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Chronic Diarrhoea in Infants and Children: Approaching and Managing the Problem

  • Pediatric Gastroenterology (SA Saeed and K Sandberg, Section Editors)
  • Published:
Current Treatment Options in Pediatrics Aims and scope Submit manuscript

Abstract

Purpose of review

Chronic diarrhoea, defined as loose and more frequent motions continuing for longer than 4 weeks, is a common presenting symptom in infants and children. While this can be the presentation of a significant underlying disease process, it can also be benign or self-resolving. This review serves to highlight the range of conditions that can manifest with chronic diarrhoea, while emphasising approaches to assessment and management.

Recent findings

Increasing recognition of chronic diarrhoea in the context of immunodeficiency, especially those that feature gut inflammation, has changed the approach and management of these conditions. Similarly, the understanding of the aetiology and pathogenesis of various types of congenital diarrhoea (typically presenting in infancy with severe course) have advanced in recent years along with new genetic discoveries, leading to new approaches. New management options are also being considered for conditions such as antibiotic-associated diarrhoea and lymphangiectasia.

Summary

Increasing recognition of the role of critical factors such as diet, genetic risks, and disruptions to the intestinal microbiota has resulted in exciting new approaches to some of the conditions that can present with chronic diarrhoea in childhood.

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References and Recommended Reading

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  1. Schiller LR, Pardi DS, Sellin JH. Chronic diarrhea: diagnosis and management. Clin Gastroenterol Hepatol. 2017;15:182.

    Article  Google Scholar 

  2. DuPont H. Persistent diarrhea: a clinical review. JAMA. 2016;315:2712–23.

    Article  CAS  Google Scholar 

  3. Kaiser L, Surawicz CM. Infectious causes of chronic diarrhoea. Best Pract Res Clin Gastroenterol. 2012;26:563–71.

    Article  Google Scholar 

  4. Einarsson E, Ma’ayeh S, Svärd SG. An up-date on Giardia and giardiasis. Curr Opin Microbiol. 2016;34:47–52.

    Article  Google Scholar 

  5. Fink MY, Singer SM. The intersection of immune responses, microbiota, and pathogenesis in giardiasis. Trends Parasitol. 2017;33:901–13.

    Article  CAS  Google Scholar 

  6. Leung AKC, Leung AAM, Wong AHC, Sergi CM, JKM K. Giardiasis: an overview. Recent Patents Inflamm Allergy Drug Discov. 2019;13:134–143.

    Article  CAS  Google Scholar 

  7. Espenhain L, Riess M, Müller L, Colombe S, Ethelberg S, Litrup E, et al. Cross-border outbreak of Yersinia enterocolitica O3 associated with imported fresh spinach, Sweden and Denmark, March 2019. Euro Surveill. 2019;24(24).

  8. Strydom H, Wang J, Paine S, Dyet K, Cullen K, Wright J. Evaluating sub-typing methods for pathogenic Yersinia enterocolitica to support outbreak investigations in New Zealand. Epidemiol Infect. 2019;147:e186.

    Article  CAS  Google Scholar 

  9. Ochoa TJ, Salazar-Lindo E, Cleary TG. Management of children with infection-associated persistent diarrhea. Semin Pediatr Infect Dis. 2004;15:229.

    Article  Google Scholar 

  10. Bernaola Aponte G, Bada Mancilla CA, Carreazo Pariasca NY, Rojas Galarza RA. Probiotics for treating persistent diarrhoea in children. Cochrane Database Syst Rev. 2010;(11):CD007401 Systematic review evaluating probiotics for AAD.

  11. •• Thiagarajah JR, Kamin DS, Acra S, Goldsmith JD, Roland JT, Lencer WI, et al. Advances in evaluation of chronic diarrhea in infants. Gastroenterology. 2018;154:2045–2059.e6 Clear and focused overview of these important conditions, emphasising pathogenesis, assessment, and management aspects.

    Article  Google Scholar 

  12. Nowak-Węgrzyn A, Katz Y, Mehr SS, Koletzko S. Non-IgE-mediated gastrointestinal food allergy. J Allergy Clin Immunol. 2015;135:1114–24.

    Article  Google Scholar 

  13. Lee WI, Chen CC, Jaing TH, Ou LS, Hsueh C, Huang JL. A nationwide study of severe and protracted diarrhoea in patients with primary immunodeficiency diseases. Sci Rep. 2017;7:3669.

    Article  Google Scholar 

  14. Akkelle BS, Tutar E, Volkan B, Sengul OK, Ozen A, Celikel CA, et al. Gastrointestinal manifestations in children with primary immunodeficiencies: single center: 12 years experience. Dig Dis. 2019;37:45–52.

