Children Digestive Tract
The gastrointestinal tract is a sensing, reactive device that monitors the
material flowing through it. Symptoms arising from this system provide
information about its dysfunction. Seven basic symptoms signal gastrointestinal
tract displeasure with food choices - nausea, heartburn, vomiting, bloating,
pain, constipation and diarrhea.
Parents need to know two basic principles of digestion management
1. If you don't like what comes out - change what goes in.
2. Treat symptoms as information. When the gastrointestinal tract complains,
adjust your child's food intake until the complaints disappear.
The 5 most common infant digestive problems are
All five may occur together and are likely to be food-related. The
"irritable" or reactive bowel syndrome begins in infancy with colic, bloating,
regurgitation, vomiting and diarrhea. Colic in infancy is abdominal pain with
the attendant emotional distress of the infant and his parents. Jenkins et al
demonstrated that food allergy is a major cause of infantile colitis.
The combination of gastrointestinal symptoms with congestion, cough, hives,
and/or eczema should suggest the diagnosis of food allergy until proven
otherwise. The food allergy is likely to be the delayed pattern and will not
show up on skin or RAST tests. The diagnosis must be confirmed by proper diet
revision, which will resolve the problem if food-related.
Breast-fed infants are exposed to food allergy through their mothers' milk.
Harmatz and Bloch stated that: "Infants presenting with manifestations of atopic
disease including atopic dermatitis, colic, colitis, or diarrhea and with
exclusive breast feeding should be considered to have maternal diet
protein-related disease." In their review of the passage on food proteins
into mother's milk they stated that measurements of IgE responses (total IgE,
IgE RAST and skin tests) were not helpful diagnosing infants who had symptoms
from breast milk. Jacobsson and Lindberg demonstrated that cow's milk in the
maternal diet can cause colic in breast-fed infants. Lothe et al demonstrated
that infantile colic is a symptom of cows milk protein intolerance and remitted
when a cows milk formula was replaced with nutramigen, a hypoallergenic formula,
based on hydrolysed casein.
A mother may have to retreat to a hypoallergenic diet to rescue her infant
from colic with or without more obvious manifestations of food allergy. Adequate
nutrition can be supplied by Phase 1 foods (Alpha Nutrition Program)
during the 10 days required to clear her infant's symptoms. Exclusion of single
high risk food groups such as milk and eggs may not be adequate to solve the
infant's problem. Once the infant is comfortable, mother may then reintroduce
low risk foods and expand her diet, monitoring her infant for recurrent
Diarrhea - Acute Infections
Bout of diarrhea are common in toddlers for food borne infections. In
third-world terms, infectious diarrhea is a leading cause of death in children
and can be prevented by improvements in water quality, home hygiene, sewage
disposal and food handling - all features that affluent communities take for
Water and electrolyte loss is the major cause of death when diarrhea is
severe - frequent watery bowel movements can dehydrate and infant and small
child quickly. Both sodium and potassium are lost and should be replaced. The
treatment is oral dehydration (ORT) - the simplest solution is water as a 0.9 %
salt solution by mouth. Commercial products such as pedialyte are used as ORT.
Rice water has been effective in third world countries - rice is boiled in large
amounts of water ( 6 cups per 1 cup of rice) and the liquid is poured off and
fed to the child.
Maximal water absorption occurs when the sodium concentration is 40-90mmol/L
and glucose contrition is 110-140mmol/L; the total osmolalility of the solution
should be 290mOsm/L. Cola for example has an osmolality of 750 mOsm/L; undiluted
apple-juice is 730 mOsm/L - both are too concentrated to feed to a child
Tolerance for Foods
The gastrointestinal tract in normal circumstances learns to tolerate foods
that are presented regularly. Oral tolerance to food is learned by infants as
solid foods are introduced. In the best case, tolerance to regularly eaten food
endures throughout the life of the individual. Infants do best on breast milk
for the first six months and develop tolerance to solid foods if the are
introduced slowly over the next six months. Some infants are hypersensitive and
feeding them is difficult; their tolerance mechanisms do not work very well or
are slow to accept new foods. These infants must be fed very carefully and their
breast-feeding mothers often have to follow a careful diet to avoid food
antigens in the breast milk. More permissive tolerance may not show up until the
second year and may be limited for the entire life of that individual.
Many events alter or reduce food tolerance. An infectious gastroenteritis,
for example, may leave the gastrointestinal tract in a hypersensitivity state
and the patient reports decreased tolerance to many foods. This post-infectious
hypersensitivity may lead to chronic "reactive bowel" symptoms.
