Chronic non-specific diarrhea of infancy aka toddler's diarrhea
- Definition: Chronic diarrhea lasting 3-4 weeks in a child between
1-5 years of age, who is active and growing well. Abdominal pain may be
present, but no other problems. May follow a gastroenteritis.
- Normally resolves by age 4
most common cause of chronic diarrhea
- typically the first stool of the day is large and better consistency,
then looser during day.
- No stools usually passed at night.
- The stool
frequency varies between two and ten
- Due to
rapid transit they are malodorous
and often contain undigested food
- Who? Children who
have CNSD are 6 to 58 months of
age (1/2 to 5 years; children ages 11
to 24 months are affected most commonly) and are otherwise in excellent
- Pertinent negatives:
- They do not
exhibit evidence of malabsorption syndrome or enteric infection.
- Weight gain
is typically normal, unless insufficient caloric intake results from dietary
intended to control the diarrhea (eg, dairy restriction).
- Analysis for
enteric pathogens is not revealing.
- after an AGE or other illness where diet is restricted to
mainly oral fluids, especially juices.
- excessive fluid intake
- carbohydrate metabolism
- normally, There is no
evidence of carbohydrate malabsorption, and the
stool pH is greater than 5.5
and negative for reducing substances. Transit time is reduced, but absorption
Occasionally, an identifiable dietary factor contributes to the diarrhea
and carb malabsorption may occur (sorbitol and fructose): capacity of intestine to
absorb fructose is limited, but glucose-dependent fructose co-transport means
that foods with equal amounts of glucose and fructose are better absorbed. IF
excessive fructose>glucose intake, fructose malabsorption occurs.
- Sorbitol is
nonabsorbable and inhibits fructose absorption.
eg, too much fruit juice - excessive sorbitol and fructose leads to
carbohydrate intolerance. Esp apple and pear juice (sorbitol)
- motility disorder:
- persistent immature bowel motility pattern; food transits through
stomach and small bowel too fast (failure to initiate normal postprandial
delayed gastric emptying & persistence of small-bowel fasting motility
- It has been
suggested that affected infants have
increased gastrointestinal motility and that CNSD is a variant of
irritable bowel syndrome (IBS). Indeed, the family history of children who
have CNSD often reveals a sibling or
parent who has IBS.
- low fiber diet: dietary fiber (pectin) important for binding water
to help form solid stools.
- A reduced
fat intake is believed to increase small bowel motility through failure of the
ileum to release inhibitory gastrointestinal hormones.
DDX: important to work up ddx, since many of these are serious...
- infxn: giardia, cryptosporidiosis, bacterial AGE, bacterial overgrowth
- congenital: CF, sucrase-isomaltase deficiency
- immuno: celiac dz, cow-milk sensitive enteropathy, food allergy
- misc: post infectious enteropathy, encopresis, hormone secreting tumors
- iatrogenic: laxatimes, munchausen by proxy
- Ask about the 4F's (fiber, fluid, fat, fruit juices).
of the contributing dietary factors. Response should be in a few days to a couple of weeks.
introduce whole wheat bread and fruits
content of the diet is to 4 to 6 g/kg per day; increase dietary fat to
at least 35-40% of energy intake. Substitution of whole milk for low-fat may
discourage overconsumption of fruit juices (see
Juice and Water)
- restrict fluid intake. No more than 150 cc/kg/d
electrolyte solutions are used for the initial management of children who have
viral gastroenteritis and are mildly or moderately dehydrated but are not
helpful in the management of CNSD.
lactose intolerance develops in approximately 1% of children following viral
gastroenteritis, usually it is a transient phenomenon, resolving after 2 to 4
lactose-free diet is not helpful
in the management of CNSD.
- Loperamide and aspirin have been used to normalize bowel patterns
refractory to dietary therapy but should be discouraged
Referral, if no response after 2 weeks, growth delay, or other
- If consulting, get the following tests: sweat chloride, celiac disease
panel (antigliadin and antiendomysial antibodies), serum albumin, ESR, stool
Sudan III stain for fecal fat.
Keep in mind:
Normally, the intestines preferentially secrete
potassium bicarbonate into the lumen and reabsorb sodium chloride. Because
diarrheal stools are high in in potassium, increased stool output can lead to
depletion of potassium stores.
Baldassano RN, Liacouras CA. Chronic diarrhea: a practical approach
for the pediatrician. Pediatr Clin North Am. 1991;38:667-686
Davidson M, Wasserman R. The irritable colon of childhood (chronic
nonspecific diarrhea syndrome). J Pediatr. 1966;69:1027-1038
Kneepkens CM, Hoekstra JH. Chronic nonspecific diarrhea of childhood:
pathophysiology and management. Pediatr Clin North Am. 1996;43:375-390