Loose stool in young children isn’t an uncommon problem, as those of us who practice pediatric gastroenterology can attest. The practical consensus is that if your child passes three or more watery or loose stools in a row, it’s considered diarrhea. If the diarrhea starts acutely, it’s often due to an infection or an intolerance to a certain food, and this often resolves on its own and by eliminating the offending food source.
However, if the problem persists for longer than six months, it’s considered chronic diarrhea and will need to be evaluated by your child’s physician.
When should you be concerned regarding your child’s loose stools?
The short-term concern is whether your child can maintain fluid balance. If he or she is passing a good amount of urine and isn’t showing signs of dehydration, like excessive thirst, and can drink and keep fluids down, immediate concern is low. On the contrary, if your child is showing signs of dehydration or is unable to drink due to vomiting, and hasn’t passed urine for more than 12 hours, or is becoming lethargic, seek medical help.
If your child isn’t dehydrated, there are other warning signs to keep an eye on:
— Is your child growing well? If your child is growing and gaining weight, the concern to seek immediate medical help is low. On the contrary, if your child’s growth is faltering in weight and in height, or if she lacks energy, seek advice from your pediatrician.
— Is your child having visible blood in stool with diarrhea? This would suggest possible inflammation in the intestine and would be a reason to seek medical help.
— Is your child pale, suggesting anemia? This may suggest poor iron intake, poor absorption of iron or loss of blood from the intestine.
— Is your child repeatedly vomiting? This would also be a reason to ask for help.
— Repeated diaper rash may indicate malabsorption of simple carbohydrates, leading to acidic stools.
Even if your child isn’t showing any of these symptoms, but has persistent loose stools lasting weeks, it would be prudent to seek help.
What are some causes of long-standing diarrhea in young children?
The most common cause of frequent loose stools in young children (ages 1 to 5) is toddler’s diarrhea. These children have three or more loose stools; they don’t have other symptoms and grow well. They often have worse diarrhea if they’re consuming lots of fruit juice or have a diet rich in higher fructose-containing fruits, like apples and pears. They may show improvement with a relatively higher fiber diet and higher fat food.
Infections aren’t a common cause of long-standing diarrhea, and they’re often self-limiting. However, infections by certain microscopic parasites like giardia can be long-lasting. Rarely, underlying immune deficiency may associated with prolonged bacterial or parasitic infections. Children with immune deficiency may have poor growth or develop repeated serious infections.
Malabsorption of lactose, the sugar in milk, can cause repeated diarrhea in children. This is due to an inability to break down the sugar by lactose, the enzyme present in the lining of the bowel. It’s typically seen in older children. Malabsorption of sucrose (table sugar) due to sucrase deficiency is uncommon, and the symptoms are similar to lactose intolerance. Symptoms are seen when sucrose is introduced into the child’s diet, usually after 6 months of age.
Celiac disease. This is a form of allergy to gluten, a protein in wheat barley and rye that affects the lining of the small intestine. This leads to inflammation of the lining of the small intestine, causing diarrhea from poor absorption of nutrients. It can also lead to poor growth in some children.
A lack of adequate digestive enzymes made by the pancreas. This can lead to frequent loose, bulky and fatty stools secondary to improper digestion and poor growth.
Occasionally, inflammatory bowel disease like ulcerative colitis or Crohn’s disease can cause diarrhea. These children have frequent bowel movements, with blood in stools and poor growth.
Short bowel. Children with this condition, which refers to a lack of adequate bowel length to digest and absorb nutrients, will often experience diarrhea and poor growth.
Rarely, genetic causes can lead to inflammation of the bowel or poor function of the lining of the bowel. These children often have more frequent loose stools and poor growth, and they sometimes require tube feeds or intravenous nutrition to help with nutrition.
What evaluation is necessary for chronic diarrhea?
If your child has long-standing loose stools, it’s prudent to seek help from his or her doctor. The doctor will take a detailed history and perform a physical exam to assess association of loose stools with any specific foods, plus evaluate growth and ensure there are no other concerns related toorgans in the body beyond the intestine.
If your child is thriving, and the frequency of bowel movements are variable, he or she likely has toddler’s diarrhea. If your child’s growth is adversely affected, the doctor will likely perform tests including a blood count to look for anemia, blood chemistry to ensure the electrolytes are normal and blood protein to see if the albumin is OK. If your child is suffering from anemia or low albumin, the possibility of GI inflammation will be considered.
A celiac disease antibody panel can help diagnose the disorder. If the tests support this diagnosis, your child’s pediatric gastroenterologist may discuss the need for an upper endoscopy to confirm.
An upper and lower endoscopy may be required to diagnose IBC. It’s also possible your kid will undergo stool studies estimating pancreatic enzymes or fat content of the stool. Occasionally, a CT or MR scan may be required to help augment diagnosis like IBD or pancreatic abnormalities. Rare genetic disorders that may be associated with frequent diarrhea will require genetic testing to conform the diagnosis.
What are the possible management options for chronic diarrhea is children?
Celiac disease requires complete elimination of gluten. Enlisting the help of a pediatric dietitian can help. These children will require regular follow-up, including to ensure that the child is diet-compliant and growing appropriately.
Infections like Giardia require specific treatment, and treatment of immune deficiency may require the assistance of a pediatric immunologist.
Lactose intolerance symptoms improve on a low lactose diet. It’s important that children under age 5 are evaluated to rule out other secondary cause, like post-viral gastroenteritis or celiac disease.
Children with inflammatory bowel disease will require specific therapies to control inflammation. A pediatric gastroenterologist can help guide treatment.
Children with short bowel may require intravenous nutrition or tube-feeding to supplement calories, while monitoring growth and nutrient deficiencies. These children are best managed by centers equipped to manage such issues.
Specific genetic mutations that cause diarrhea will need treatments catered to that disorder.
Overall, a team approach that involves the pediatrician, pediatric gastroenterologist and pediatric dietitians and other pediatric specialists as required best serves the interest of children with chronic diarrhea. This will ensure optimal growth and development.
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