COMMENTARY

A Toddler With Tummy Troubles

Dana M.H. Dykes, MD; William F. Balistreri, MD

Disclosures

May 25, 2012

In This Article

What Else Could This Be?

An entity called chronic nonspecific diarrhea (CNSD), or "toddler's diarrhea," has been described that has traditionally been thought to be a malabsorptive process.[10] Symptom onset is typically at 6-30 months of age. Patients with CNSD often are worse after ingestion of juices and have looser stools throughout the course of the day. Unlike our patient, however, reduced weight and height gain are not typically associated with these symptoms, and these children usually improve on their own. CNSD would not be an appropriate consideration as a diagnosis for Madeline, given the concerns about her growth.

Madeline's chronic diarrhea and weight loss suggest a maldigestive or malabsorptive process causing difficulties digesting or absorbing food. Maldigestion often stems from a congenital or acquired loss of digestive enzymes or bile acids required to digest food. Although primary enzyme deficiencies causing maldigestion are rare, postinfectious and inflammatory conditions, such as milk protein allergy, can damage intestinal mucosa, making digestion and absorption of ingested food difficult.

Madeline's primary care provider thought that her symptoms suggested a malabsorptive disorder and considered some tests to pursue as a next step while she was waiting to be seen by a specialist. The primary care provider considered some causes of fat and protein malabsorption associated with pancreatic insufficiency, such as cystic fibrosis and Shwachman-Diamond syndrome, but in the absence of greasy stools chose to investigate a more common explanation first: celiac disease.

Madeline's pediatrician was concerned about celiac disease because as many as 1 child in 100 is affected, and celiac disease frequently presents during the toddler years.[11] Madeline's blood work, obtained before her referral, had indicated a mild iron-deficiency anemia. The primary care provider discussed with the family that even though her celiac testing results on a commercially available assay were normal, celiac disease must be ruled out given her anemia, poor growth, diarrhea, and abdominal distention. The family is confused about what this means and asks you how they should proceed to evaluate for possible celiac disease.

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