Pediatric Annals

EDITORIAL 

A Pediatrician's View: Infantile Diarrhea: Etiologies and Newer Treatment

Milton I Levine, MD

Abstract

So many times in my career as a pediatrician I have looked back and realized that I started practice in the "dark ages" of medicine. Then, almost suddenly, there was a wave of new knowledge. This has occurred in practically every area of the sciences, including cardiology, hematology, genetics, immunology, endocrinology, neurology, and gastroenterology.

When I was an intern at the New York Nursery and Child's Hospital in 1928, infantile diarrhea was one of the most serious problems faced in the first year o life. Several facts were known at the time. One was that there were many more cases of diarrhea among formula-fed infants than there were among those who were breast fed. Accordingly, there were breast milk centers in New York City, founded by Mrs. William Randolph Hearst, where mothers with excess breast milk could sell it for 350 an ounce to be provided free for poor families.

Infantile diarrhea was often associated with infections in various parts of the body, especially the nasopharynx. As a matter of fact, many of the infants we examined and treated for severe enteritis had congested throats and reddened eardrums.

Then, one of the foremost pediatricians of the day, Dr. William McKim Marriott, Professor of Pediatrics at Washington University in St. Louis, became interested in "alimentary intoxication." Dr. Marriott was an excellent biochemist, who, while at Johns Hopkins between 1914 and 1917, performed considerable research on acidosis in alimentary intoxication.

In the mid- 1920s Dr. Marriott stated that infections of the middle ear might be responsible for the severe diarrhea of infancy. So strong was his influence that in many pediatric institutions, including our own, mastoidectomies were performed on all of the infants so suffering, in spite of their debilitation. This surgical approach was being performed during my internship. It was given up after a few years.

In the decades that followed, antibiotics were discovered, the sciences of bacteriology, virology and immunology were greatly improved, breast feeding was encouraged, and new improved proprietary formulas appeared in the stores. The mortality from diarrhea decreased markedly but there were still numerous cases.

For a special reason I must repeat the following incident which I related in a previous issue of Pediatric Annals.

In the late- 1950s, one of our Residents in Pediatrics at New York Hospital told me that he was considering going into a new area - pediatric gastroenterology. What did I think of it?

I advised him against it. "Any well-trained pediatrician should be able to successfully handle the digestive disorders of infants and children," I told him.

He thought it over and decided against my advice. To my knowledge he became the first pediatric gastroenterologist in the US and, with those that followed, opened up a new and important area in pediatrics. I have often regretted my lack of foresight.

I was reminded once again of this incident, for this former Pediatric Resident at New York Hospital, Dr. Murray Davidson is now one of the foremost pediatric gastroenterologists and is the Guest Editor for the present symposium.

Dr. Davidson is Professor of Pediatrics of the State University of New York at Stony Brook, and Chief of the Division of Gastroenterology and Nutrition of the Schneider Children's Hospital of the Long Island Jewish-Hillside Medical Center.

Readers of this issue of Pediatric Annals covering the subject of infantile and childhood diarrhea will be quick to realize that the contributors all constitute outstanding specialists in North America. Their information is not only recent but highly authoritative.

The first article deals with "Viral Diarrhea" and is authored by Dr. J. R. Hamilton, Professor of Pediatrics…

So many times in my career as a pediatrician I have looked back and realized that I started practice in the "dark ages" of medicine. Then, almost suddenly, there was a wave of new knowledge. This has occurred in practically every area of the sciences, including cardiology, hematology, genetics, immunology, endocrinology, neurology, and gastroenterology.

When I was an intern at the New York Nursery and Child's Hospital in 1928, infantile diarrhea was one of the most serious problems faced in the first year o life. Several facts were known at the time. One was that there were many more cases of diarrhea among formula-fed infants than there were among those who were breast fed. Accordingly, there were breast milk centers in New York City, founded by Mrs. William Randolph Hearst, where mothers with excess breast milk could sell it for 350 an ounce to be provided free for poor families.

