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A case report on intractable diarrhoea of infancy with failure to thrive

By: Dr. Lalit Bharadia

MD, DNB, PDCC (Pediatric Gastroenterology), Fellowship in Pediatric Gastroenterology (Auckland), Consultant Pediatric Gastroenterologist, Santokba Durlabhji Memorial Hospital and Pediatric Gastro Clinic, Jaipur

Key Points:

Initial Case Presentation:

A 4-month-old baby boy with an emaciated look, presented to Pediatric Gastroenterologist with a history of diarrhoea since the age of 1 month. Baby had been hospitalized twice before and was then referred to the specialist.

History:

He was born healthy, full term and weighed 3 kgs (weight/age z-score = 0 to -2). From birth, the mother could not establish breastfeeding. As a result, baby was fed expressed breast milk, cow’s and goat’s milk in a bottle. Since the age of 1 month, he was reported to have diarrhoea with stool frequency of 10-15 times per day. His weight gain was extremely poor and at the time of referral i.e. age: 4 months, he weighed 3.53 kgs (weight/age z- score = < -3). Baby was irritable, looked emaciated and had fever for more than 1 week. In the past, the baby was treated with parental antibiotics, ORS and Zinc.

Hemogram done prior to referral showed Hemoglobin:8.4 gm/dL, Total leukocyte count: 8500/µl, Eosinophils: 2% and Platelets: 250,000/µl.

Management:

Intractable diarrhoea (defined as severe chronic diarrhoea associated with malnutrition) with failure to thrive during early infancy can be an indication of CMPA1 (Cow’s Milk Protein Allergy). We suspected CMPA. There is no confirmatory test for CMPA and diagnostic elimination, followed by the challenge remains the mainstay to diagnose the same.

Visit 1 ( Age: 4 months) – The management of CMPA calls for removal of milk protein and initiation of hypoallergenic formula as per the guidelines. We advised the mother to eliminate cow’s and goat’s milk and start with Amino Acid Formula (AAF) (LCP) ad libitum with vati and spoon. Additionally, zinc and multivitamin drops were prescribed for 2 weeks. Simultaneously, the mother was advised to start with relactation with removal of dairy from her own diet. The decision to opt for AAF over an extensively hydrolyzed formula (eHF) was made based on the fact that the child had failure to thrive. AAF minimizes the risk of failure on eHF and further weight loss.

Visit 2 (Age: 4 months 1 week) – In the follow-up visit, after a week, there was a marked improvement in irritability. Baby was cooing. There was an increase in weight by 190 gms in 5 days. Baby now weighed 3.72 kgs and passed formed stool once in 24 hrs. Since relactation was not successful, mother was advised to feed the baby exclusively on AAF as a sole source of nutrition. Vitamin D drops were also prescribed.

Visit 3 (Age: 4 months 3 weeks) – In the follow-up visit after 2 weeks, he weighed 4.29 kgs (weight gain was about 40 gm/day) with normal stool consistency (once daily). We advised the mother to start with rice-based milk free complementary food in small volume, once a day and steady increase in volume basis the tolerance. Further, rice + pulse based milk free complementary food was also advised if the earlier was tolerated. AAF continued to be the main source of nutrition for the baby. Complementary feed was started early in this case to ensure alternate dietary option in case the AAF was not available on a continuous basis or if it was difficult for the family to buy it for long term.

During the next 1 month his weight gradually improved.

Visit 4 (Age: 6 months)- The baby weighed 6.19 kgs (weight/age z-score = -2 to -3) and was now taking AAF (70%) and rice powder – based milk free cereal (30%). Mother was advised to start with home-based complementary foods like semolina, mashed fruits and vegetables, dal, ragi porridge in water with gradual reduction in AAF. Vegetable oil was advised to be added in all meals to increase the energy density.

Visit 5 (Age: 7 months, 3 weeks) – The baby now weighed 7 kgs (weight/age z-score = 0 to -2), coming back on the normal growth trajectory (Refer Growth Chart). He was tolerating complementary foods and the intake of AAF further decreased to 25%. At this time, we challenged the baby with ghee, which he tolerated well. Mother was advised to add butter over next 2 weeks and was made to start in the clinic itself, which he tolerated well. We further added butter milk in the subsequent visit, followed by biscuits, curd etc. under medical supervision. Monthly weight monitoring was advised. By nine months, he was able to tolerate whole milk served in the form of kheer, daliya etc.

Weight-for-age BOYS:

Birth to 2 years (z-scores)

figure 1WHO Child Growth Standards

Discussion:

Cow’s milk intake is quite common in infants in India. Breastfeeding has a preventive role in development of allergy. Unfortunately this child received CMP (Cow’s Milk Protein) very early, which increased the risk of allergy. For most of these infants the severity of the symptoms and their significant improvement on commencing the elimination diet is enough to confirm the diagnosis.

As per the guidelines, the mainstay of treatment for CMPA in infants is complete avoidance of all cow’s milk protein. Optimizing an allergic child’s nutrient intake to ensure normal growth and development is, thus, the principal goal of their nutritional management.2 

Hence, initiation of therapeutic formula was essential in order to ensure the provision of adequate nutrition for optimal growth.

