Chronic non-specific diarrhoea.

Recurrent, unexplained diarrhoea is the most common intestinal complaint in children aged 6 months to 3 years. We studied 27 consecutive children with this complaint and followed them up until the age of 5 years. Diarrhoea began at the mean age of 9 months (range 4 to 16 months) and resolved in 21 children by 3 years of age. Twelve children had had infantile colic earlier. In six patients diarrhoea was caused by food allergy (cows'' milk allergy and allergy to fresh vegetables). Episodes of diarrhoea persisted in four of these six. Twenty one children had unexplained diarrhoea: this resolved in 19. Nutritional deficiencies were rare; only one child had iron deficiency. Relative weights of the children were significantly lower at 2 years than at 1 year of age. At 5 years of age six of the children continued to have episodes of diarrhoea, and abdominal pains, headaches, and atopy occurred more commonly than in the general population. We suggest that there are two major subgroups among children with recurrent diarrhoea--children with food allergy and those who react to environmental stresses with a variety of somatic symptoms.     

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

The effect of orally administered immunoglobulin (IgAbulin^R) on chronic non-specific diarrhoea of infancy was studied in seven children, median age 26 (21-36) months and duration of diarrhoea 32 (18-84) weeks. Routine laboratory tests for malabsorption and small bowel biopsies were taken in all children before and after 3 weeks of IgAbulin^R treatment. The biopsy specimens were analysed with regard to histopathology, electronmicroscopy, immunohistochemistry and microbiology. The number of stools decreased from a median of 4.0 (3.0-5.0) to 1.5 (1.0-3.5) ( p < 0.05) stools per day over the study period.     

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 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. Similary, 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.Conclusion 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.     

Apple juice,fructose, and chronic nonspecific diarrhoea

Apple juice contains fructose and sorbitol, substances that have been shown to be incompletely absorbed by most people. As this might have clinical consequences, especially in young children, we investigated the absorption of the carbohydrate content of apple juice in apple juice consuming toddlers with chronic nonspecific diarrhoea as compared to controls, using the breath hydrogen (H₂) test. Incomplete absorption of the carbohydrates from 250 ml of apple juice, as indicated by a maximum breath H₂ increase of 20 parts per million (ppm), was found in all nine patients (mean ±SEM 57±8 ppm), and in five out of eight controls (22±7 ppm) (P<0.01). Six patients were retested with apple juice enriched with glucose, which is known to improve fructose absorption. The maximum breath H₂ increase as well as the area under the breath H₂ curve decreased significantly. It was thus estimated that fructose accounted for 80% of the incomplete absorption and sorbitol for 20%. Elimination of apple juice from the diets of the nine patients resulted in normalisation of both the frequency and the consistency of the stools. Incomplete absorption of the carbohydrates, particularly fructose, from apple juice seems to be quite common, and may contribute to chronic diarrhoea in young children.Abbreviations H₂ hydrogen - ppm parts per million     

Raised urinary secretory IgA in chronic diarrhoea.

Secretory IgA outputs in urine have been measured in 24 malnourished Gambian children who had been admitted to hospital with chronic diarrhoea and in 43 children from a rural Gambian village. Village children of poor nutritional state (less than or equal to 74% weight for age compared with the National Center for Health Statistics reference curve) had secretory IgA outputs that were only one third of those of better nourished individuals. In contrast, the patients with chronic diarrhoea had secretory IgA outputs that were significantly raised compared with village children, regardless of nutritional state. These results demonstrate that secretory IgA production in the urinary tract can be stimulated by intestinal disease, suggesting that malnourished children are able to mount a response to mucosal infection and supporting the hypothesis of a common secretory immune system.     

Prevalence and treatment of giardiasis in chronic diarrhoea and malnutrition.

To determine the prevalence of giardiasis in Gambian children with chronic diarrhoea and to assess their response to treatment, 31 children with chronic diarrhoea and malnutrition were investigated for giardiasis using a combination of serology (specific antigiardia IgM antibody) and microscopy of faeces and jejunal biopsy specimens. Fourteen of 31 children with chronic diarrhoea had giardiasis compared with only four of 33 healthy age and sex matched control children. Four of 15 malnourished children without diarrhoea were giardia positive. Twenty-three children with chronic diarrhoea were reinvestigated after treatment with metronidazole; giardia was found in 11 of them. These results show that giardia is highly prevalent in children with chronic diarrhoea and malnutrition and that the infection does not respond to standard therapeutic measures.     

