Diarrhoea in Children

We have selected the following expert medical opinion based on its clarity, reliability and accuracy. Credit: Sourced from the MSD Manual, Consumer Version; authored by Dr Deborah M. Consolini (see below). Please refer to your own medical practitioner for a final perspective, assessment or evaluation.

Overview

Diarrhoea is a very common problem in children. Diarrhoea is frequent, loose, or watery bowel movements (BMs) that differ from a child’s normal pattern. Sometimes diarrhoea contains blood or mucus. Identifying mild diarrhoea may be difficult because in healthy children, the number and consistency of BMs vary with age and diet. For example, breastfed infants who are not yet receiving solid food often have frequent, loose stools that are considered normal. A sudden increase in number and looseness may indicate diarrhoea in these infants. However, having watery stools for more than 24 hours is never normal.

Children with diarrhoea may lose their appetite, vomit, lose weight, or have a fever. If diarrhoea is severe or lasts a long time, dehydration is likely. Infants and young children can become dehydrated more quickly, sometimes in less than 1 day. Severe dehydration can cause seizures, brain damage, and death.

Worldwide, diarrhoea causes 1.5 million deaths a year mostly in underdeveloped countries. In the United States, diarrhoea accounts for about 9% of hospitalizations for children under 5 years old.

Causes of diarrhoea

Likely causes of diarrhoea depend on whether it lasts less than 2 weeks (acute) or more than 2 weeks (chronic). Most cases of diarrhoea are acute.

Common causes

Acute diarrhoea is usually caused by:

• Infectious gastroenteritis
• Food poisoning
• Use of antibiotics
• Food allergies

Gastroenteritis is usually caused by a virus, but it can be caused by bacteria or a parasite.

Food poisoning usually refers to diarrhoea, vomiting, or both caused by eating food contaminated by toxins produced by certain bacteria, such as staphylococci or clostridia.

Certain antibiotics can alter the types and number of bacteria in the intestine. As a result, diarrhoea can occur. Sometimes using antibiotics enables a particularly dangerous bacterium, Clostridium difficile, to multiply. Clostridium difficile releases toxins that can cause inflammation of the lining of the large intestine.

Chronic diarrhoea is usually caused by:

• Dietary factors, such as lactose intolerance or overconsumption of certain foods
• Infections (particularly those caused by parasites)
• Coeliac disease
• Inflammatory bowel disease

Less common causes

• Acute diarrhoea can also result from more serious disorders such as appendicitis, intussusception, and haemolytic-uremic syndrome (a complication of certain types of bacterial infection). These serious disorders are usually associated with other worrisome symptoms besides diarrhoea, such as severe abdominal pain or swelling, bloody stools, fever, and ill appearance.
• Chronic diarrhoea can also result from disorders that interfere with the absorption of food (malabsorption disorders), such as cystic fibrosis, and a weakened immune system (due to a disorder such as AIDS or use of certain drugs).
• Diarrhoea sometimes results from constipation. When hardened stool accumulates in the rectum, soft stool may leak around it and into the child's underwear.

Evaluation of diarrhoea

Warning signs

Certain symptoms are cause for concern. They include:

• Signs of dehydration, such as decreased urination, lethargy or listlessness, crying without tears, extreme thirst, and a dry mouth
• Ill appearance
• High fever
• Blood in stool
• Pain in the abdomen and, when touched, extreme tenderness
• Bleeding in the skin (seen as tiny reddish-purple dots [petechiae] or splotches [purpura])

When to see a doctor

Children with any warning signs should be evaluated by a doctor right away, as should those who have had more than 3 or 4 episodes of diarrhoea and are not drinking or are drinking very little.

If children have no warning signs and are drinking and urinating normally, the doctor should be consulted if diarrhoea lasts 2 days or more or if there are more than 6 to 8 episodes of diarrhoea a day. If diarrhoea is mild, a doctor’s visit is unnecessary. Children with diarrhoea for 14 days or more should be seen by a doctor.

What the doctor does

Doctors first ask questions about symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause and the tests that may need to be done (see section: Some Causes and Features of diarrhoea).

Doctors ask what the bowel movements look like, how frequent they are, how long they last, and whether the child has other symptoms, such as fever, vomiting, or abdominal pain.

Doctors also ask about potential causes, such as diet, use of antibiotics, consumption of possibly contaminated food, recent contact with animals, and recent travel.

A physical examination is done, looking for symptoms of dehydration and disorders that can cause diarrhoea. The abdomen is checked for swelling and tenderness. Doctors may also evaluate the child's growth.

Some Causes and Features of diarrhoea

Please note: Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present.

