Functional Diarrhea in Toddlers

(Chronic Nonspecic Diarrhea)

32

Ernesto Guiraldes and Jos Luis Roessler

Denition and Epidemiology

Functional diarrhea in toddlers or chronic
nonspecific diarrhea (CNSD) is a frequent reason for consultation to ambulatory pediatrics
and pediatric gastroenterology, being the leading cause of chronic diarrhea in otherwise well
children, 13 years of age, from an industrialized country [16]. It seems to predominate in
middle and upper socioeconomic strata although
its exact prevalence in different regions of the
world is not known. By definition, CNSD occurs
without underlying, preexistent nutrient malabsorption [6].
This chapter focuses on CNSD in toddlers and
older infants and excludes the protracted (intractable) and deteriorating diarrheal syndrome,
evolving from an acute diarrheal episode, and
whose incidence in Western countries has sharply
declined in more recent decades. This latter
entity, pathophysiologically related to malnutrition
and to protracted or overlapping (and often multiple) gastrointestinal infections leading to pro-

E. Guiraldes, M.D. (*)

Pontificia Universidad Catlica de Chile
and Universidad Mayor, El Bosque Sur 827,
Providencia, 7510328, Santiago, Chile
e-mail: eguirald@puc.cl
J.L. Roessler, M.D.
Pediatric Gastroenterology Division, Pediatrics
Department, Hospital Flix Bulnes, Santiago, Chile

longed dehydration, malabsorption, and wasting,

is still an important cause of secondary malnutrition and diarrheal mortality in the developing
world [7, 8].

Clinical Presentation
The consensus committee Rome III has classified
CNSD within the functional digestive disorders
of infancy and childhood and defined it as follows: CNSD is defined by daily painless
recurrent passage of three or more large unformed
stools for four or more weeks with onset in
infancy or preschool years. There is no evidence
for failure-to-thrive if the diet has adequate calories. The child appears unperturbed by the loose
stools, and the symptom resolves spontaneously
by school age [6]. The Rome III diagnostic criteria proper [6] are described below, in the section Diagnosis.
The diagnosis of CNSD should come immediately to mind in all patients 1236 months of age,
who look healthy, well nourished, and active and
have a pattern of intermittent or nearly constant
runny stools containing recognizable undigested
vegetable matter [5]. As Hoekstra perceptively
adds: Every pediatrician knows the tableau
vivant of extremely worried parents around a
sparkling, healthy looking child who appears to
be unaware of all the commotion [5]. Often
CNSD has begun following a viral gastroenteritis. When instructed, rather vaguely, to use

C. Faure et al. (eds.), Pediatric Neurogastroenterology: Gastrointestinal Motility

and Functional Disorders in Children, Clinical Gastroenterology,
DOI 10.1007/978-1-60761-709-9_32, Springer Science+Business Media New York 2013

355

E. Guiraldes and J.L. Roessler

356

plenty of clear fluids, in order to prevent dehydration, parents offer recreational clear liquids
time and again with the misguided belief that
these constitute a physiological therapy and thus
start a vicious cycle of ongoing diarrhea. Periods
of improvement in stool characteristics seem to
occur rather randomly while relapses may also
coincide with infections (mostly upper respiratory) and other causes of biopsychosocial stress.

Pathophysiology
Given the obvious difficulty in performing prospective intervention studies on CNSD and the
ethical constraints to such research, most data
pertaining to this entity is retrospective (and circumstantial) and basically points to the pathogenic mechanisms discussed below.
In most cases, the mechanism of diarrhea
appears, convincingly, to be related to excessive
intake of fluids, particularly those with a high osmolarity, such as soft drinks and fruit juices, as well as
products (and supplements) that contain fructose or
sorbitol [35, 9]. The latter is a nonabsorbable alcohol sweetener which, when taken in certain amounts,
can induce osmotic diarrhea in like fashion an
excess of fructose does. Several authors have
reported positive (abnormal) breath hydrogen tests
after intake of fruit juices rich in fructose content,
by children [1012]. It has been suggested that in
patients with CNSD, the aforementioned products
generate hypermotility, a concept that is in accordance with experimental studies. A pathogenic relationship exists, too, between CNSD and the
ingestion of a diet low in fat [2, 4, 5, 9], which is
plausible, as fat in the diet induces a physiological
slowing of intestinal transit.
Hoekstra et al. [12] have suggested that, in apple
juices, in addition to fructose, the increased presence of nonabsorbable sugars resulting from the
enzymatic processing of apple pulp is an important
etiological factor in CNSD. The same group has
discouraged the use of fructose breath tests in children suspected of CNSD because of the significant
overlapping distribution of results in the control
group, which would preclude any meaningful
classification of abnormal vs. normal groups [12].
Lebenthal-Bendor et al. [13] studied toddlers and

