Medical Care
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). [15, 16]
Chronic diarrhea due to proximal small bowel bacterial overgrowth is treated with oral broad-spectrum antibiotics, particularly those with anaerobic coverage (eg, metronidazole). [17] More recently, rifaximin has also been found to be very effective in adults. [18] 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. [19]
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.
Surgical Care
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.
Consultations
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.
Diet
Dietary concerns include the following:
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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.
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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.
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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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The small intestine is a major site of absorption.
