Of the childhood diseases parents must deal with, diarrhea is one of the least pleasant, especially with a child in diapers. Unfortunately, it is among the most common. With an understanding of the mechanisms of diarrhea and the appropriate treatment, we can minimize our children's discomfort and our own custodial chores.
Diarrhea, defined as both frequent and watery stools, is most often caused by a gastro-intestinal viral infection. Certainly there are other causes, including bacterial infections, parasitic infections, food intolerance, food allergies, bowel functional problems and other inflammatory conditions. The viral, bacterial and parasitic forms are contagious, which is why, just as in other infectious diseases, good hand-washing, particularly after using sanitary facilities, is imperative.
Associated symptoms, such as persistent fever, prolonged diarrhea (over 7 days despite proper therapy) and weight loss, are suggestive of a process other than simple viral diarrhea. Bacterial and parasitic infections require specific laboratory testing and prescription therapy. Although food intolerance, food allergies, bowel functional problems (e.g., Irritable Bowel Syndrome and constipation) and inflammatory conditions (regional enteritis and ulcerative colitis) are often associated with diarrhea, these specific medical conditions require specialized therapy that is individualized to the patient by their personal physician. That management is beyond the scope of this article. Any suspicion that these conditions are present should trigger a visit to the child's doctor.
The viruses that cause gastrointestinal upset are typically acquired directly from another human. These viruses enter the body through the mouth, eyes or nose either by respiratory secretions or from touching the face with unclean hands. Recent reports have identified the water supply on some cruise ships as a source of outbreaks of shipboard diarrhea. Fever and cold symptoms are commonly associated with these infections. This differs from parasitic infections, which are devoid of cold symptoms and fever, or bacterial infections, which may be associated with fever, but not cold symptoms. Bloody loose stools are otherwise more suggestive or non-viral causes of the diarrhea. Of note is that cancer is almost never a cause of bloody stools in children. Bacterial, parasitic, inflammatory and mechanical causes (constipation or benign polyps) are the things that should come to mind first.
Bacterial enteritis is acquired by ingestion of contaminated food or water. Responsibility for outbreaks of certain enteral bacterial infections has been attributed to nearly every food group from salad and milk products to meat and vegetables, especially when stored or washed improperly. Whether here or abroad, be sure your restaurant food is served and eaten while hot and freshly cooked and avoid partaking of food from curbside vendors (even in the U.S.) because of the uncertainty of the cart heating unit being able to maintain temperature of the food at a level that kills bacteria. Poultry, especially chicken eggs and turkey, are known common carriers of salmonella. Some authorities recommend not rinsing the Thanksgiving turkey before cooking it, since you would risk splashing salmonella all over the food preparation area. Hand washing after handling chicken egg shells (or after handling pet amphibians) will also help avoid contamination. Avoid raw egg products (some Caesar salad dressings). Typhoid vaccine is available for prevention of salmonella infections in travelers to countries where this infection is prevalent.
Travelers to developing countries and campers are at increased risk for parasitic, as well as bacterial, intestinal infections. In countries that do not have sanitary drinking water supply systems (especially common in rural areas), waste water may contaminate drinking water. In these situations, it is best to drink only commercially bottled carbonated beverages or water. Campers may wish to carry iodine pills to sanitize ground water for drinking. Alternatively and more effectively, camping suppliers can provide small portable water pumps, which filter out all infectious organisms. Vigorous boiling for one minute eliminates parasitic and bacterial organisms, but may not kill all viruses.
The mainstay of management of viral diarrhea is dietary. Fluid replacement is critical, especially in the young infant. There is no fluid that particularly stops diarrhea, but there are liquids that will not exacerbate it. Electrolyte solutions, such as Pedialyte®, Lytren®, Kaolectrolyte® and Gerber Liquilytes Oral Maintenance Solution® are all appropriate, either in liquid or freeze push-pop form, depending on the age of the child. Older children with diarrhea often resort to sports drinks, such as Gatorade® or Powerade® for their fluid and electrolyte replacement. Although supported by some studies, fruit juice is usually not recommended in this situation because it tends to be laxative. Cow milk products are not recommended because of four factors:
The dissolved mineral content (solute load) causes an obligatory urinary fluid loss which may compromise the child's fluid balance further
Cow milk sugar, called lactose, is difficult to digest in the presence of a viral enteritis because the necessary enzyme, lactase, is not being produced during and after the illness (Cow milk products should be avoided for at least three days or longer after a viral intestinal insult)
Cow milk protein may not be well digested in the presence of a viral enteritis
Conventional belief holds that nasopharyngeal mucus becomes thicker after ingestion of milk (there is currently no solid scientific evidence to prove or disprove this supposition)
Occasionally, rice or soy beverages are recommended for children who need an enhanced calorie intake or who refuse other liquids. When the child exhibits a desire to eat solid foods, the usual initial offerings consist of foods that are naturally constipating: Bananas, Rice, Apples and Toast (called the BRAT diet). Fruits other than bananas and apples are laxative. Toast represents starchy foods, such as bread, cake, cracker, pasta, potatoes, etc. Vegetables and meats are neither harmful during diarrhea nor helpful in making the stool quality less uncomfortable.
In the occasional child whose diarrhea is very frequent and very watery, a plant extract called attapulgite, sold under the names of Kaopectate® and Diasorb®, will help make the stool less frequent and less watery. (These brands also market a product containing bismuth subsalicylate. We do NOT recommend these for children.) Attapulgite is not absorbed and there is no toxicity associated with it. The same brands, however, market other ingredients under similar brand names, so care should be taken to read the label before administering these preparations to a child. Note that these preparations do not cure an intestinal viral illness. Only time and supportive care can accomplish this goal. We do not recommend agents that inhibit intestinal motility (e.g., Lomotil®, paragoric or Immodium®) to treat viral diarrhea. These agents can make a child more lethargic and lead to accumulation of the diarrhea in the intestine, which allows enhanced absorption of bacterial toxins. They appear to work only by hiding the diarrhea from the child's caretaker. Custodial care of the infant in this situation includes prevention of diaper rash by application of a topical diaper rash cream (e.g., Desitin®, A and D Ointment®, Diaperene®, J&J Ointment®, Balmex®, etc.).
If any of the warning signs mentioned in this article appear during the course of your child's diarrhea, you should consult with your child's doctor. In uncomplicated viral diarrhea, as long as you administer adequate fluid intake, the process will eventually end.
