Chronic diarrhea in infant

Question 1

DDx of chronic diarrhea in infant

Answer 1

1. infection (Giardia lamblia) - Hx of similar D/Hx of acute G.E.
2. Secondary lactose intolerance (post infective rota virus)
3. Food allergy or intolerance (specific food: Cow’s milk protein stool showing alpha1-antitrypsin (AT), eosinophil cationic protein (ECP), immunoglobulin (Ig) A, and cow’s milk-specific IgA antibodies
4. Functional (Toddler’s) diarrhea - commonest, see bits of vegetable food
5. Coeliac Disease - rare
6. CF
7. Immunodeficiency (Campylobacter or Salmonella)

Question 2

Clinical Features of Cow’s Milk Protein Intolerance

Answer 2

• GIT: vomiting, diarrhea, colic and constipation
• Respiratory: wheeze, rhinitis, asthma
• Dermatological: atopic dermatitis, eczema, urticaria
• Behavioral: irritability, crying and milk refusal

Question 3

HPI: GIT

Answer 3

Analysis of bowel habits:
- when started? Duration (>2 weeks) and frequency >3 per day
- amount? consistency? colour? does it contain blood/mucous?
odor? is it difficult to flush?
- preceded by acute GE?

associated vomiting?
abdominal pain?
what about appetite?
increase in tummy size?

Question 4

HPI: General survey questions

Answer 4

wt loss
fever
activity

Question 5

HPI: Nutritional History in detail

Answer 5

• was breastfed or formula? For how long?
• Time of weaning? Is it complete or partial weaning?
• Recent dietary changes e.g. introduction of formula milk? cereal, bread?
• Time of start to give him mix food? And what type of food you start with?
• Did you give by mouth or through NGT?
• Did you give special type of food?
• how many times per day?
• had allergy to any type of food?

Question 6

HPI: Analysis of weight loss

Answer 6

• when did it become a concern that his weight is not increasing?
• how did you know he is not gaining weight?
• is this drop in weight gradually or rapid drop? Over how much time?
• Any intervention done for that? Does he change feeding pattern after that? Any response for that?
• do you have a chart for his growth previously?
• any ff-up for his weight?
• any dietitian involved?

Question 7

HPI: MSS

Answer 7

• skin changes?
• joint pain?

Question 8

HPI: Respiratory

Answer 8

• cough?
• musical sound?
• difficulty of breathing?

Question 9

HPI: CNS

Answer 9

any abnormal movement?

Question 10

Past Medical History

Answer 10

• medical/surgical
• travel history
• hospital admission? or surgical admission?
• birth history?
  -Drug history?

Question 11

Allergic History

Answer 11

• to food, to drug
• any skin change in face?
• any seasonal symptoms?

Question 12

Family History

Answer 12

• similar condition
• atopy, celiac, CF, IBD

Question 13

Red flag features in chronic diarrhea

Answer 13

• FTT
• blood stool
• severe frequent diarrhea
• systemic upset

Question 14

Definition: Cow’s milk protein intolerance

Answer 14

a clinical syndrome resulting from sensitization to one or more proteins in cow’s milk

Question 15

Diagnosis of protein milk intolerance

Answer 15

• clinical manifestation and history
• blood tests to r/o other causes: CBC, S/E, albumin, LFT, celiac screen (tissue TG + IgA), inflammatomatory markers
• SPT and IgE RAST can help to r/o allergy
  histologic confirmation if suspected colitis or enteropathy
• sweat test/fecal elastase - for CF
• Duodenal biopsy

Question 16

Stool analysis

Answer 16

• alpha1-antitrypsin (AT), eosinophil cationic protein (ECP), immunoglobuin (Ig) A, and cow’s milk specific IgA antibodies
• send for microbial C/S, virology and reducing substances

Question 17

Management of cow’s milk intolerance

Answer 17

Milk exclusion with milk substitute for 2-4 weeks
- hydrolysed protein formula
soya based milk for those more than 6 months because of phytoestrogen in soya milk
- Amino acid-base formula in case of multiple food allergy e.g. soya, egg, wheat and peanute
- in breast feeding mothers - should exclude cow milk from diet
- dietitian - monitoring using serial weight measurement
- prognosis is good resolve by 3rd birthday