Issn Print: 0277-2116

Publication Date: 1996/11/01


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Severe and Protracted Diarrhea

Mohammed I. El Mouzan

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To the Editor: I have read with interest the article of Dr. Alfredo Guarino et al. (1) and would like to make the following comments. I agree with the authors that the definition of “Intractable diarrhea” is more and more confusing. In 1968, Avery et al. coined this term to describe a group of infants with severe diarrhea and malnutrition with onset in the first 3 months of life and lasting >2 weeks. At least three stool cultures were negative for bacterial pathogens (2). Subsequently, the same terminology was used to describe patterns of chronic diarrhea different from the original definition; e.g., some investigators included infants and children aged >3 months (3,4), whereas others included children with intestinal infections (5,6); still others restrict the definition of intractable diarrhea of infancy to the syndrome of severe chronic diarrhea associated with malnutrition which is not easily resolved by conventional management (7). Finally, many investigators are avoiding this terminology in favor of more general terms such as chronic, protracted, or persistent diarrhea, which include entities that are still described by others as “intractable diarrhea of infancy” (1). Furthermore, the word intractable no longer applies to many cases since the advent of total parenteral nutrition (TPN) and continuous enteral feedings (6).
For all these reasons, there is a need to redefine the term “Intractable diarrhea of infancy.” A panel recommendation or a consensus report should help clarify this issue. Because this symptom is no longer intractable or restricted to infancy, there is little justification for continuing its use in the pediatric literature.
The definition of severity used by the authors in their series is arbitrary and highly selective. To define severity by the need for TPN excludes patients who have chronic diarrhea and severe malnutrition but who do not need TPN once the diagnosis is established. This is true of infants with undiagnosed conditions such as cow's milk protein intolerance or glucose-galactose malabsorption. This definition of severity also excludes severe cases of various causes successfully managed by enteral feedings, which may suggest to some readers that these are not important causes of severe protracted diarrhea. It would therefore be of interest to know the etiology of protracted diarrhea (whether requiring TPN or not) observed by the authors in their highly specialized center over this long time period (1977-1993).
The identification of rotaviruses as causes of severe protracted diarrhea in immune-competent children is of interest and contrary to the general teaching in that viral gastroenteritis is a self-limited condition in immunocompetent patients. It would be useful if the authors could clarify the degree to which the immunocompetency of these patients was established and whether during their illness some degree of immunodeficiency is possible (i.e., secondary to postinfectious syndrome with malnutrition). The postinfectious syndrome, a common cause of chronic diarrhea in developing countries, also occurs in industrialized countries (8) and may be severe enough to require TPN (9).
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