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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 3  |  Page : 115-117

A case of infantile diarrhoea


Department of Paediatrics, MGM Medical College, Navi Mumbai, Maharashtra, India

Date of Submission14-May-2021
Date of Decision25-May-2021
Date of Acceptance31-May-2021
Date of Web Publication30-Jun-2021

Correspondence Address:
Dr. Ankita Choudhary
Department of Pediatrics, Medical College, Navi Mumbai - 410 206, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpai.jpai_7_21

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  Abstract 


Introduction: Diarrhoea is the second most common cause of deaths among children less than 5 years of age (15%) and half of the cases occur from 6 to 12 months of age. Deaths among hospitalised children, are mostly among the malnurished, demanding urgent diagnostic, therapeutic and nutritional intervention. Aim: To sensitise practicing pediatricians about such double dangers as high index of suspicion helps in early diagnosis and prompt intervention. Case: Eight month old baby presented with acute gastroenteritis (AGE) for 2 days. Exclusively breast-ded upto 6 monts of age. The child was treated with WHO recommended standard of care for AD such as oral rehydration solution (ORS), Zinc and usual complimentary feeds, including formula milk which the baby was on for last 2 months. Did show some initial improvemnt but worsened by week end; with large explossive stools, abdominal distension and perianal excoriation. Managed as secondary lactose intolerance post-viral AGE. Cow's milk protein allergy (CMPA) was thought unlikely in absence of any history of diarrhoea despite top feeds. Continued Zinc and complimentary feeding, but replaced formula milk with soy based feed. Th baby improved over next 4 days, started gaining weight and was discharged. Conclusion: Formula-fed infants with secondary lactose intolerance, when changed to lactose-free diet, may have early resolution of diarrhea and less scope of treatment failure. Being cheaper, Soy is considered a better alternative for short-term use in selected cases in developing countries as ours.

Keywords: Infantile diarrhea, lactose-free, soy-based formula


How to cite this article:
Choudhary A, Mohanty N. A case of infantile diarrhoea. J Pediatr Assoc India 2020;9:115-7

How to cite this URL:
Choudhary A, Mohanty N. A case of infantile diarrhoea. J Pediatr Assoc India [serial online] 2020 [cited 2022 Dec 9];9:115-7. Available from: http://www.jpai.in//text.asp?2020/9/3/115/320124




  Introduction Top


Acute diarrhea in children under 2 years of age is conventionally known as infantile diarrhea. 50% of diarrhea among under-5 children occurs between 6 months and 1 year of age. Over 70% are of viral etiology, with rotavirus being the most common.[1] Diarrhea is the second most common cause of mortality among under-5 children (15%) in India, next to pneumonia (17%). Death usually occurs due to dehydration and/or dyselectrolytemia, peculiarly occurring among the malnourished children in developing countries. Continued feeding is as vital as rehydration with reduced osmolar oral rehydration solution (RORS), as per the WHO, irrespective of age and etiology.[2] Diarrhea in children is also a major factor for parenteral anxiety and concern and accounted for loss in their daily wage. If diarrhea persisted beyond 14 days, it is termed chronic diarrhea, deserving detail etiological investigation and appropriate management, particularly focusing on nutritional aspects.[3]


  Case Top


Eight month old girl child was brought to the pediatric outpatient department, with complaints of loose stools, 8–10 times in a day for the last 2 days. There was no visible blood in stool. The child vomited 2–3 times in a day and had mild fever, coryza, cough, and passing urine normally. She was exclusively breast-fed up to 6 months of age. Complimentary feeding included formula milk from bottle and home-based soft diet. She had been put on cow's milk one week back. On examination, her weight was 7.5 Kg (7 Kg 2 weeks back); length was 70 centi-metres (CM) and mid-arm circumference (MAC) was 11 CM. Pulse 90 per minute, regular, of good volume. BP was 86/60 mm Hg and capillary refill time (CRT) was less than 2 seconds. She found afebrile, alert, but irritable and thirsty. She had mild pallor, slightly dry mouth, and sunken eyes, but the skin pinch was going back readily.

