Postenteritis syndrome in infants or young children may be due to a bacterial or viral origin on the one hand, but on the other hand, it may also occur due to nutrient deficiency or as a concomitant of another organic disease. For a therapy, the psychological factors as well as the social circumstances have to be explored and considered in addition to these factors.
What is postenteritis syndrome?
Postenteritis syndrome is a malabsorption syndrome resulting from chronic gastroenteritis accompanied by recurrent or protracted diarrhea. The acute characterization is four to eight weeks. It is associated with underweight or weight loss with or without insufficient weight and length growth in infancy. This disease occurs most frequently between 6 and 24 months of age. Prior to this time, children often develop acute gastroenteritis of bacterial or viral origin due to rotaviruses, for example.
Causes
Acute gastroenteritis of bacterial or viral origin may be the cause of postenteritis syndrome. The cause is due to changes in the intestinal flora with dejugation of bile acids and hydroxylation of fatty acids and toxin products but also as a result of superficial mucosal lesions with secondary disaccharidase deficiency. Another cause can be found in a pronounced nutrient deficiency, which is why children in developing countries suffer from the disease in a very high percentage. In highly developed countries of the so-called “First World”, this symptomatology is usually found as an accompaniment to an organic disease. It is particularly common in neurological and gastrointestinal diseases, but also in connection with infantile cerebral palsy. Nevertheless, depending on the underlying criteria regarding underweight or frequency of an existing underlying disease, between 2 and 24 percent of young patients are in inpatient treatment. Sugar intolerance is also frequently present.
Symptoms, complaints, and signs
Chronic recurrent diarrhea occurs during the nutritional buildup between 6 and 24 months of age. Despite this, children develop without signs of malabsorption. A markedly reduced general condition with excessive fatigue to lethargic phases increasingly accompanies the postenteritis syndrome. An abdomen that is markedly diffusely distended meteoistically is seen on palpation. Nausea and masticatory and dysphagia are common accompanying symptoms. Sometimes a transport disorder is seen in the esophagus. Preexisting pneumonia or pneumonia that develops during the course of the disease may cause shortness of breath.
Diagnosis and course of the disease
In any case, the underlying disease must be diagnosed as well as the pathology of the parallel failure to thrive. It is also important to exclude other recurrent diarrhea by differential diagnosis. These include cystic fibrosis, celiac disease, cow’s milk intolerance or food allergy, and congenital disaccharidase deficiency. The extent is determined on the basis of standard values from the body weight, the body length as well as their relation to each other. A possible sugar intolerance can be diagnosed by laboratory stool tests as well as by a breath test. If the sugar substance identified as allergenic is removed from the food chain, the problem of the disease often resolves itself. The preceding anamnesis deals, among other things, with the family and social environment. This allows factors such as neglect, available food, and psychological or psychiatric illnesses of the parents to be ruled out. Genetic reasons can also be identified in this way. Thus, the first priority is the diagnosis as well as the determination of the exact extent followed by a clarification of the pathogenesis. This is divided into the areas:
- 1. insufficient food intake due to chronic vomiting, swallowing or chewing disorders, transport disorders of the esophagus but also shortness of breath in an existing heart or lung disease.
- 2. an increased need for energy
- 3. impaired intestinal absorption (malabsorption).
If laboratory evidence of iron deficiency is found, it may indicate an existing malabsorption in the upper duodenum.In rare cases, a duodenal biopsy including determination of the activity of disaccharidases or evidence of partial villous atrophy is required. The final step is a physical examination. This often reveals a reduced general condition accompanied by pallor and sometimes also signs of incipient dehydration with fatigue and even lethargy. In addition, palpation often reveals a pressure-sensitive and diffusely meteoist distended abdomen. The skin of the perianal region is often sore due to liquid stools. Sometimes there is even superinfection caused by thrush. Furthermore, there is the possibility of dysfunction in the form of disaccharide or monosaccharide adsorption (lactose or fructose) due to a damaged intestinal mucosa caused by acute gastroenteritis. Osmotic diarrhea may be exacerbated by unabsorbed carbohydrates. Their persistence or secondary malabsorption is thereby promoted. The further course of the disease is unfortunately characterized by a more or less severe impairment of somatic and psychosocial but also motor development. This fact has a negative impact on future cognitive performance as well as on vital immune functions and infection defense. This construct of limitations requires early corrective action to minimize damage. Furthermore, malnourished children in underdeveloped countries, as well as nonbreastfed children in civilized countries, may experience a vicious circle of malnutrition, malabsorption, and chronic failure to thrive as a result of a postenteritis syndrome.