Helicobacter pylori in Gambian children with chronic diarrhoea and malnutrition.

Infection with Helicobacter pylori (formerly Campylobacter pylori) was studied by measuring antibody titres to H pylori in Gambian children. Serological evidence of infection was found in 12 of 82 (15%) infants aged less than 20 months; this increased to 62 of 135 (46%) in those aged 40-60 months. Positive serology was found in 41 of 77 (53%) infants with chronic diarrhoea and malnutrition (mean age 19 months, range 5-36) compared with 18 of 70 (26%) of age matched healthy controls and nearly a quarter (12/49, 24%) of age matched undernourished (marasmic) subjects. These data show that infection with H pylori is common in the Gambia and that in infancy this infection is associated with chronic diarrhoea and malnutrition.     

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.     

Investigation of chronic diarrhoea in infancy

Diarrhoea in infants and young children is defined as > 200 g/day of stools, and occurs when there is an imbalance between intestinal fluids absorption and secretion. This may be caused by either a decreased absorption (osmotic diarrhoea) or an increased secretion (secretory diarrhoea). Chronic diarrhoea defines intestinal loss of water and electrolytes with increased stool frequency, reduced consistency and larger volume over more than 14 days. This disorder in children shows a wide range of aetiologies depending on the age. The knowledge of common and rare aetiologies is important to optimize the diagnostic approach. A stepwise approach, starting with a comprehensive history, physical examination, inspection and collection of stool samples, helps to devise appropriate diagnostic and therapeutic management. In this article we discuss the pathophysiology, aetiology and possible approach to chronic diarrhoea in infancy.     

Blood and bone-marrow patterns in chronic diarrhoea in children

Summary One hundred and five children suffering from chronic diarrhoea were investigated for the type of anaemia and marrow morphology. Anaemia was mild in 30%, moderate in 65% and severe in 5% patients. Red cell morphology showed evidence of iron deficiency in 55% children and macrocytosis in 25%. The erythropoiesis was normoblastic, purely iron deficient and frankly megaloblastic in about an equal number of patients. Dimorphic anaemia was seen in 18 patients. The relationship between the type of deficiency anaemia observed and the aetiological factor is discussed. From the Departments of Haematology and Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, 11.     

Sigmoidoscopy in children with chronic mucoid diarrhoea in rural St. Lucia

Sixty-nine per cent of a group of children with chronic mucoid diarrhoea who would not normally be seen in a tertiary health care facility had endoscopically demonstrable abnormality in the distal bowel, especially in the distal rectum. Sigmoidoscopy and punch biopsy of the rectum are safe procedures which can be undertaken in primary health care facilities. The inclusion of such investigations will facilitate the elucidation of the aetiology of chronic mucoid diarrhoea.     

Plasma zinc levels in children with chronic diarrhoea

We measured the plasma zinc concentration in a group of children with chronic diarrhoea. Fifteen patients with untreated coeliac disease had a mean plasma zinc level significantly lower than that of healthy children (69μg/dl vs 96μg/dl). In patients with chronic post-enteritic diarrhoea (n=70) the mean plasma zinc level was in the normal range (100μg/dl). The latter result suggests that our country a secondary zine deficiency is not a feature of chronic post-enteritic diarrhoea.     

Apple juice. An unappreciated cause of chronic diarrhea

Chronic nonspecific diarrhea (CNSD) remains a common pediatric problem. Previous reports have suggested disordered small intestinal motility, food intolerances, dietary fat restriction, and excessive fluid consumption as possible contributory factors. We have recently encountered a subset of children with CNSD in whom nonexcessive apple juice intake seemed to cause their diarrhea. In five subjects, ingestion of 240 mL of apple juice disclosed evidence of significant carbohydrate malabsorption by breath-hydrogen testing and resulted in diarrhea. Withdrawal of apple juice from the diets of these subjects was curative in all cases. Before embarking on an expensive and time-consuming evaluation for CNSD in otherwise healthy children, a brief restriction of apple juice intake may be warranted.