Abstinence From Food- Unwarranted Treatment of Chronic Non-Specific Diarrhea of
August 1, 1998
Abstinence From Food- Unwarranted Treatment of Chronic Non-Specific Diarrhea of Childhood
ABSTRACT & COMMENTARY
Synopsis: Children with chronic non-specific diarrhea are often on restricted diets that are deficient in total calories. Change to a normal diet often results in improvement.
Source: Boehm P, et al. Chronic non-specific diarrhea in childhood: How often is it iatrogenic? Acta Paeditr 1998;87:268-271.
Epidemiological data, the appropriateness of the medical approach, the effectiveness of unrestricted diet, and the subsequent course of chronic non-specific diarrhea (CNSD) were evaluated in 20 children, mean age at diagnosis 4.7 years and mean duration of diarrhea 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 diarrhea and increased weight. A telephone interview performed 5.6 years 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 years.
COMMENT BY A. CRAIG HILLEMEIER, MD, FAAP
While there have been many advances in the world of pediatrics during the 1990s, one of them has not been the elimination of chronic non-specific diarrhea in children 6 months to 4 years of age. This group of children grow fine with no indication of malabsorption but persist with frequent loose stools. These sometimes "mucousy" stools often raise the anxiety levels of parents because of the frequent appearance of undigested food products (hence the name peas and carrots diarrhea) and the significant challenge they often pose to carpet cleanliness and toilet training.
While Boehm and colleagues record an experience seen in Italy, it is not altogether dissimilar from a picture often seen throughout the world. They followed 20 children with diagnosis of chronic nonspecific diarrhea for at least two months who did not have cystic fibrosis, celiac disease, stool WBCs, carbohydrate, or fat malabsorption, and had no evidence of bacterial, parasitic, or viral infection. The median age was about 2.5 years and most had a history that sounded like an infectious gastroenteritis at the onset of their symptoms. One of the interesting findings was that 80% of children were maintained on various elimination diets, even though they reported no improvement, and almost half were on such strict diets they were on less than 70% of their recommended caloric intake. Boehm et al found that during a one-week supervised period while on an unrestricted diet that was relatively high caloric, the stool frequency dropped from an average of almost six per day to almost two per day. Boehm et al found at five-year follow-up that all cases of diarrhea had ultimately "sorted themselves out," but half of the mothers had returned to restriction diets periodically when the diarrhea returned even though they continued to report no improvement in symptoms.
Elimination diets probably have little role in chronic diarrhea unless you are treating a specific entity such as celiac disease (wheat free) or lactose intolerance (milk free). It is well accepted that children with chronic diarrhea who are on restricted diets often have improvement in symptoms when placed on a high-fat diet. The tendency to ascribe chronic diarrhea to multiple protein allergies is simply not a good idea and can usually be disproved by a short (4-7 day) dietary restriction. Another excellent point that Boehm et al make is the need that many parents have to blame certain dietary foods for non-specific symptoms such as diarrhea. It is our duty as health care providers to make sure that these children have adequate nutrition to insure growth.
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