Diagnosis

Acute watery diarrhea, no dehydration.

Management

She was put on RORS at the rate of 10 ml/kg in sips after each purge (about 75 ml) back home. She was advised to continue usual feeds from family pot, including formula she is already on. At the same time, home-based fluids such as vegetable soup, rice gruel, kanji, yoghurt, coconut water, and plain water were allowed. Oral zinc solution 20 mg twice daily was also started. Vomiting had stopped after a stat dose of 4 mg syrup ondansetron on reporting to emergency room as she was not retaining ORS. Once stabilized, she was sent home and advised to return after 3 days or if diarrhea worsens or the child became unresponsive any time.

The baby was brought back after 5 days. Mother said that although stool frequency had come down in the first 2–3 days, it now increased to 10–12 times in the last 24 h, with passage of watery and explosive stool with a lot of gas. She used to have intermittent abdominal distension and relieved after motions.However, accepting feeds and low osmolar ORS (LORS). On examination, her weight had reduced to 7.2 Kg; was irritable but had no dehydration. There was mild abdominal distension, but no tenderness, organomegaly or any free fluid in abdomen. Borborygmi was present. There was perianal excoriation. There was no rash, urticaria or wheezing. She was diagnosed as secondary lactose intolerance following viral acute gastroenteritis (AGE).

Investigations

Stool pH 4.5, reducing substance (Cliitest) ++, RBC 2-4 per high power field (HPF), pus cells 0-3 per HPF, no Giardia lamblia. Hydrogen breath test could not be done. Hb 10.5 Gm/dL, TLC 4.500/mm3 (P47, L56, M5, E2); Na+ 135, K+ 5.5, RBS 110 mg/dL. Supported presumptive diagnosis on clinical ground..

Course

Parents were counseled about the condition and outcome. They were advised to continue LORS, Zinc and usual feeds she was on. On reviewing after another 3 days, as the baby was still passing 8–10 explosive stools per day, her formula milk was substituted with soy-based formula, 4–6 feeds per day, 90–120 ml in each feed. In the next 3–4 days, her stool frequency decreased to 2–3 per day and consistency changed. Perianal excoriation had also subsided. Her appetite had improved and weight increased to 7.8 kg. The child was active and playful. Parents advised to continue soy formula for another 2–3 weeks in addition to home-based complimentary feeds, zinc, and calcium supplementation and report every week to follow-up clinic.


  Discussion Top


In acute viral diarrhea, particularly in rotavirus diarrhea, the enterocytes lining the intestinal villi get damaged. They are no longer able to provide the enzyme lactase, which is normally secreted for digestion and absorption of lactose present in milk. Such undigested lactose now passes down to lower intestine and colon, where it is split by gut flora to lactic acid, hydrogen (picked up by breath analyzer, after 2 h of milk feed), and carbon dioxide. These lead to osmotic diarrhoea, acidic stool (Low pH, peri-anal excoriation) and explossive purging due to watery stool, accompanying gases e.g. Carbon dioxide, Hydrogen; also absorbed and expired through lungs. Young, yet immature enterocytes lack in lactase activity which exacerbates lactose malabsorption and increased diarrheal episodes till the villi get fully epithelialized. This process starts from crypts and progress to reach the tips of micro-villi over 2 to 3 weeks.[3],[4] Dietary nucleotide supplementation is said to enhance such repair process in animal studies. Since the intestinal surface is involved in a patchy manner, there is no absolute lactase deficiency, warranting to completely with-hold milk in diet altogether or dilute it. However, curd can decrease lactose load, besides having lactobacilli (probiotics), also useful in early resolution of diarrhea.

