Definition.

Diarrhea, defined as increased total daily stool output, is usually associated with increased stool water content (see Chapters 287 and 321). For infants and children, this would result in stool output greater than 10 g/kg/24 hr or more than the adult limit of 200 g/24 hr. Diarrhea lasting longer than 2 wk is considered chronic. Diarrhea results from altered intestinal water and electrolyte transport. The gastrointestinal tract of the infant handles approximately 285 mL/kg/24 hr of fluid (intake plus intestinal secretion) with a stool output of 5-10 g/kg/24 hr. The efficient mechanisms responsible for this absorptive capacity are caused by the function of several transport proteins located at the brush border membrane of the small and large intestine. The transport of electrolytes across the gastrointestinal tract contributes to the overall absorptive process of the small and large intestine. The stool output in infants and children contains approximately, per liter, 20-25 mEq of sodium, 50-70 mEq of potassium, and 20-25 mEq of chloride

INTRALUMINAL FACTORS PANCREATIC DISORDERS Cystic fibrosis Shwachman-Diamond syndrome Johannson-Blizzard syndrome Isolated pancreatic enzyme deficiencies Chronic pancreatitis Pearson syndrome BILE ACID DISORDERS Chronic cholestasis Terminal ileum resection Bacterial overgrowth Chronic use of bile acid sequestrants Primary bile acid malabsorption INTESTINAL DISORDERS Intraluminal osmolarity Carbohydrate malabsorption Congenital and acquired sucrase, lactase deficiencies Congenital and acquired monosaccharide deficiency Excessive carbonated fluid intake Excessive intake of sorbitol, Mg (OH)2, and lactulose

MUCOSAL FACTORS ALTERED INTEGRITY Infections:bacterial, viral, fungal Infestations:parasitic Cow's milk and soy protein intolerance Inflammatory bowel disease (ulcerative colitis, microscopic colitis, Crohn)

ALTERED IMMUNE FUNCTION Autoimmune enteropathy Eosinophilic gastroenteropathy AIDS Combined immunodeficiency syndromes Immunoglobulin A and G deficiencies

ALTERED FUNCTION Defects in C1-/HCO3, Na+/H+, bile acids, acrodermatitis enteropathica, selective folate deficiency, abetalipoproteinemia ALTERED DIGESTIVE FUNCTION Enterokinase deficiency Glucoamylase deficiency ALTERED SURFACE AREA Celiac disease, postgastroenteritis syndrome Microvillus inclusion disease Short bowel syndrome ALTERED SECRETORY FUNCTION Enterotoxin-producing bacteria

INTRALUMINAL FACTORS

MUCOSAL FACTORS Tumors secreting vasoactive peptides ALTERED ANATOMIC STRUCTURES Hirschsprung disease Partial small bowel obstruction

Common Causes of Chronic Diarrhea INFANCY Postgastroenteritis malabsorption syndrome Cow's milk/soy protein intolerance Secondary disaccharidase deficiencies Cystic fibrosis CHILDHOOD Chronic nonspecific diarrhea Secondary disaccharidase deficiencies Giardiasis Postgastroenteritis malabsorption syndrome Celiac disease Cystic fibrosis ADOLESCENCE Irritable bowel syndrome Inflammatory bowel disease Giardiasis Lactose intolerance

Treatment:
y Chronic nonspecific diarrhea o generally presents in well-appearing toddlers between 1 and 3 yr of age (toddler's diarrhea). o The diarrhea is often brown and watery, at times containing undigested food particles.

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If the child's fluid intake is >150 mL/kg/24 hr, fluid intake should be reduced to no more than 90 mL/kg/24 hr. o Parents may note that the child is irritable in the 1st 2 days after the fluid restriction; however, persistence in this approach for several more days results in a decrease in the stool frequency and volume. o If the dietary history suggests that the child is ingesting significant amounts of fruit juices, then the offending juices should be decreased. o Sorbitol, which is a nonabsorbable sugar, is found in apple, pear, and prune juices, and can cause diarrhea in toddlers. o Moreover, apple and pear juices contain higher amounts of fructose in excess of glucose concentration, a feature postulated to cause diarrhea in toddlers. Levels of dietary fat intake may also play a role in chronic diarrhea. If the child's fat intake has been restricted by the parents, then fat intake can be increased to 40% of the total calories per day. If the diarrhea is secondary to carbohydrate intolerance, then a trial period of decreased lactose or sucrose may be initiated. Lactase (LactAid) can be used to aid in the digestion of lactose. If diarrhea persists, a trial of a lactose-free or sucrose-free diet is indicated. Alternatively, breath hydrogen tests can document the presence of lactose or sucrose intolerance. A glucose or lactulose breath hydrogen test can be used for the diagnosis of bacterial overgrowth. If the patient presents with weight loss and the stool examination shows fat, the possibility of chronic diarrhea secondary to a malabsorption syndrome needs to be considered. The most common cause of chronic diarrhea associated with the malabsorption is postgastroenteritis malabsorption syndrome. These patients respond well to a predigested formula. In the event that the patient shows intolerance to oral feeding with a predigested formula such as Pregestimil or Alimentum, nasogastric drip-feeding with an elemental formula should be considered for a period of 34 wk. A patient presenting with suspected small intestinal bacterial overgrowth should undergo evaluation for surgical, medical, and nutritional support. Surgical treatment is indicated if the patient has malrotation or partial small bowel obstruction. Antibiotic therapy is usually initiated with metronidazole in combination with ampicillin or trimethoprim-sulfamethoxazole. Diarrhea caused by Giardia lamblia can be treated with metronidazole or nitazoxanide, whereas Cryptosporidium parvum is treated with nitazoxanide. Patients presenting with secretory diarrhea, especially during the 1st mo of life, need to be considered for nutritional support, because the most likely cause is a congenital defect in transport proteins. In older children with secretory diarrhea, the cause needs to be identified 1st, and therapeutic consideration is directed toward the cause of the secretory diarrhea. o