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Extent and duration of small intestinal mucosal injury in intractable diarrhea of infancy
Insights
Intractable diarrhea of infancy (IDI) often causes prolonged small intestinal injury. Early and extended use of elemental diets (ED) is crucial for recovery, even with persistent histologic and enzymatic changes.
Area of Science:
- Pediatric Gastroenterology
- Gastrointestinal Pathology
Background:
- Intractable diarrhea of infancy (IDI) presents a significant clinical challenge.
- Early onset diarrhea (before 3 months) can lead to prolonged symptoms and investigations.
Purpose of the Study:
- To assess the extent and duration of small intestinal mucosal injury in infants with IDI.
- To evaluate the efficacy of elemental diets in managing IDI.
Main Methods:
- Small bowel biopsies were performed on 30 infants with IDI.
- Histologic grading of mucosal injury and measurement of disaccharidase activities were conducted.
- Follow-up biopsies and growth data were analyzed.
Main Results:
- All 30 infants showed significant mucosal injury, with 11 exhibiting grade IV atrophy.
- Disaccharidase activities, particularly lactase, were diminished, correlating with atrophy severity.
- Seventy percent of repeat biopsies showed persistent injury for up to six months.
Conclusions:
- Prolonged small intestinal mucosal injury is common in IDI.
- Elemental diets (ED), sometimes including parenteral nutrition (PN), are effective management tools.
- Early initiation and extended duration of ED are recommended due to persistent histologic and enzymatic changes.
Abstract:
Thirty infants with intractable diarrhea of infancy (IDI) underwent small bowel biopsies in order to determine the extent and duration of small intestinal mucosal injury. The onset of the persistent diarrhea occurred prior to 3 months of age and continued for an average of 48 days prior to investigation. In 18 cases, no associated entities were found. Mucosal injury was invariably found in all 30 infants: grade IV injury in 11, grade III in eight, grade II in nine, and grade I atrophy in one. Disaccharidase activities were diminished and corresponded to the degree of atrophy. Lactase activity was diminished to a greater extent than sucrase and maltase. Significant, persistent mucosal injury existed for an average of six months in 16 of the 23 (70%) repeat biopsies. All infants were given an elemental diet (ED). Twelve of the 30 infants required parenteral nutrition (PN). These infants were gradually advanced to an oral elemental diet and maintained on this diet until histologic findings and disaccharidase levels were normal. Eighteen infants were fed and maintained on an elemental diet by mouth from time of admission until normal histologic findings and disaccharidases were found. No mortality occurred during management and follow-up. Twenty-two of the 28 infants in whom follow-up growth data were available excelled in weight and height velocity. The data suggest that prolonged injury to the small intestinal mucosa is a common finding in many cases of intractable diarrhea of infancy. Elemental diets should be started early in the course of protracted diarrhea in young infants, and may need to be continued for several months since histologic and enzymatic changes of the small intestine may persist for extended periods.