Description

• Benign chronic diarrhea in a toddler or a preschool child who appears healthy and is normally active and who is growing, without evidence of systemic illness, infection, malabsorption, or malnutrition
• Also known as chronic nonspecific diarrhea of childhood, toddler’s diarrhea, and irritable bowel of childhood

Epidemiology

• The typical age is 12 to 36 months, but range is 6 months to 5 years.
• Prevalence 6–7%

Risk Factors

General Prevention

• Limit the consumption and delay the introduction of sorbitol or fructose-rich fruit juices to the infant diet.
• In the treatment of acute gastroenteritis, parents should be instructed to give an oral rehydration solution (ORS) and resume normal feeding early, avoiding diet restrictions.
• Avoid restrictive diets that may cause caloric deprivation.

Pathophysiology

• Carbohydrate malabsorption
  • Diarrhea is often preceded by acute gastroenteritis or other viral infection that results in dietary restrictions. Increased oral fluids, including juices, are used to compensate for stool losses and to prevent dehydration.
  • Capacity of the small intestine to absorb fructose is limited. Foods that contain equivalent amounts of fructose and glucose are more readily absorbed because of the additive effect of a glucose-dependent fructose cotransport mechanism.
  • Excessive consumption of juices high in sorbitol (which inhibits fructose absorption) and those with a high fructose-to-glucose ratio (e.g., apple juice) result in fructose malabsorption and increased intraluminal gas caused by fermentation. The end result is abdominal distension, excessive flatulence, and diarrhea.
  • Colonic function: possibly, disruption of colonic ability to ferment unabsorbed carbohydrates into short-chain fatty acids (SCFAs), which maintain colonic function and prevent colon-based diarrhea
• Disturbed motility: short mouth-to-anus transit time
  • Persistence of immature bowel motility pattern; failure of initiation of normal postprandial delayed gastric emptying
  • Low-fat meals. Meals with high dietary fat delay gastric emptying.
  • Excess fluid intake. Infant’s colon already operates in high efficiency (in children, higher volume of fluids reach the cecum). Excessive fluids can lead to diarrhea.
  • Low-fiber diet. Dietary fiber serves as a bulking agent.
  • Excessive fecal bile acids. Rapid transit resulting in excess conjugated bile salt entering the colon. Bacterial degradation produces unconjugated bile salts, which decrease net water absorption in the colon.

Etiology

• Nutritional factors: excessive consumption of fruit juice; high-carbohydrate, low-fat, and low-fiber diet
• Disordered intestinal motility (i.e., variant of irritable bowel syndrome of infancy) with rapid transit