Pediatric Malabsorption Syndromes Treatment & Management
- Author: Stefano Guandalini, MD; Chief Editor: Carmen Cuffari, MD more...
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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). More recently, rifaximin has also been found to be very effective in adults. 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.
- 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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- 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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- 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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- 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.
Siddiqui Z, Osayande AS. Selected disorders of malabsorption. Prim Care. 2011 Sep. 38(3):395-414; vii. [Medline].
Fasano A, Berti I, Gerarduzzi T, et al. Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study. Arch Intern Med. 2003 Feb 10. 163(3):286-92. [Medline].
Meyer R, Venter C, Fox AT, Shah N. Practical dietary management of protein energy malnutrition in young children with cow's milk protein allergy. Pediatr Allergy Immunol. 2012 Mar 22. [Medline].
Abenavoli L, Proietti I, Vonghia L, et al. Intestinal malabsorption and skin diseases. Dig Dis. 2008. 26(2):167-74. [Medline].
Scarpellini E, Giorgio V, Gabrielli M, et al. Prevalence of small intestinal bacterial overgrowth in children with irritable bowel syndrome: a case-control study. J Pediatr. 2009 Sep. 155(3):416-20. [Medline].
Bruno MJ, Haverkort EB, Tytgat GN, van Leeuwen DJ. Maldigestion associated with exocrine pancreatic insufficiency: implications of gastrointestinal physiology and properties of enzyme preparations for a cause-related and patient-tailored treatment. Am J Gastroenterol. 1995 Sep. 90(9):1383-93. [Medline].
Wedlake L, A'Hern R, Russell D, Thomas K, Walters JR, Andreyev HJ. Systematic review: the prevalence of idiopathic bile acid malabsorption as diagnosed by SeHCAT scanning in patients with diarrhoea-predominant irritable bowel syndrome. Aliment Pharmacol Ther. 2009 Oct. 30(7):707-17. [Medline].
Mokrowiecka A, Daniel P, Slomka M, Majak P, Malecka-Panas E. Clinical utility of serological markers in inflammatory bowel disease. Hepatogastroenterology. 2009 Jan-Feb. 56(89):162-6. [Medline].
Ritchie BK, Brewster DR, Davidson GP, Tran CD, McNeil Y, Hawkes JS. 13C-sucrose breath test: novel use of a noninvasive biomarker of environmental gut health. Pediatrics. 2009 Aug. 124(2):620-6. [Medline].
Gabrielli M, D'angelo G, Di Rienzo T, Scarpellini E, Ojetti V. Diagnosis of small intestinal bacterial overgrowth in the clinical practice. Eur Rev Med Pharmacol Sci. 2013 Dec. 17 Suppl 2:30-5. [Medline].
Rizzello CG, De Angelis M, Di Cagno R, et al. Highly efficient gluten degradation by lactobacilli and fungal proteases during food processing: new perspectives for celiac disease. Appl Environ Microbiol. 2007 Jul. 73(14):4499-507. [Medline].
[Guideline] Hill ID, Dirks MH, Liptak GS, et al. Guideline for the diagnosis and treatment of celiac disease in children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2005 Jan. 40(1):1-19. [Medline].
Quigley EM, Quera R. Small intestinal bacterial overgrowth: roles of antibiotics, prebiotics, and probiotics. Gastroenterology. 2006. 130:S78-90. [Medline].
Lauritano EC, Gabrielli M, Scarpellini E, et al. Antibiotic therapy in small intestinal bacterial overgrowth: rifaximin versus metronidazole. Eur Rev Med Pharmacol Sci. 2009 Mar-Apr. 13(2):111-6. [Medline].
Kumpf VJ. Pharmacologic Management of Diarrhea in Patients With Short Bowel Syndrome. JPEN J Parenter Enteral Nutr. 2014 Jan 24. [Medline].
Volta U, Granito A, Fiorini E, et al. Usefulness of antibodies to deamidated gliadin peptides in celiac disease diagnosis and follow-up. Dig Dis Sci. 2008 Jun. 53(6):1582-8. [Medline].
Adachi JA, DuPont HL. Rifaximin: a novel nonabsorbed rifamycin for gastrointestinal disorders. Clin Infect Dis. 2006 Feb 15. 42(4):541-7. [Medline].
Cavataio F, Guandalini S. Cow's milk allergy. Guandalini S, ed. Essential Pediatric Gastroenterology. McGraw-Hill; 2005. 175-92.
Cole CR, Ziegler TR. Small bowel bacterial overgrowth: a negative factor in gut adaptation in pediatric SBS. Curr Gastroenterol Rep. 2007 Dec. 9(6):456-62. [Medline].
Crenn P, Messing B, Cynober L. Citrulline as a biomarker of intestinal failure due to enterocyte mass reduction. Clin Nutr. 2008 Jun. 27(3):328-39. [Medline].
Fonnesu C, Giovinale M, Verrecchia E, et al. Gastrointestinal amyloidosis: a case of chronic diarrhoea. Eur Rev Med Pharmacol Sci. 2009 Mar. 13 Suppl 1:45-50. [Medline].
Goulet O, Ruemmele F. Causes and management of intestinal failure in children. Gastroenterology. 2006. 130 (2 Suppl 1):S16-28. [Medline].
Green PH, Jabri B. Celiac disease. Annu Rev Med. 2006. 57:207-21. [Medline].
Guandalini S, Dincer AP. Nutritional management in diarrhoeal disease. Baillieres Clin Gastroenterol. 1998. 12:697-717. [Medline].
Gupte GL, Beath SV, Kelly DA, et al. Current issues in the management of intestinal failure. Arch Dis Child. 2006. 91:259-64. [Medline].
Kneepkens CM, Hoekstra JH. Chronic nonspecific diarrhea of childhood: pathophysiology and management. Pediatr Clin North Am. 1996 Apr. 43(2):375-90. [Medline].
Longo N, Elsas LJ. Human glucose transporters. Adv Pediatr. 1998. 45:293-313. [Medline].
Love MW, Dawson PA. New insights into bile acid transport. Curr Opin Lipidol. 1998 Jun. 9(3):225-9. [Medline].
Maldonado J, Gil A, Narbona E, Molina JA. Special formulas in infant nutrition: a review. Early Hum Dev. 1998 Dec. 53 Suppl:S23-32. [Medline].
Montalto M, Curigliano V, Santoro L, et al. Management and treatment of lactose malabsorption. World J Gastroenterol. 2006. 12:187-91. [Medline].
Montalto M, Santoro L, D'Onofrio F, Curigliano V, Visca D, Gallo A, et al. Classification of malabsorption syndromes. Dig Dis. 2008. 26(2):104-11. [Medline].
Nakamura T, Takeuchi T, Tando Y. Pancreatic dysfunction and treatment options. Pancreas. 1998 Apr. 16(3):329-36. [Medline].
Robayo-Torres CC, Quezada-Calvillo R, Nichols BL. Disaccharide digestion: clinical and molecular aspects. Clin Gastroenterol Hepatol. 2006. 4:276-87. [Medline].
Weiss B, Skourikhin Y, Modan-Moses D, Broide E, Fradkin A, Bujanover Y. Is adult height of patients with celiac disease influenced by delayed diagnosis?. Am J Gastroenterol. 2008 Jul. 103(7):1770-4. [Medline].
Zanchi C, Di Leo G, Ronfani L, Martelossi S, Not T, Ventura A. Bone metabolism in celiac disease. J Pediatr. 2008 Aug. 153(2):262-5. [Medline].