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Chronic Nonspecific Diarrhea

Diarrhea is considered chronic when it persists for longer than 3 weeks. Chronic nonspecific diarrhea (CNSD) presents in toddlers between 18 months and 3 years of age, with frequent, large, watery stools in the absence of physical or laboratory signs of malabsorption or infection and without effect on growth or development. Children have 3 to 6 large, watery bowel movements daily. The diarrhea spontaneously resolves in 90% of children.

Fluid intake exceeds the absorptive capacity of the intestinal tract. Malabsorption of carbohydrates (sucrose, fructose, sorbitol) in fruit juices contributes.

Presentation. CNSD presents between 18 months and 3 years, with 3-6 large, loose, watery stools per day for more than 3 weeks. Stools may have been loose throughout infancy, especially in breast fed infants.

Stools may have been formed until a recent episode of gastroenteritis or other acute illness; or the stools may have become diarrheal.

Stooling is most frequent in the morning and does not occur during sleep. There is an absence of nausea, vomiting, abdominal pain, flatulence, blood, fever, anorexia, weight loss, or poor growth.

Differential Diagnosis

The differential diagnosis of chronic diarrhea in the 6-to 36-month-old child also includes disaccharidase deficiency, protein intolerance, enteric infection, and malabsorption.

Lactase deficiency

Lactase deficiency may cause diarrhea associated with milk ingestion. In toddlers it is usually is caused by gastroenteritis.

Lactose intolerance caused by acute viral gastroenteritis.

Congenital sucrase-isomaltase deficiency also is rare, producing symptoms when sucrose-containing formula or foods are

Disaccharidase deficiency can be confirmed by eliminating the specific carbohydrate or by breath hydrogen analysis after ingestion of lactose or sucrose.

Milk-induced colitis occurs in infants younger than 1 year of age who typically appear healthy but lose blood in their stool after ingesting milk protein. In

Treatment of CNSD

Fluid intake is gradually reduced to less than 100 mL/kg/day. Water is substituted for juice to reduce the child's interest in drinking. Switching from the

Fat intake is increased to 4 g/kg/day by adding whole milk to the diet. If lactose intolerance is

Butter, margarine, or vegetable oil are liberally added to

Dietary fiber can be increased by consumption of fresh fruits and vegetables or

Removing dairy products to avoid lactose malabsorption may leave the child's diet with insufficient calories. Gluten-free diets and diets that restrict other proteins, such as cow milk protein, also