Overview of Diarrhea by Dr. Arun Aggarwal

Diarrhea refers to the passage of loose or watery stools or an increased frequency of stools. Diarrhea is not a disease but is a symptom of a number of illnesses. Diarrhea can lead to dehydration, which alters the child's natural balance of water, and to electrolyte (sodium, potassium, chloride) imbalance. It can be serious if not treated promptly.

Frequency — It is normal for young infants to have up to 3 to 10 stools per day, although this varies depending upon the child's diet (breast milk versus formula; breastfed children usually have more frequent stools). Older infants, toddlers, and children normally have one to two bowel movements per day.

Consistency and color — The consistency and color of a child's stool normally changes with age, which highlights the importance of knowing what is normal for your child. Young infants, especially those who are breastfeeding, usually have soft stools. Their stools may be yellow, green, or brown, and/or appear to contain seeds or small curds.

All children's stools can vary as a result of their diet. Development of stools that are runny, watery, or contain mucus is a significant change that should be monitored. The presence of visible blood or black stools is never normal and always requires medical attention.

DIARRHEA CAUSES — The most common cause of acute diarrhea is a viral infection. Other causes include bacterial infections, side effects of antibiotics, and infections not related to the gastrointestinal (GI) system. In addition, there are many less common causes of diarrhea.

Viral infection — Viral infection is the leading cause of diarrhea in children. Symptoms of viral infection can include fever, watery diarrhea, vomiting, abdominal cramps, lack of appetite, headache, and muscle aches.

Viral infection usually begins 12 hours to 5 days after exposure and resolves within three to seven days. No specific treatment is available for viral causes of diarrhea. Children with diarrhea from viral infections are best treated with supportive measures (oral rehydration solution; age-appropriate diet, limiting foods high in fat and simple sugars; and rest).

Bacterial infection — more common in locations where there is unsafe drinking water and poor handling of sewage. Persistent high fever and diarrhea that is bloody or contains mucus are more common with bacterial diarrhea. Most children with bacterial infection do not require antibiotics and will improve with time and supportive measures.

Parasitic infection — common in locations where there is unsafe drinking water and poor handling of sewage. Diarrhea from parasitic infections may last for weeks to months.

HOME CARE OF DIARRHEA —

Dietary recommendations —

• Most children with diarrhea tolerate full-strength cow's milk products. It is not necessary to dilute or avoid milk products, except in children with known allergies to cow's milk.
• Recommended foods include a combination of complex carbohydrates (rice, wheat, potatoes, bread), lean meats, yogurt, fruits, and vegetables. High-fat foods are more difficult to absorb and should be avoided.
• The unnecessary restriction of a child's diet to clear liquids or the BRAT diet (bananas, rice, applesauce, toast) results in inadequate intake of nutrients (calories and/or protein). Giving only clear liquids for several days can actually prolong diarrhea (called "starvation stools").

Monitoring for dehydration — Mild dehydration is common in children with diarrhea. Signs and symptoms of mild dehydration include a slightly dry mouth, increased thirst, and slightly decreased urine output (one wet diaper or void in six hours). Common features of moderate or severe dehydration include markedly decreased urination (less than one wet diaper or void in six hours), lack of tears when crying, dry mouth, and sunken eyes.

Oral rehydration therapy — ORT does not cure diarrhea, but it does help to treat the dehydration that often accompanies it.

Parents should first measure out the total amount to be given with a standardized medicine syringe or measuring cup or spoon, rather than a regular cup or spoon. A child who refuses to drink or vomits immediately after drinking ORS should be monitored closely for worsening dehydration. Children who are not dehydrated may drink ORS after every episode of vomiting to prevent dehydration.

Medications — Medications such as antibiotics and antidiarrheal agents are generally not necessary and could be harmful for infants or children with diarrhea. Rarely, antibiotics may be used in cases of bacterial infection when a specific cause of the diarrhea has been found or is strongly suspected. Inappropriate use of antibiotics will not improve diarrhea. Furthermore, antibiotics can cause side effects and lead to development of antibiotic resistance.

Probiotics — There are "healthy" bacteria (called probiotics) that may help reduce the duration of diarrhea (by about 12 to 30 hours).

PREVENTING SPREAD — Care with hand washing, diapering, and keeping sick children out of school or daycare until the diarrhea is gone are a few ways to limit the number of people exposed to the infection.

Children who have diarrhea should not swim in swimming pools. Those who are not toilet trained should avoid swimming in swimming pools for one week after the diarrhea has recovered.

WHEN TO SEEK HELP FOR DIARRHEA — The following is a list of signs and symptoms that are worrisome and require immediate medical attention:

• Bloody diarrhea
• Refusal to eat or drink anything for more than a few hours in infants and for more than eight hours in children
• Moderate to severe dehydration
• Abdominal pain that comes and goes or is severe

SUMMARY

• Most episodes of acute diarrhea resolve on their own. However, immediate medical attention should be sought for children who have any of the following: bloody diarrhea; signs of moderate to severe dehydration; refusing to eat or drink anything; abdominal pain that comes and goes or is severe; behavior changes, including lethargy or decreased responsiveness.
• The most common cause of acute diarrhea is a viral infection. Other causes include bacterial infections, side effects of antibiotics, and body-wide infections not related to the gastrointestinal (GI) system.
• Children who are not dehydrated should continue to eat their regular diet. Children who are dehydrated should be rehydrated, after which they can resume their normal diet.
• Oral rehydration therapy (ORT) should initially be given to children who are dehydrated. Common signs and symptoms of dehydration include decreased urination (less than one wet diaper or void in six hours), lack of tears when crying, dry mouth, sunken eyes, and weight loss.
• Medications such as antibiotics and antidiarrheal agents are generally not recommended.
• Parents with children who have diarrhea should be cautious to avoid spreading infection to themselves, their family, friends, and others. Care with hand washing, diapering, and keeping sick children out of school or day care are a few ways.