Infantile diarrhea was often associated with infections in various parts of the body, especially the nasopharynx. As a matter of fact, many of the infants we examined and treated for severe enteritis had congested throats and reddened eardrums.

Then, one of the foremost pediatricians of the day, Dr. William McKim Marriott, Professor of Pediatrics at Washington University in St. Louis, became interested in "alimentary intoxication." Dr. Marriott was an excellent biochemist, who, while at Johns Hopkins between 1914 and 1917, performed considerable research on acidosis in alimentary intoxication.

In the mid- 1920s Dr. Marriott stated that infections of the middle ear might be responsible for the severe diarrhea of infancy. So strong was his influence that in many pediatric institutions, including our own, mastoidectomies were performed on all of the infants so suffering, in spite of their debilitation. This surgical approach was being performed during my internship. It was given up after a few years.

In the decades that followed, antibiotics were discovered, the sciences of bacteriology, virology and immunology were greatly improved, breast feeding was encouraged, and new improved proprietary formulas appeared in the stores. The mortality from diarrhea decreased markedly but there were still numerous cases.

For a special reason I must repeat the following incident which I related in a previous issue of Pediatric Annals.

In the late- 1950s, one of our Residents in Pediatrics at New York Hospital told me that he was considering going into a new area - pediatric gastroenterology. What did I think of it?

I advised him against it. "Any well-trained pediatrician should be able to successfully handle the digestive disorders of infants and children," I told him.

He thought it over and decided against my advice. To my knowledge he became the first pediatric gastroenterologist in the US and, with those that followed, opened up a new and important area in pediatrics. I have often regretted my lack of foresight.

I was reminded once again of this incident, for this former Pediatric Resident at New York Hospital, Dr. Murray Davidson is now one of the foremost pediatric gastroenterologists and is the Guest Editor for the present symposium.

Dr. Davidson is Professor of Pediatrics of the State University of New York at Stony Brook, and Chief of the Division of Gastroenterology and Nutrition of the Schneider Children's Hospital of the Long Island Jewish-Hillside Medical Center.

Readers of this issue of Pediatric Annals covering the subject of infantile and childhood diarrhea will be quick to realize that the contributors all constitute outstanding specialists in North America. Their information is not only recent but highly authoritative.

The first article deals with "Viral Diarrhea" and is authored by Dr. J. R. Hamilton, Professor of Pediatrics at the University of Toronto, and Chief of the Division of Gastroenterology at the Hospital for Sick Children in Toronto, Canada.

Dr. Hamilton is recognized as an international authority on the subject of viral enteritis. In this article he reviews the subject, noting at the outset that the human rotavirus is at present the most common cause of acute diarrhea in infants throughout the world. The pathophysiology of viral enteritis is discussed as well as reasons why viral diarrhea may at times persist - for normally the virus is quickly shed from intestinal mucosa.

The section on treatment is of special value for it specifies the importance of maintaining the child's fluid and electrolyte balance. In all except the most severe cases, oral rehydration may be successfully used, reserving intravenous therapy for the more ' serious cases. The oral rehydration solution used so successfully throughout the world by the World Health Organization is described.

At a meeting of the American Society for Microbiology on October 9, 1984, Dr. Timo Vesekari, Professor of Pediatrics at the University of Tampere, Finland, discussed a new vaccine for rotavirus. This researcher reported on an oral vaccine (placed in milk) which appears to give 90% protection against rotavirus.

The second article in this symposium deals with a subject frequently met by all practicing pediatricians - the problem of milk allergy in infancy. It has been contributed by Dr. Joyce D. Gryboski, Clinical Professor of Pediatrics, and Director of Pediatric Gastroenterology, Yale University School of Medicine, New Haven, Connecticut.