infants given formulae containing modified food

starch (acetylated distarch phosphate) and found
that this regime increased breath hydrogen and produced loose stools and, if given together with sorbitol and fructose, manifest diarrhea developed.
The limited research that has been carried out
on motility and CNSD suggests that intestinal
motility is disturbed in children with CNSD [14]
although the available evidence does not actually
prove that this is the primary mechanism of disease. Most clinicians agree that in CNSD there
is a significantly shortened time in mouth-to-anus
transit [5], which would be one of the explanations for the characteristic presence of noticeable
undigested vegetable material in feces. Most
likely this results from a reduced colonic transit
time. In children with CNSD, food may fail to
interrupt the migratory motor complex (MMC:
the intestinal housekeeper, a periodic series of
physiologically excitatory myoelectric and
related contractile activity) [14], perhaps owing
to an immature gut motor development.
It is not generally well recognized that the
water content of normally looking stools is
7075 %, while in watery stools this will be 90 %.
This small increase in water content can thus
make all the difference in the parental perception
of health and disease [5]. In CNSD, this increase
in stool water content does not entail a true malabsorptive mechanism and can be rightfully considered a cosmetic disorder of the stools. When
the anomalous dietary patterns are corrected and
the childs diet is normalized, the typical result is
a sustained return to normal stools [26, 9].

Diagnosis
The diagnostic criteria according to the Rome III
consensus [6] are as follows.
For more than 4 weeks, daily painless, recurrent passage of three or more large, unformed
stools, in addition to all of these characteristics:
1. Onset of symptoms begins between 6 and
36 months of age.
2. Passage of stools occurs during waking
hours.
3. There is no failure to thrive if caloric intake is
adequate.

32 Functional Diarrhea in Toddlers (Chronic Nonspecific Diarrhea)

Although CNSD was described several

decades ago and has recently been validated
by committees of experts [6, 9], the fact is that
in general pediatric practice, this is a diagnosis that often is mislabeled. Yet, the typical
clinical and dietary history of toddler diarrhea,
when properly elicited, should allow the practitioner to make a prompt diagnosis with minimal inconveniences and costs for the patient
and family and ideally with a minimum of
laboratory tests. However, the relative ease of
diagnosis and simplicity of treatment of this
condition are suspicious and not convincing
enough to some physicians seeking a more
complex pathophysiological rationale or a
more organically based explanation.
Therefore, it is not uncommon that CNSD is
omitted in the differential diagnosis of children with chronic or intermittent diarrhea, and
the typical symptom complex is often labeled
as lactose intolerance or other enzymatic malfunction, intestinal immaturity, food allergy,
enteroparasitosis, small bowel bacterial overgrowth syndrome, or other diagnosispopular or trendy for each geographical region or
historical period [15]. These tentative diagnoses are characteristically followed by the prescription of prolonged and equally
unsubstantiated dietary regimes [15] that are
sometimes highly costly as well as by trials of
a panoply of medications, including antibiotics, antispasmodics, or whichever product is
in vogue.
While it is common in certain places that
every child with chronic diarrhea is referred to a
pediatric gastroenterologist, CNSD can be
promptly diagnosed and treated by a proactive
general practitioner or general pediatrician. The
evaluation of children with chronic diarrhea
requires a complete clinical history and a sound
physical examination [6]. Factors that may cause
or exacerbate diarrhea, such as diet, antibiotics,
products with laxative effects, and past enteric
infections, should be investigated. Dietary factors (already commented) are the mainstay of the
history and the subsequent diagnostic rationale.
When laboratory tests are performed, these
should reveal no abnormalities and be consistent
with a normal nutritional and absorptive status

357

[6]. It is suggested that some alternative conditions, such as giardiasis, cryptosporidiosis,

Clostridium difficile infection, and celiac disease
(CD), be ruled out [6]. The latter does often
cause a visible deterioration of the patients
nutritional status so it is not usually a differential
diagnosis that comes to the clinicians mind
faced to CNSD. However, it should be kept in
mind that the nutritional and anthropometric
consequences of CD may not be fully evident in
the short term and that in some cases, this entity
does not behave typically in the pediatric age
range and presents in a mild fashion.

Treatment
In the absence of warning signs, the sound management of chronic nonspecific diarrhea should be
based on the immediate prescription of a normal
dietary regime, with a drastic reduction in the
excessive fluid intake and the suppression of hyperosmolar and carbonated drinks and industrial juices
mentioned above [5, 6]. It has also been suggested
that frequent intake of cold fluids and ingestion of
food between meals be avoided, in order to prevent
a disruption on the MMC and intestinal hypermotility. A normal proportion of fat should be restored
in the diet. The use of antibiotics, antidiarrheal
medications, and elimination diets has no rational
basis or therapeutic advantages and should thus be
discouraged. Parents should be given advice and
support in what regards the mechanisms and prognosis of CNSD [6] since they are typically confused
and concerned at the persistence of symptoms and
the lack of apparent improvement on the childs
stool patterns. It is particularly important to avoid
iatrogenic consequences, manifested mainly in the
abuse of highly restrictive diets, which may cause
nutritional deficiencies in the child and domestic
disruption within the family.

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