    Article  Google Scholar 

  15. •• Uhlig HH, Schwerd T, Koletzko S, Shah N, Kammermeier J, Elkadri A, et al. The diagnostic approach to monogenic very early onset inflammatory bowel disease. Gastroenterology. 2014;147:990–1007.e3. Important review of VEO-IBD and investigation approach.

    Article  Google Scholar 

  16. Lebwohl B, Sanders DS, Green PHR. Coeliac disease. Lancet. 2018;391(10115):70–81.

    Article  Google Scholar 

  17. Kho A, Whitehead M, Day AS. Coeliac disease in children in Christchurch, New Zealand: presentation and patterns from 2000-2010. World J Clin Pediatr. 2015;4:148–54.

    Article  Google Scholar 

  18. Pekki H, Kurppa K, Mäki M, Huhtala H, Sievänen H, Laurila K, et al. Predictors and significance of incomplete mucosal recovery in celiac disease after 1 year on a gluten-free diet. Am J Gastroenterol. 2015;110:1078–85.

    Article  CAS  Google Scholar 

  19. Bannister EG, Cameron DJ, Ng J, Chow CW, Oliver MR, Alex G, et al. Can celiac serology alone be used as a marker of duodenal mucosal recovery in children with celiac disease on a gluten-free diet? Am J Gastroenterol. 2014;109:1478–83.

    Article  CAS  Google Scholar 

  20. Alhassan E, Yadav A, Kelly CP, Mukherjee R. Novel nondietary therapies for celiac disease. Cell Mol Gastroenterol Hepatol. 2019;8:335–345. Overview of emerging therapies for celiac disease.

    Article  Google Scholar 

  21. ImmusanT discontinues phase 2 clinical trial for Nexvax2® in patients with celiac disease. http://www.immusant.com/ImmusanT%20Nexvax2%20P2%20-%2025Jun19%20Final.pdf. Accessed 13 Oct 2019.

  22. Lemberg DA, Day AS. Crohn disease and ulcerative colitis in children: an update for 2014. J Paediatr Child Health. 2015;51:266–70.

    Article  Google Scholar 

  23. Critch J, Day AS, Otley A, King-Moore C, Teitelbaum JE, Shashidhar H, et al. Use of enteral nutrition for the control of intestinal inflammation in pediatric Crohn disease. J Pediatr Gastroenterol Nutr. 2012;54:298–305.

    Article  Google Scholar 

  24. • Levine A, Wine E, Assa A, Sigall Boneh R, Shaoul R, Kori M, et al. Crohn’s disease exclusion diet plus partial enteral nutrition induces sustained remission in a randomized controlled trial. Gastroenterology. 2019;157:440–450.e8 First formal evaluation of this new treatment approach.

    Article  Google Scholar 

  25. • Svolos V, Hansen R, Nichols B, Quince C, Ijaz UZ, Papadopoulou RT, et al. Treatment of active Crohn’s disease with an ordinary food-based diet that replicates exclusive enteral nutrition. Gastroenterology. 2019;156:1354–1367.e6. First report of this novel food-based approach to management.

    Article  Google Scholar 

  26. •• Mitchell H, Porter J, Gibson PR, Barrett J, Garg M. Review article: implementation of a diet low in FODMAPs for patients with irritable bowel syndrome-directions for future research. Aliment Pharmacol Ther. 2019;49:124–39 Overview of low FODMAP diet approaches.

    Article  Google Scholar 

  27. Chumpitazi BP, Cope JL, Hollister EB, Tsai CM, McMeans AR, Luna RA, et al. Randomised clinical trial: gut microbiome biomarkers are associated with clinical response to a low FODMAP diet in children with the irritable bowel syndrome. Aliment Pharmacol Ther. 2015;42:418–27.

    Article  CAS  Google Scholar 

  28. Brown SC, Whelan K, Gearry RB, Day AS. Low FODMAP diet in children and adolescents with functional bowel disorder: a clinical case note review. J Gastroenterol Hepatol Open. 2019. https://doi.org/10.1002/jgh3.12231.

  29. Benninga MA, Faure C, Hyman PE, St James Roberts I, Schechter NL, Nurko S. Childhood functional gastrointestinal disorders: neonate/toddler. Gastroenterology. 2016;150:1443–55.e2.

    Article  Google Scholar 

  30. Zeevenhooven J, Koppen IJ, Benninga MA. The new Rome IV criteria for functional gastrointestinal disorders in infants and toddlers. Pediatr Gastroenterol Hepatol Nutr. 2017;20:1–13.

