Strongly increased fat excretion of our son (4y)

Question

Dear expert team,
in the frame of two stool fat collections an increased excretion of fat (up to 45%) has been diagnosed. More than one year ago, this value was however much lower.
We ask ourselves, if such a deterioration is "normal". Our son "chews" the Kreon always 2-3 times, before he swallows it. Can this be a problem? Which consequences may such a high fat value have?
We would be very happy about answers to our questions.
Best regards,
M.

Answer

Hello,
you report, that in the frame of an analysis of the stool's fat content of your 4-year-old son, that seems to have been analysed from a 3x24 hours stool collection, a strongly increased fat excretion via the stool of up to 45% (fat resorption coefficient 55%?) has been detected. At a former control about 1 year ago, this value had been much lower. You ask, if the worsened fat utilization could be due to the fact, that your son chews the Kreon pellets before swallowing and ask at the same time, if such a high fat excretion could have negative consequences.
The extent of stoof fat excretion in CF children is influenced by the amount of nutritional fat intake, the dosage of pancreatic enzmyes (Kreon), the way of enzyme giving (e.g. as wrong usage the intake of the whole dosage at the beginning of the meal or at the end respectively the optimal usage with distribution over the meal). Via chewing of the Kreon pellets, the natural acid protection of the enzymes is destroyed and therefore the effectiveness of the enzymes is lowered markedly.
Additionally e.g. gut infections or an antibiotic therapy could briefly influence the fat resorption negatively.
In case the eating habits of your son and the way and amount of the Kreon intake have not changed markedly over the last year, then the stool fat excretion should rather be in the range of the one from the last year.
Under the aspect of changed eating habits, one have also to think about e.g. substantial drinking of fruit juices, that may fasten the bowel passage.
Furthermore it has to be revealed if the stool fat analyses have been made seperately for each 24-hours stool collection or if only one sample out of one stool collection has been taken for analysis. In case of the latter, it would be eventually possible that via this untypical way of analysis a false pathologcial value has been measured.
In case to clarify the problem, as a first step, the enzyme dosage as well as the enzyme intakte should be again analysed with a nutritional expert and probably be improved. Hereby it has absolutely to be tried to give your son the Kreon pellets that way, that he swallows them quickly and unchewed (e.g. administration on a small spoon with juice, yoghurt or mashed potatoes).
Altogether, the dosage of the pancreas enzymes should be adapted like this, that not more than 15% of the intaken nutrtional fat amount is excreted undigested via the stool, if possible. In case all former values of your son have been higher, it has to be discussed, if the enzyme dosage has to be increased over the usual maximal dosage of 10.000 units lipase per kg bodyweight and day up to e.g. 15.000 units.
In single cases a combination of Kreon with a Rizopus-Lipase preparation (Nortase®) could be helpful.
You have to discuss this with your CF-Team.
After taking the above mentioned aspects into account, of course a control investigation of the stool fat excretion should be done.
Finally it has to be said, that such a high stool fat excretion can not be tolerated, as it has negative consequences. Besides the insufficient weight gain, lack of vitamins, chronic loss of bile acids with subsequent liver damage and the risk of developing a so-called DIOS have to be mentioned as examples.
We hope to have helped you and your son with this information and wish you much luck.
Yours sincerely,
Dr. H.-G. Posselt

16.02.2014