In the instant case, parents gave no history of diarrhea or blood in stool ever earlier, although the child had been on formula milk from 6 months onward and cow's milk of late. Hence, possibility of cow's milk protein allergy (CMPA) remained most unlikely. Even in CMPA-induced diarrhea, children do tolerate soy formula. However, the NASPGHAN and ESPGHAN recommend soy only after 6 months of age.[3] However, the Middle East Consensus group do not agree and insist for extensively hydrolyzed formula (eHF), only irrespective of age and Amino ACID formula where severe anaphylactic reactions are apprehended.[5] Further, it is claimed that allergens such as β-conglycinin and glycinin (7S and 11S globulins) present in soy infant formula (SIF) do cross-react with cow's milk protein-induced IgE in some, resulting in adverse reaction in 10%–15% of infants reported from the US[6] but hardly reported from India. The increased content of aluminum was also a cause of concern earlier but taken care of now. It also thought that certain isoflavones in soy could exert hormone as the effect on reproductive system but no strong evidence of any adverse effects on endocrine (thyroid), reproductive, and immune functions and neurocognitive development in children on SIF.[7] Being cheaper than eHF, soy is a better alternative for short-term use in selected cases, accepted in resource-scarce countries as ours.


  Conclusion Top


Reviewing studies evaluating effects of reducing or avoiding lactose in young children (<5 years) with diarrhea on duration and/or severity of the illness, it was concluded that lactose-free products might reduce the duration of the diarrhea by an average of 18 h, as compared with lactose-containing formula.[8] A systemic review suggested that lactose-free milk, if proven effective, will have a significant impact on the morbidity of formula-fed infants with AGE in developing countries.[9] Young children with acute diarrhea, who are not predominantly breast-fed, when change to a lactose-free diet, may result in earlier resolution of acute diarrhea and reduced incidence of treatment failure.[10]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hart CA, Cunlife NA, Nakagomi OD. “Diarrhoea Caused by Viruses,” in Manson's Tropical Diseases. In: Cook GC, Zumla AL, editors. 22nd ed. Philadelphia, PA, USA: Saunders Elsevier; 2009. p. 815-24.  Back to cited text no. 1
    
2.
World Health Organization. Clinical Management of Acute Diarrhoea: WHO/UNICEF Joint Statement. Geveva; World Health Organization: 2004. Available fom: https://apps.who.int/iris/handle/10665/68627. [Last accessed on 2021 May 14].   Back to cited text no. 2
    
3.
Guarino A, Ashkenazi S, Gendrel D, Lo Vecchio A, Shamir R, Szajewska H, et al. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition/European Society for Pediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe: Update 2014. J Pediatr Gastroenterol Nutr 2014;59:132-52.  Back to cited text no. 3
    
4.
Kay MH, Porto AF. Secondary Lactose Intolerance. The Cleveland Clinic, Cleveland. Greenwich: OH and Yale University/Greenwich Hospital; 2012.  Back to cited text no. 4
    
5.
Vandenplas Y, Abuabat A, Al-Hammadi S, Aly GS, Miqdady MS, Shaaban SY, et al. Middle East consensus statement on the prevention, diagnosis, and management of cow's milk protein allergy. Pediatr Gastroenterol Hepatol Nutr 2014;17:61-73.  Back to cited text no. 5
    
6.
Rozenfeld P, Docena GH, Añón MC, Fossati CA. Detection and identification of a soy protein component that cross-reacts with caseins from cow's milk. Clin Exp Immunol 2002;130:49-58.  Back to cited text no. 6
    
7.
Hüser S, Guth S, Kulling SE. Effects of isoflavones on breast tissue and the thyroid hormone system in humans: A comprehensive safety evaluation. Arch Toxicol 2018;92:2703-48.  Back to cited text no. 7
    
8.
Nabulsi M, Yazbeck N, Charafeddine F. Lactose-free milk for infants with acute gastroenteritis in a developing country: Study protocol for a randomized controlled trial. Trials 2015;16:46.  Back to cited text no. 8
    
9.
MacGillivray S, Fahey T, McGuire W. Lactose avoidance for young children with acute diarrhoea. Cochrane Database Syst Rev 2013;2013:CD005433. doi: 10.1002/14651858.CD005433.pub2.  Back to cited text no. 9
    
10.
Saunders N, Friedman JN. Lactose avoidance for young children with acute diarrhea. Paediatr Child Health 2014;19:529-30.  Back to cited text no. 10
    




 

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