    Article  Google Scholar 

  31. Burdet C, Nguyen TT, Duval X, Ferreira S, Andremont A, Guedj J, et al. Impact of antibiotic gut exposure on the temporal changes in microbiome diversity. Antimicrob Agents Chemother. 2019;63:e00820–19.

  32. Noor A, Krilov LR. Clostridium difficile infection in children. Pediatr Ann. 2018;47:e359-e365. Abdullatif VN, Noymer A. Clostridium difficile infection: an emerging cause of death in the twenty-first century. Biodemography Soc biol. 2016;62:198-207. An outline of the rising impact of this pathogen.

    Article  Google Scholar 

  33. Suárez-Bode L, Barrón R, Pérez JL, Mena A. Increasing prevalence of the epidemic ribotype 106 in healthcare facility-associated and community-associated Clostridioides difficile infection. Anaerobe. 2019;55:124–9.

    Article  Google Scholar 

  34. Goldenberg JZ, Lytvyn L, Steurich J, Parkin P, Mahant S, Johnston BC. Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database Syst Rev. 2015;(12):CD004827. Cochrane review of this topic.

  35. Pai S, Aliyu SH, Enoch DA, Karas JA. Five years experience of Clostridium difficile infection in children at a UK tertiary hospital: proposed criteria for diagnosis and management. PLoS One. 2012;7:e51728.

    Article  CAS  Google Scholar 

  36. Saha S, Khanna S. Management of Clostridioides difficile colitis: insights for the gastroenterologist. Ther Adv Gastroenterol. 2019;12:1756284819847651.

    Article  Google Scholar 

  37. Cammarota G, Gallo A, Ianiro G, Montalto M. Emerging drugs for the treatment of Clostridium difficile. Expert Opin Emerg Drugs. 2019;24:17–28.

    Article  CAS  Google Scholar 

  38. • Surawicz CM, Brandt LJ, Binion DG, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108:478–98 North American guideline to treatment of this infection.

    Article  CAS  Google Scholar 

  39. • Debast SB, Bauer MP, Kuijper EJ, European Society of Clinical Microbiology and Infectious Diseases. European Society of Clinical Microbiology and Infectious Diseases: update of the treatment guidance document for Clostridium difficile infection. Clin Microbiol Infect. 2014;20(Suppl 2):1–26 European guideline to treatment of this infection.

    Article  CAS  Google Scholar 

  40. Chen B, Avinashi V, Dobson S. Fecal microbiota transplantation for recurrent clostridium difficile infection in children. J Inf Secur. 2017;74(Suppl 1):S120–7.

    Google Scholar 

  41. https://www.fda.gov/vaccines-blood-biologics/safety-availability-biologics/important-safety-alert-regarding-use-fecal-microbiota-transplantation-and-risk-serious-adverse. Accessed 13 Oct 2019.

  42. Capurso G, Traini M, Piciucchi M, Signoretti M, Arcidiacono PG. Exocrine pancreatic insufficiency: prevalence, diagnosis, and management. Clin Exp Gastroenterol. 2019;12:129–39.

    Article  Google Scholar 

  43. Uc A, Fishman DS. Pancreatic disorders. Pediatr Clin N Am. 2017;64:685–706.

    Article  Google Scholar 

  44. Von der Weid P-Y, Day AS. Pediatric lymphatic development and intestinal lymphangiectasia. In: Kuipers E, editor. Encyclopedia of gastroenterology. second ed: Elsevier; 2020;158–169. https://doi.org/10.1016/B978-0-12-801238-3.66051-8.

    Google Scholar 

  45. • Ozeki M, Hori T, Kanda K, Kawamoto N, Ibuka T, Miyazaki T, et al. Everolimus for primary intestinal lymphangiectasia with protein-losing enteropathy. Pediatrics. 2016;137:e20152562 Report of clinical experience illustrating potential benefits of this novel therapy.

    Article  Google Scholar 

  46. Abraham BP, Sellin JH. Drug-induced, factitious, & idiopathic diarrhoea. Best Pract Res Clin Gastroenterol. 2012;26:633–48.

    Article  Google Scholar 

  47. Shelton JH, Santa Ana CA, Thompson DR, Emmett M, Fordtran JS. Factitious diarrhea induced by stimulant laxatives: accuracy of diagnosis by a clinical reference laboratory using thin layer chromatography. Clin Chem. 2007;53:85–90.

    Article  CAS  Google Scholar 

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Correspondence to Andrew S. Day MB, ChB, MD, FRACP.

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Dr. Day reports personal fees from Janssen, personal fees from Sanofi and personal fees from AbbVie.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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Day, A.S. Chronic Diarrhoea in Infants and Children: Approaching and Managing the Problem. Curr Treat Options Peds 6, 1–11 (2020). https://doi.org/10.1007/s40746-020-00187-3

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