence is less than 5%.

• Gastrointestinal presentation- acute vomiting and diarrhoea, chronic diarrhoea

• Foods: egg, milk, peanut, wheat, soy , nuts, fish, and shell fish account for 90-95%.

• Immunologic mechanisms: IgE mediated, and non IgE mediated.

Diagnosis

• Skin tests-generally not helpful. Need food challenge test.

• RAST is reliable (unless has high IgE or bad eczema).

• Small bowel biopsy.

• Food challenges (open or blind).

Food Hypersensitivity

• Non-IgE mediated:

• Protein enteropathies: cow milk, soy, others

• Gluten sensitive enteropathy

• Milk colitis

• Eosinophilic gastroenteropathy

Secretory diarrhoea

• Tumours ( neuroblastomas, ganglioneuromas, pancreatic tumours that secrete VIP (vasoactive intestinal polypeptide) in continual diarrhoea rather than intermittent, and in whom diarrhoea continues even after feeding is stopped.

• Measure Stool electrolytes (Na and K).

Management of chronic non-specific diarrhoea of childhood.

• What should be done?• 6 week exclusion diet with help of a dietician.• Trial of CMP/egg-free diet ie. no diary or eggs (5-

10% respond). Fluids reduce in fructose/juice content.

• Trial of metronidazole.• Reassurance/Loperamide.• Follow-up.

What do you think?