Diarrhea in Children

Overview

Diarrhea is a very common problem in children younger than age five. In developing or non-industrialized countries, multiple episodes of diarrhea can lead to serious problems such as malnutrition (poor nutrition). In the United States and Canada, young children have an average of two episodes of diarrhea per year.

Diarrhea is defined as an increase in the number of stools or the presence of looser stools than is normal for the individual, i.e. more than three bowel movements each day. Acute diarrhea is when diarrhea occurs for less than 3 weeks total. When diarrhea lasts longer than three weeks, it is considered to be chronic.

Symptoms

Diarrhea may be watery or contain blood. Stool may float which may indicate that there is increased fat present in the stool. Diarrhea may also be accompanied by:

  • Urgency with bowel movements, which means that children feel that they have to get to the bathroom immediately or they will have an accident.
  • Abdominal pain and/or bloating
  • Rectal pain
  • Nausea and/or vomiting
  • Weight loss
  • Fever

Individuals with diarrhea are at risk for dehydration, which occurs when someone is unable to take in sufficient fluid orally to meet their daily requirements and compensate for losses in their stools. Signs of dehydration include:

  • decrease in urine output/wet diapers
  • dry lips and mouth
  • lack of tears when crying
  • increased irritability and fussiness
  • increased sleepiness/decreased energy level

Physicians can determine if someone is dehydrated and how severely they are dehydrated by examining them. Parents can monitor children for signs of dehydration.

Causes

Acute Diarrhea
Acute diarrhea may be due to infections with bacteria, viruses or parasites. Diarrhea is more common in children attending day care and is usually due to a virus. While cases of diarrhea due to infection are usually mild and go away on their own, it is important to avoid becoming dehydrated from loss of body fluid in diarrheal stools.

Chronic Diarrhea
There are many causes of chronic diarrhea. Chronic diarrhea is due to a disease that causes inflammation of the bowel and/or malabsorption of nutrients.

Common causes of chronic diarrhea are shown below:

  • Diarrhea following infection (post infectious diarrhea):
    – Infections such as giardia can lead to chronic diarrhea
  • Chronic nonspecific diarrhea:
    – Seen in toddlers and is usually dietary in origin, such as from drinking too much juice or carbohydrate sweetened liquids such as sports drinks or other products. It resolves by simply limiting the amount of juice or carbohydrate sweetened liquid intake.
  • Celiac disease (gluten intolerance):
    – With an estimated incidence of 1:133 individuals, Celiac disease presents with chronic symptoms including constipation, diarrhea, poor weight gain, decreased energy, and abdominal distension. Children with type I diabetes and other autoimmune disorders as well as Down’s syndrome are at increased risk for Celiac disease.
  • Inflammatory bowel disease (ulcerative colitis and Crohn disease):
    – A disease where there is inflammation of the intestines and/or colon that can lead to chronic diarrhea. Other symptoms include weight loss or poor weight gain, poor growth and abdominal pain.
  • Lactose intolerance:
    – An inability to digest lactose, a sugar found in milk and milk products, can lead to chronic diarrhea. Other symptoms include abdominal pain and distention, excessive burping and gas.
  • Irritable bowel syndrome:
    – A common cause of diarrhea in teenagers, although many patients will present with abdominal pain and diarrhea that alternates with constipation.
  • Diarrhea after antibiotic use (antibiotic associated colitis):
    – Diarrhea can be seen after antibiotic use and is thought to be due to an imbalance between the ‘good and bad’ bacteria in the intestine. One such bacterium is called Clostridium difficile.
  • Food allergies:
    – Food allergies can present with diarrhea as well as skin rashes, abdominal pain, poor growth, nausea and vomiting.

Risk Factors

Risk factors for infectious causes of diarrhea include travel to foreign countries, swimming in lakes and ponds, attendance at day care, foster home and school as well as sick contacts at home. Recent antibiotic use can also put individuals at risk for developing diarrhea. Celiac disease and inflammatory bowel disease (IBD) have been associated with certain genes and families with first-degree relatives with these diseases are at greater risk.

Diagnosis

Acute Diarrhea
Diarrhea due to acute infection (acute gastroenteritis) usually does not require tests. In some cases doctors will order blood tests to determine if a child is dehydrated. Collection of stool samples (stool cultures) can be done to identify the specific cause of the diarrhea in some children, especially if they have blood in stools.  Stool cultures can take from 2 to 5 days before a result is available. Stool studies can also be done to look for parasites including Giardia. In many cases of acute infectious diarrhea, a precise cause will not be identified despite stool testing.

Chronic Diarrhea
The diagnosis of chronic diarrhea usually requires confirmatory tests. Establishing the exact cause of chronic diarrhea may require several different tests, some of which are listed below:

  • Blood tests to look for anemia and inflammation, assess for dehydration and nutrition status and screen for possible Celiac disease.
  • Stool studies to look for possible bacterial, viral or parasitic etiologies.
  • X-ray studies are not routinely performed but may be useful in some circumstances to evaluate the liver and gastrointestinal tract if other causes are suspected.
  • Upper endoscopy and/or colonoscopy with biopsy to access for inflammation. An upper endoscopy can help to definitively diagnose Celiac disease. A colonoscopy is invaluable in making the diagnosis of inflammatory bowel disease and figuring out what portion of the colon is involved with the inflammation. It can also help to diagnose diarrhea that follows antibiotic use and to diagnose rare conditions such as lymphocytic colitis.
  • Lactose breath hydrogen test to diagnose lactose intolerance.

Your physician can assist you in choosing the best treatment after determining the cause of your child’s diarrhea.

Treatment

Ensure Adequate Hydration
Children with mild dehydration can be treated outside of the hospital with special oral rehydration solutions (ORS) that can be purchased at the pharmacy or grocery store. Oral rehydration solutions are the best way to rehydrate a child who is able to drink and is not vomiting. Although other drinks such as juices, colas and sports drinks are frequently used, they are not a good substitute for ORS, and can actually worsen the diarrhea. Patients with more severe diarrhea, vomiting and dehydration may require intravenous fluids (fluids given through a vein in the arm) in the hospital.

Diet
In a child who is otherwise healthy, it is very important to start feeding them their regular diet as soon as possible. Breast fed infants should be nursed normally during episodes of acute gastroenteritis. Formula fed infants can continue their regular diet and older children should be re-introduced to their regular diet as soon as possible. Older children may avoid dairy initially and try a bland diet consisting of bananas, apple sauce, rice, and toast.

Medications
Antibiotics may be prescribed for children with specific bacterial or parasitic illnesses, although in most cases antibiotics do not change how long the diarrhea lasts or its severity. Probiotics (commercially manufactured tablets or capsules that contain “good bacteria”) may be useful in decreasing the severity of symptoms in the presence of an imbalance of good and bad bacteria in the intestines. Medications that slow down bowel movements are not recommended in children with acute diarrhea although they may occasionally play a role in children with chronic diarrhea.

Supportive Care
Careful hand washing should be practiced by all family members especially after diaper changes.

Author(s) and Publication Date(s)

Marsha H. Kay, MD, FACG, The Cleveland Clinic, Cleveland, OH, and Anthony F. Porto, MD, MPH, Yale University/Greenwich Hospital, Greenwich, CT – Updated December 2012.

Marsha H. Kay, MD, The Cleveland Clinic, Cleveland, OH, and Vasundhara Tolia, MD, Children's Hospital of Michigan, Detroit, MI – Published September 2004.

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