Dr. Gryboski notes that there is presently no absolute diagnostic criteria for milk allergy. The primary test lies in the elimination of milk from the diet. As to etiology, she points out that heredity plays a large part. This is followed by a careful review of what is known today of the physiological disorders associated with milk allergy. Among these are the decrease in the IgA containing cells, and also low IgG levels.

The symptomatology is described in detail from the simple colic to the more severe attacks with diarrhea, bleeding, anemia, hypoproteinemia, generalized edema and failure to grow.

Dr. Gryboski warns that the major differential in diagnosis is lactose intolerance. She closes her article with a plan of treatment for infants and children allergic to milk.

The next article, titled "Common Bacterial Causes of Bloody Diarrhea," is by Dr. Arnold Silverman, Professor of Pediatrics at the University of Colorado Health Sciences Center, and Director of Pediatrics at the Denver General Hospital.

This is a most interesting discussion of the various bacterial organisms which cause such intestinal reactions. Step by step Dr. Silverman covers the most common enteric pathogens such as shigella, salmonella, the pathogenic E. coli, and those of more recent recognition as causative agents, including campybbacter, yersinia, Clostridia difficile, and venereal agents.

In each instance the bacteria are described, the pathophysiology detailed, the clinical picture presented as well as the laboratory features and the most effective treatment.

A valuable chart is included, a differential diagnostic table of the various organisms relating to the age of the child, the season, incubation period, the signs and symptoms, the findings on endoscopy, histology and barium enema as well as the treatment for each entity.

The following contribution deals with one of the great advances in modern pediatrics - the use of total parenteral nutrition to maintain the physiological needs of infants and children suffering severe diarrhea disabilities. It has been written by Dr. Marvin C. Ament, Professor of Pediatrics and Chief of the Division of Pediatric Gastroenterology and Nutrition of the UCLA Medical Center, Los Angeles.

In this well-organized article, Dr. Ament first describes those diarrheal conditions where intravenous therapy is indicated. If indicated, how should it be given, by peripheral veins or by central venous catheters? Following this is a discussion on how to evaluate the needs of the individual child, taking into consideration calories, energy, protein, electrolytes, vitamins and trace metals. In this discussion also, he emphasizes the need to guard against anemia as well as hypoalbuminemia.

The article is supplemented by specific directions for determining the needs of each child suffering from severe diarrhea. It should be of the greatest help to those pediatricians responsible for treating infants hospitalized or even at home for this debilitating condition.

The final article in the symposium, "Lactose Intolerance and Diarrhea. Are They Related?" has been written by Dr. Anastasios G. Angelides, Gastroenterologist of the Schneider Children's Hospital of the Long Island Jewish-Hillside Medical Center, and Assistant Professor of Pediatrics at the State University of New York, Stony Brook, New York and Dr. Murray Davidson, Guest Editor of this issue.

The authors note that lactase deficiency is definitely associated with diarrhea and other abdominal symptoms in many infants and children. It seems strange that it wasn't until 1959 that this fact was fully recognized. This is particularly curious when studies show that 83% of blacks and 24% of whites are deficient in this enzyme.

The studies presented in this article give evidence that diarrhea is not the only problem caused by lactase deficiency in infants. These infants, fed cow's milk, may also develop progressive malnutrition. However, the degree of symptoms, including diarrhea, abdominal pain, and failure to gain adequately varies greatly among infants and children with lactose malabsorption.

Doctors Angelides and Davidson present the laboratory studies on lactose malabsorption, although the condition can certainly be suspected on clinical grounds alone. The management of children with this condition is next considered with the advice that since lactose stimulates the absorption of calcium as well as magnesium, zinc and possibly iron, children given lactose-free formulas should be monitored for such deficiencies.

Dietary approaches for children with hypolactasia are given, including the use of a recent commercial preparation of lactase which may be added to cow's milk. This discussion underlines the importance of a clinical entity that must not be overlooked in cases of diarrhea in children.

10.3928/0090-4481-19850101-04

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