Auto-brewery syndrome; or, the time my toddler got drunk on toast

This afternoon, a story about a woman whose bladder fermented her own urine landed in my inbox. 

I was skimming the newsletter quickly, but that story stopped me in my tracks. I have never before seen clinical documentation of a case like this – but I have lived it. Reading her story, I figured it was high time I shared the tale of the one of the most bizarre things that has ever happened to us – and that’s saying something, considering that I once gave birth to a child whose intestines were growing on the outside of his body. 

This is the story of the time my two-year-old got drunk from eating toast. 

It started out like any other Saturday morning. We woke early, made breakfast, probably watched cartoons. This was at the peak of L’s oral aversion, and also at the peak of us trying to increase his oral intake to try to work toward weaning him off of TPN. That morning all he would eat was toast, so toast is what he ate. He downed two slices for breakfast, and then we went off to play for an hour at The Little Gym, where he ran and tumbled with friends and was perfectly happy and well. When we got home, he asked for toast again, so I gave him another slice. And at lunchtime, when he gagged and refused to touch anything on the balanced plate I set in front of him and asked again for toast, well, I was thrilled he was eating anything at all, so toast he had. 

Then he went down for his nap. And when he awoke, I immediately knew something was very, very wrong. 

He couldn’t stand up without support. When he tried to walk, he stumbled back and forth and then fell down. He was in good spirits, all things considered, but seemed to be confused about where he was and what was happening to him, and he could barely even sit upright without falling over. 

These sudden, unexpected symptoms prompted us to rush him to the ER. When we got there, the attending physician was alarmed, but didn’t quite know what to make of his condition. His bloodwork seemed normal, at least for him. Nothing neurological seemed to be causing these symptoms. But by this point, I was having to hold his head up for him because he seemed to be having trouble controlling it. 

Parents in our online short gut support group encouraged us to check for D-lactic acidosis, but the pediatric ER team had never heard of that and didn’t know what test to run. We finally got in touch with his GI specialist, who was familiar with D-lactic acidosis and ordered a test, but it was a test with some lag time, and so we were finally admitted to the pediatric unit for close observation. 

By this point it was well past L’s bedtime, and he had fallen asleep on me. We were wheeled up to his room in a transport bed together, with him sleeping the whole way. Around midnight, the floor pediatrician tried to rouse him, not wanting to let him sleep too long without examination given his neurological symptoms – and he couldn’t be awoken.  

At this point, the medical team was rather unsuccessfully trying to hide their concern, and I was trying to contain my panic. Nothing seemed out of the ordinary, all tests were coming back clear — so what in the world was wrong with my baby

Around 4 a.m., L awoke on his own, as chipper as could be. He wanted to cuddle, wanted to play, wanted to sing a song, and seemed thoroughly unconcerned about all the bustle and fuss surrounding him, having spent a good portion of his life in busy hospital rooms. We were kept for observation for another day, kept him NPO to help flush his system, and then were sent home. 

Four days later, the test confirmed a buildup of D-lactate. Because his dilated intestine moved very slowly and allowed food matter to sit in the dilated section for long periods of time, normal gut bacteria tended to build up into small bowel intestinal overgrowth, and feeding that legion of bacteria so many carbs in such a short amount of time caused them to produce an excess of D-lactate, which enters the bloodstream and causes symptoms similar to inebriation. 

It’s not quite the same as auto-brewery syndrome because his gut produced D-lactate instead of ethanol, but the result is largely the same. That wild 24 hours of anxiety that left both parents and medical professionals perplexed and alarmed essentially boiled down to this: L got “drunk” on toast, passed out hard, slept it off and woke up raring to go. 

His overgrowth and D-lactate production was likely exacerbated by the lactated ringers he was receiving intravenously at the time. We stopped lactated ringers and have avoided them since, and have not had another incident of D-lactic acidosis (or at least not one that has been severe enough to produce symptoms). L’s tapering surgery has helped a lot too, because his better-functioning gut doesn’t allow food matter to linger long enough to ferment in this way anymore.

But if you’ve ever wondered why we have to limit carbs and sugar, well, one major reason is because the body is a strange and wondrous place that sometimes gets a little bored and likes to recruit an army of bacteria to brew its own poo-beer. 

D-lactic acidosis is rare, but it’s fairly common among short gut patients. If you’re interested, you can read more about it here.

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