Acute diarrhoea (lasting less than 2 weeks)

Gastroenteritis due to viruses, bacteria, or parasites (most common)

• Often with vomiting
• Dehydration common especially among infants and young children
• Sometimes fever and abdominal pain
• Rarely blood in stool
• Sometimes recent contact with infected people (such as those at a day care centre, at a camp, or on a cruise), with animals at a petting zoo (where Escherichia [E.] coli may be acquired), or with reptiles (which may be infected with Salmonella bacteria) or recent consumption of undercooked, contaminated food or contaminated water

Food allergy (not common)

• Hives, swelling of the lips, and difficulty breathing within minutes to several hours after eating
• Sometimes vomiting
• Often an already identified food allergy

Antibiotic use (not common)

• Recent use of antibiotics
• Often no other symptoms

Haemolytic-uremic syndrome (rare)

• Abdominal pain, vomiting, and usually bloody diarrhoea for a few days, followed by development of pale skin and decreased urination
• Sometimes bleeding in the skin (seen as tiny reddish-purple dots or splotches)

Chronic diarrhoea (lasting more than 2 weeks)

Allergy to cow's milk protein

• Vomiting
• Poor feeding
• Weight loss, poor growth, or both
• Blood in stools

Excessive consumption of fruit juices (especially apple, pear, and prune)

• Drinking more than 4–8 ounces of fruit juice a day
• Often no other symptoms except diarrhoea

Inflammatory bowel disease such as Crohn disease and/or ulcerative colitis

• Blood in stool, crampy abdominal pain, weight loss, loss of appetite, and poor growth
• Sometimes arthritis, rashes, sores in the mouth, and tears in the rectum

Lactose intolerance (Inability to digest lactose, the sugar in milk and dairy products)

• Abdominal bloating, passing of gas (flatulence), and explosive diarrhoea
• diarrhoea after consumption of milk and dairy products

Malabsorption disorders such as Celiac disease/ Cystic fibrosis/ Acrodermatitis enteropathica

• Light-coloured, soft, bulky, and unusually foul-smelling stool that may appear oily
• Abdominal bloating and flatulence
• Poor weight gain
• With cystic fibrosis, frequent respiratory infections
• With acrodermatitis enteropathica, rash and cracks in the corners of the mouth

A weakened immune system due to HIV infection or an immunodeficiency disorder/ Use of drugs that suppress the immune system

• Frequent infections
• Weight loss or poor weight gain
• Sometimes an already identified HIV infection

Tests and special investigations

If diarrhoea lasts less than 2 weeks and warning signs are not present, the cause is probably gastroenteritis due to a virus, and testing is usually unnecessary. However, if doctors suspect another cause, tests are done to check for it.

Tests are typically done when children have warning signs. If they have signs of dehydration, blood tests are done to measure levels of electrolytes (sodium, potassium, calcium, and other minerals necessary to maintain the fluid balance in the body). If other warning signs are present, tests may include a complete blood cell count, urine tests, examination and analysis of stool, abdominal x-rays, or a combination.

Treatment of diarrhoea

Specific causes of diarrhoea are treated. For example, if children have celiac disease, gluten is removed from their diet. Antibiotics that cause diarrhoea are stopped if a doctor recommends it. Gastroenteritis due to a virus usually disappears without treatment.

Drugs to stop diarrhoea, such as loperamide, are not recommended for infants and young children.

Dehydration

Because the main concern in children is dehydration, treatment is focused on rehydrating by giving fluids and electrolytes. Most children with diarrhoea are successfully treated with fluids given by mouth (orally). Fluids are given by vein (intravenously) only if children are not drinking or are severely dehydrated. Oral rehydration solutions that contain the right balance of carbohydrates and sodium are used. In many countries, these solutions are widely available without a prescription from pharmacies and most supermarkets. Sports drinks, sodas, juices, and similar drinks have too little sodium and too much carbohydrate and should not be used.

If children are also vomiting, small, frequent amounts of fluid are given at first. Typically, 1 teaspoon (5 millilitres) is given every 5 minutes. If children keep this amount down, the amount is gradually increased. If the child is not vomiting, the initial amount of fluid does not need to be limited. With patience and encouragement, most children can take enough fluid by mouth to avoid the need for intravenous fluid. However, children with severe dehydration may need intravenous fluids.

Diet

As soon as children have received sufficient fluids and are not vomiting, they should be given an age-appropriate diet. Infants may resume breast milk or formula.

In children with chronic diarrhoea, the treatment depends on the cause, but providing and maintaining adequate nutrition and monitoring for possible vitamin or mineral deficiencies are most important.

KEY POINTS

• Diarrhoea is common among children.
• Gastroenteritis, usually due to a virus, is the most common cause.
• Children should be evaluated by a doctor if they have any warning sign (such as signs of dehydration, severe abdominal pain, fever, or blood or pus in stool).
• Testing is rarely necessary when diarrhoea lasts less than 2 weeks.
• Dehydration is likely if diarrhoea is severe or lasts a long time.
• Giving fluids by mouth effectively treats dehydration in most children.
• Drugs to stop diarrhoea, such as loperamide, are not recommended for infants and young children.

About the author

Dr Deborah M. Consolini

MD

Assistant Professor of Paediatrics, Sidney Kimmel Medical College of Thomas Jefferson University; Chief, Division of Diagnostic Referral, Nemours/Alfred I. duPont Hospital for Children

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