As per the recent iMap 2017 Guidelines3 and ESPGHAN 2012 Guidelines4 for non-breast fed infants with severe CMPA, hypoallergenic formula like an amino acid formula (AAF) should be the formula of choice. We have seen a considerable improvement in baby’s weight and symptom relief with the use of AAF.

Complementary foods were introduced starting from milk free cereals. We followed the concept of milk ladder to introduce milk protein in the child’s diet. It is a plan to re-introduce milk products gradually and in stages, starting with foods that contain only a small amount of well-cooked milk and progressing towards un-cooked dairy products and fresh milk. We started with Ghee → Butter → Butter Milk → Baked Milk (Biscuits) → Curd, under supervision.

Summary:

Intractable diarrhoea with failure to thrive can be an indication of CMPA in young infants. This case illustrates the importance of appropriate nutritional management of severe CMPA with an AAF in children to ensure normal growth and development.

References:-

  1. Hizarcioglu-Gulsen H, et al. Intractable diarrhea of infancy: 10 years of experience. J Pediatr Gastroenterol Nutr. 2014 Nov; 59(5):571-6.
  2. Christie, Lynn, et al. Food allergies in children affect nutrient intake and growth. Journal of the American Dietetic Association 102.11 (2002): 1648-1651.
  3. Venter, Carina, et al. Better recognition, diagnosis and management of non-IgE-mediated cow’s milk allergy in infancy: iMAP—an international interpretation of the MAP (Milk Allergy in Primary Care) guideline. Clinical and translational allergy 7.1 (2017): 26.
  4. Koletzko S, Niggemann B, Arato A, et al. Diagnostic approach and management of cow’s-milk protein allergy in infants and children: Espghan gi committee practical guidelines. J Pediatr Gastroenterol Nutr. 2012;55(2):221-229.

Important Notice:

The World Health Organization (WHO)* has recommended that pregnant women and new mothers be informed of the benefits and superiority of breast-feeding, in particular, the fact that it provides the best nutrition and protection from illness for babies. Mothers should be given guidance on the preparation for and maintenance of lactation, with special emphasis on the importance of the well-balanced diet both during pregnancy and after delivery. Unnecessary introduction of partial bottle feeding or other foods and drinks should be discouraged since it will have a negative effect on breast-feeding. Similarly mothers should be warned of the difficulty of reversing a decision not to breastfeed. Before advising a mother to use an infant formula, she should be advised of the social and financial implications of her decision. For example, if a baby is exclusively bottle-fed, more than one can (500g) per week will be needed, so the family circumstances and cost should be kept in mind. Mother should be reminded that breast milk is not only the best but also the most economical food for babies. If a decision to use infant formula is taken, it is important to give instruction on correct preparation methods, emphasizing that unboiled water, unsterilized bottles or incorrect dilution can lead to illness.

*See: International Code of Marketing of Breast Milk Substitutes, adopted by the World Health Assembly in Resolution WHA 34.22, May 1981.

Mothers should be explained the following advantages & nutritional superiority of breastfeeding:

  1. Immediately after delivery, breast milk is yellowish and sticky. This milk is called colostrum, which is secreted during the first week of delivery. Colostrum is more nutritious than mature milk because it contains more protein, more anti-infective properties which are of great importance for the infant’s defence against dangerous neonatal infections. It also contains higher levels of, Vitamin ‘A’.
  2. Breast miIk:
    1. is, a complete and balanced food and provides all the nutrients needed by the infant (for the first six months of life).
    2. has anti-infective properties that protect the infants from infection in the early months.
    3. is always available.
    4. needs no utensils or water (which might, carry germs) or fuel for its preparation.
  3. Breastfeeding is much cheaper than feeding infant milk substitutes as the cost of the extra food needed by the mother is negligible compared to the cost of feeding infant milk substitutes.
  4. Mothers who breast-feed usually have longer periods of infertility after child birth than non-lactators.

Details of management of breast feeding, as under:

  1. Breast-feeding.
    1. Immediately after delivery enables the contraction of the womb and helps the mother to regain her figure quickly.
    2. is successful when the infant suckles frequently and the mother wanting to breast-feed is confident in her ability to do so.
  2. In order to promote and support breast-feeding the mother’s natural desire to breast feed should always be encouraged by giving, where needed, practical advice and making sure that she has the support of her relatives.
  3. Adequate care for the breast and nipples should be taken during pregnancy.
  4. It is also necessary to put the infant to the breast as soon as possible after delivery.
  5. Let the mother and the infant stay together after the delivery, the mother and her infant should be allowed to stay together (in hospital, this is called “rooming-in”).
  6. Give the infant colostrum as it is rich in many nutrients and anti-infective factors protecting the infants from infections during the few days of its birth.
  7. The practice of discarding colostrum and giving sugar water, honey water, butter or other concoctions instead of colostrum should be very strongly discouraged.
  8. Let the infants suckle on demand.
  9. Every euort should be made to breast-feed the infants whenever they cry.
  10. Mother should keep her body and clothes and that of the infant always neat and clean.

MEET DANONE