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Pediatric Malabsorption Syndromes Treatment & Management

  • Author: Stefano Guandalini, MD; Chief Editor: Carmen Cuffari, MD  more...
 
Updated: Jul 17, 2015
 

Medical Care

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  • Clearly, treatment of malabsorption syndromes depends on the specific entity being considered and thus widely varies.
  • Although several new possibilities of gluten predigestion and detoxification and ways of increasing intestinal barrier tightness to gluten penetration are currently under active investigation and offer promising results, the only current therapeutic option for celiac disease remains the gluten-free diet, which is a diet completely devoid of wheat, barley, and rye (see Celiac Disease).[13, 14]
  • Chronic diarrhea due to proximal small bowel bacterial overgrowth is treated with oral broad-spectrum antibiotics, particularly those with anaerobic coverage (eg, metronidazole).[15] More recently, rifaximin has also been found to be very effective in adults.[16] Because this entity often occurs in individuals who have an anatomic or functional predisposition (eg, short gut, motility disorders), repeated courses are typically needed.
  • Malabsorption secondary to short gut needs to be aggressively treated, and pharmacological options are now available.[17]
  • In children with chronic diarrhea secondary to bile acid malabsorption, the use of cholestyramine (Questran) to bind bile acids may help to reduce the duration and severity of the diarrhea.
  • Any loss of pancreatic enzymes can be replaced with oral supplements.
  • Immunosuppressive medications can be used to control autoimmune enteropathy and should be prescribed only by a specialist.
  • Children with malabsorption secondary to food allergic enteropathy need to be on an elimination diet, avoiding offending food antigens. Their identification is often the result of empiric trials because food allergic enteropathies cannot be diagnosed by immunoglobulin E (IgE) measurement, either by radioallergosorbent assay test (RAST) or skin prick tests.
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Surgical Care

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  • Most children with short gut syndrome are eventually weaned off parenteral nutrition and do not require surgery. However, in some children, disease is refractory to enteral feeding, and other children develop end-stage liver disease from the prolonged supplementation of parenteral nutrition. Consider liver, gut, or multivisceral transplantation in these children.
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Consultations

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  • In children in whom a malabsorption syndrome is suspected to cause growth failure or is associated with high morbidity, prompt referral to a pediatric gastroenterologist is recommended.
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Diet

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  • Carbohydrate intolerance
    • Initiate treatment in patients with severe acquired carbohydrate intolerance by eliminating all dietary carbohydrates until the diarrhea is resolved. Then, slowly reintroduce carbohydrates.
    • In infants, use a glucose polymer (Polycose)–based formula (eg, Pregestimil). In patients with the most severe carbohydrate intolerance, use MJ3232A, a casein-based formula that contains essential amino acids and medium-chain triglyceride (MCT) oil and no carbohydrates. If MJ3232A is used, parenteral dextrose must be supplied.
    • Once the diarrhea has resolved, slowly reintroduce fructose into the diet as the only enteral carbohydrate source.
    • Begin with 14 g fructose/L formula, and gradually advance in 14-g increments to a maximum of 56 g fructose/L formula. Once this goal is reached, slowly replace fructose with Polycose until 56 g Polycose/L formula is tolerated. Once 56 g Polycose/L formula is tolerated, begin introducing Pregestimil, a lactose-free formula.
    • For older children, eliminate simple carbohydrates and lactose from the diet until the diarrhea is resolved. Simple sugars, including fruit juices, should be avoided for several weeks.
    • If after several weeks of a relatively carbohydrate-free diet symptoms return when carbohydrates are reintroduced, the child most likely has a congenital defect in carbohydrate transport or digestion.
  • Fat intolerance
    • MCT oil is used to treat patients with poor weight gain that results from fat malabsorption. MCT oil does not require traditional fat metabolism and, thus, is more easily absorbed directly into the enterocyte and is transported through the portal vein to the liver.
    • Fat-soluble vitamin supplements are required for patients with fat malabsorption or short gut syndrome.
    • Supplements in patients with fat malabsorption should also include linoleic and linolenic fatty acids.
    • Patients with short gut syndrome may not be able to effectively absorb formula until mucosal hyperplasia has increased the mucosal absorption area. During this period of adaptation, appropriate parenteral nutrition may be needed to maintain optimal nutritional status.
  • Alternative formulas
    • Currently, soy formulas are not considered effective for the prevention or treatment of nutritional allergies. Instead, use hydrolyzed protein formulas.
    • High-degree protein hydrolysate formulas are used to treat infants with a cow's milk allergy, but these formulas may contain residual epitopes capable of provoking a severe allergic reaction. In these infants, use formulas with crystalline amino acids (eg, Neocate, EleCare, EO28) as the protein source.
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Contributor Information and Disclosures
Author

Stefano Guandalini, MD Founder and Medical Director, Celiac Disease Center, Chief, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Chicago Medical Center; Professor, Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Stefano Guandalini, MD is a member of the following medical societies: American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, European Society for Paediatric Gastroenterology, Hepatology & Nutrition, North American Society for the Study of Celiac Disease

Disclosure: Received consulting fee from AbbVie for consulting.

Coauthor(s)

Richard E Frye, MD, PhD Associate Professor, Department of Pediatrics, University of Arkansas for Medical Sciences

Richard E Frye, MD, PhD is a member of the following medical societies: American Academy of Neurology, Child Neurology Society, International Neuropsychological Society, American Academy of Pediatrics

Disclosure: Nothing to disclose.

M Akram Tamer, MD Professor, Program Director, Department of Pediatrics, University of Miami, Leonard M Miller School of Medicine

M Akram Tamer, MD is a member of the following medical societies: American Medical Association, Florida Medical Association

Disclosure: Nothing to disclose.

Catherine D Newland, MD Pediatric Gastroenterology Fellow, Comer Children’s Hospital, University of Chicago

Catherine D Newland, MD is a member of the following medical societies: American Academy of Pediatrics, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

B UK Li, MD Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin; Attending Gastroenterologist, Director, Cyclic Vomiting Program, Children’s Hospital of Wisconsin

B UK Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Chief Editor

Carmen Cuffari, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching.

Additional Contributors

Eric S Maller, MD 

Eric S Maller, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, American Society of Transplant Surgeons, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

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The small intestine is a major site of absorption.
 
 
 
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