Gastrointestinal Allergies to Food
In a review of gastrointestinal allergies to food, Walker-Smith and his
colleagues stated that:
"Gastrointestinal food allergies may be defined as clinical syndrome which
are characterized by the onset of gastrointestinal symptoms following food
ingestion where the underlying mechanism is an immunologically mediated reaction
within the gastrointestinal tract. There are broadly speaking two categories of
clinical syndromes which are related to the speed of onset of symptoms:
immediate and delayed. Those syndromes which manifest immediately after food
ingestion are easy to diagnose and specific IgE tests and prick tests are
frequently positive. Those with a delayed onset of up to several days are
difficult to diagnose and currently available investigations may be
unsatisfactory for routine use."
Saavedra-Delagado and Metcalfe reviewed mechanisms of food antigens causing
gastrointestinal disease. They detailed the pattern of cow's milk induced
gastroenteropathy in children, another prototype of food allergic disease, which
manifests as chronic diarrhea and is not associated with positive skin tests to
cow's milk proteins. They noted associated symptoms included chronic rhinitis
and recurrent otitis media.
Moon and Kleinman reviewed allergic gastroenteropathy in children and stated;
"The symptoms of allergic gastroenteropathy may be those of classic allergic
reactions or present as symptom complexes that may include diarrhea,
malabsorption and protein-losing enteropathy." Diarrhea, vomiting, weight loss,
abdominal pain and rectal bleeding were the dominate symptoms.
Protein-losing enteropathy occurs in children presents as edema, anemia, and
growth failure or weight loss. Food allergy will also cause a non-specific
malabsorption syndrome associated with chronic diarrhea. Following an infectious
gastroenteritis, both viral and bacterial, hypersensitivity reactions to food
are common and in infants may present as a post-enteritis milk-protein
Ciprandi and Canonica reported that 132 of 236 patients with cutaneous
manifestations of food allergy had gastrointestinal diseases - 17.8% presenting
with irritable bowel, 13.5 % with constipation, and 11% with ulcer-like
Hill and Milla reported thirteen infants with eosinophilic colitis who
improved with diet revision. All presented with chronic diarrhea containing
bloody mucus before 2 years of age. Colon erythema was noted and biopsies showed
inflammatory cell infiltrates in the lamina propria; eosinophils and plasma
cells predominated. Cows milk and eggs were routinely excluded from the diet
with improvement; 7 children did well on soya formula, but 5 required a
chicken-based formula. With food introduction, 7 children developed diarrhea
with other foods; beef (3), wheat (3), white flour (1), fish (2), pork (2) and
goats milk (1).
Hill et al reported milk allergy in children with cystic fibrosis who
continued to have diarrhea and failure to thrive despite adequate treatment with
pancreatic enzymes. A proximal small intestine biopsy was used to identify
children with milk enteropathy - thinning of the mucosa with reduced villous
height were the main findings. They estimated the incidence of milk allergy at
16% in a group of children with cystic fibrosis. The hydrolysed casein formula,
Pregestamil, was used as a milk replacement
Some children present with loose and more frequent stools either constantly
or intermittently over months to years. Some have episodes of watery stools with
urgency, cramps, and bloating. Others have low grade but persistent diarrhea.
The differential diagnosis is broad. If weight loss and iron deficiency anemia
accompany the diarrhea, Crohn's and Celiac disease must be considered. Diarrhea
with blood in the stools always suggests ulcerative colitis. Stool samples for
cultures and microscopic examination are essential. The practical point is that
most patients with chronic diarrhea will benefit from diet revision. Diet
revision will be definitive treatment especially if investigations are negative
and no specific remedy can be found. By doing careful diet revision, parents
will usually reveal that the child has normal stools with "safe foods" and will
generate a list of reactive foods that trigger recurrent diarrhea.
Many children present with constipation with and without episodes of
diarrhea. Reduced stool frequency and hard stools are associated with various
degrees of abdominal discomfort - usually bloating and distension of the
descending colon with accumulating feces. Diet revision using the Alpha
Nutrition Program as a guide will often improve bowel function especially if
high vegetable and fruit fiber intake is encouraged. Rice tends to be
constipating and this effect is balanced by having 2-3 portions of vegetables
for each portion of rice. Cow's milk is a major cause of chronic constipation,
beginning in infancy. Iacono et al reported that 21 of 27 infants with chronic
constipation improved with a milk protein-free diet; 15 of these infants had
evidence of milk allergy.
Nutrient Formulas for Infants and Children