Complications
Because of postenteritis syndrome, affected patients usually suffer from severe diarrhea that is persistent. As a result, the infants lose a lot of fluid and sometimes suffer from severe dehydration. Furthermore, parents and relatives also experience psychological discomfort or depression. The children’s abdomens are bloated, and it is not uncommon for them to suffer from nausea and vomiting. Swallowing disorders can also occur as a result of post-enteritis syndrome, making it much more difficult for the affected person to absorb food and fluids. If postenteritis syndrome is not treated, pneumonia also occurs. The children can then no longer breathe properly, so that the internal organs are also no longer supplied with sufficient oxygen. In the worst case, this can lead to irreversible damage to the organs or to a delay in development. The patient’s quality of life is considerably reduced by the postenteritis syndrome. Treatment of postenteritis syndrome is usually based on a healthy and proper diet. This can limit most of the symptoms. Special complications do not occur. Possible deficiency symptoms must be compensated in the process.
When should one go to the doctor?
Children suffering from chronic diarrhea or other gastrointestinal complaints should be presented to a pediatrician without delay. Medical advice is specifically needed for severe symptoms associated with deficiencies or dehydration. Parents who notice repeated gastrointestinal complaints in their child are best advised to speak to their pediatrician or a gastroenterologist so that the condition can be quickly clarified or ruled out. Postenteritis syndrome can be effectively treated by dietary changes and short-term administration of medications. However, if no therapy is given, the chronic recurrent diarrhea can be life-threatening. Children who are already physically weakened by another illness are particularly at risk. Acute gastroenteritis and viral or bacterial diseases such as rotavirus also increase the risk of serious complications. In addition to pediatricians or family physicians, gastroenterologists treat postenteritis syndrome. Other contacts are nutritionists as well as alternative medical practitioners who can help put together a suitable diet. If the symptoms are chronic, the child should be taken to a specialist clinic for gastrointestinal diseases.
Treatment and therapy
The nutritional buildup should be gradual with a diet rich in protein and carbohydrates that is low in lactose. This requires avoiding cow’s milk proteins as well as gluten and fructose-containing beverages for at least six to eight weeks.The chance that the symptoms will already improve with this is relatively high. If the amount of food cannot be increased, the selected foods should have a high caloric density. Ready-made food can be added. In connection with re-alimentation, lactose– and cow’s milk protein-containing ready-made food, which was tolerated before the disease, can be given. This is possible in our regions because the eutrophic children extremely rarely develop lactose or cow’s milk intolerance after gastroenteritis. Nutrition with special supplementary or substitute food can be administered in balanced or unbalanced form as tube feeding orally, by tube or by PEG (percutaneous endoscopic gastrostomy). In severe cases, supplementation with potassium, magnesium and phosphate is necessary. A vicious circle of malabsorption, malnutrition, as well as failure to thrive can occur in developing countries.
Prevention
The greatest chance of not developing postenteritis syndrome is to breastfeed as long as possible.
Follow-up care
If the child is symptom-free after therapy has been performed, no further follow-up is necessary. The intestinal flora has then usually fully recovered from its derailment. The nutritional build-up with the addition of porridge and baby food can now be continued cautiously. If diarrhea occurs again despite this, the composition of the complementary food should be examined again. A new test for potential allergens such as lactose, fructose or gluten is advisable at this point. If this measure leads to a symptom-free result, an elimination diet should be carried out. This involves gradually adding individual foods to the menu. This enables precise identification of the diarrhea trigger. In this way, even very specific intolerances can be diagnosed over time. If there are any uncertainties or questions, a trained nutritionist can help. This person can give tips on a gentle diet or even develop a meal plan for the child. This is particularly advisable if signs of malnutrition appear as a result of the post-enteritis syndrome. In most cases, minor deficiencies can be compensated for through nutrition. Under certain circumstances, however, the targeted use of nutritional supplements is also indicated. In this case, regular monitoring of the corresponding blood values should be performed.
What you can do yourself
The disease occurs primarily in children. Relatives, guardians or custodians should ensure that the child receives an adequate and healthy diet. Weight should be documented at regular intervals and compared with the guidelines for normal weight in children of that age. If the child is severely underweight or shows signs of nutrient deficiency, a medical examination should take place. In cooperation with the physician, it should be discussed which nutrient needs to be taken in more. In addition, swallowing disorders occur. For this reason, the consistency of the food should be optimized. In the case of underweight, activities that involve a large loss of calories should be avoided. The practice of sporting activities should be adapted to the possibilities of the organism and should not take up additional resources. The intake of food should be adjusted to the needs of the body and should be optimized. A diet rich in vitamins is necessary for the recovery process. In case of shortness of breath, there is a risk of anxiety or panic behavior. The affected person should be given sufficient information in advance about appropriate behavior in an emergency situation. Since intolerance to sugar is often apparent, the intake of food should be completely sugar-free. In many cases, a restructuring of the diet is necessary so that the organism is not supplied with any sugary products.
