2025 – PAGE 332 – INFECTIOUS DISEASES

CHRONIC DIARRHEA

(DOUBLE TAKE) GIARDIA

Giardia presents with intermittent watery diarrhea that has been going on for weeks. This may be accompanied by abdominal distension and may eventually cause malabsorption. Diagnose with direct fluorescent antibody testing (DFA) or ELISA, and then treat with metronidazole.

PEARLS: History may include a camping trip or a child in daycare.

CHRONIC NONSPECIFIC DIARRHEA (AKA TODDLER’S DIARRHEA)

Look for undigested food! Chronic nonspecific diarrhea (AKA toddler’s diarrhea) may present as normal stools in the morning followed by loose stool as the day progresses. The child will otherwise be healthy. It may be due to excessive carbohydrate intake. Provide reassurance and ask the family to decrease carbohydrate intake (especially juices) and INCREASE fat and fiber in the diet. They should also try to avoid very hot or cold foods.

(DOUBLE TAKE) FOOD PROTEIN INDUCED ENTEROPATHY

Food Protein Induced Enteropathy is NOT IgE mediated. It can cause problems from birth, but often presents as FAILURE TO THRIVE (FTT) after months of already being on cow’s milk formula, or less commonly from exposure to other allergenic foods. Celiac disease is a member of this group. SYMPTOMS include diarrhea ± emesis, malabsorption, anemia and failure to thrive while on formula, but not on clears or non-whole-protein-containing formulas. This CAN occur in breastfed babies, but only if enough whole protein from the mom’s diet enters the breast milk. It usually presents after switching from breastfeeding to formula. Forty percent of children are also sensitive to soy.

• DIAGNOSIS: Usually made by history, however for if you suspect celiac disease then get an upper endoscopy and duodenal biopsy to look for villous atrophy. Don’t get an allergy skin test.
• TREATMENT: If the mom is breastfeeding, try asking mom to stop drinking milk products. If that doesn’t work, change to HYDROLYSATE formula (formula containing HYDROLYZED cow’s milk proteins) or to an AMINO ACID DERIVED FORMULA. Typically resolves once the GI tract matures, although some food sensitivities may remain.
• MNEMONIC: It’s so much easier if you just call it “FORMULA INDUCED Enteropathy.” SYMPTOMS include diarrhea ± emesis and possibly BLOODY stool or flecks while on formula, but not on clears or non-whole-protein-containing formulas.
• PEARL: Think of “enter” as it’s entering the bowel cells. The wall is location of the problem. The dysfunctional bowel wall interferes with normal absorption, so this can present as failure to thrive.
• PEARL: Less severe than Food Protein Induced Enterocolitis (FPIES). Children with Food Protein Enteropathy usually have less vomiting, no bloody diarrhea and less severe reactions to the problem foods.