Chronic diarrhoea is diagnosed when your child has diarrhoea for most days for more than 4 weeks. That is not fun for anyone involved. While most episodes of diarrhoea are mostly self-limiting and mostly does not need any investigations, there are a few things the doctor should check for when it becomes chronic. (I repeat mostly because some children can develop a picture of septic shock from diarrhoea, or severe dehydration, which will be thoroughly investigated!)
Some rare causes of chronic diarrhoea are parasitic infections, inflammatory bowel diseases, malnutrition, or malabsorption secondary to diseases such as Cystic Fibrosis. Your doctor will probably request tests on the stool itself, and your child might need some blood tests.
Another more common cause is “Functional diarrhoea”, also named “Toddler’s diarrhoea”. This diagnosis is made when a child has more than 4 stools a day for more than 4 weeks, and more serious issues were excluded. It is often caused by a diet high in fruit-sugars or milk-sugars (or other nutrients that are not absorbed), thus pulling more water into the bowels, leading to diarrhoea. (This sketch will explain more thoroughly). Functional diarrhoea should clear up after a visit to a dietitian.
“Cast all your anxiety on Him because He cares for you.”1 Peter 5:7
“Prevention is better than cure” is one of my favourite mantras. The World Health Organisation has a few recommendations to prevent diarrhoea1:
- Consumption of safe food and water. (We often take this step for granted, but many people do not have access to clean water. However, we should all boil any water given to a baby under the age of 6months (especially as part of their formula) and rinse fruit and vegetables well before eating it. Take note of the expiry dates on expendable foods and keep meat separately in the fridge.)
- Handwashing for everyone. Sterilizing bottles and dummies given to babies under the age of 6months
- Immunizations against the Rota Virus has sharply decreased the number of babies admitted with severe diarrhoea and dehydration.
Unfortunately it is almost inevitable that your children will get poonamies or vulcanic vomiting at some point. Let me give you a strategy for when the poo hits the fan:
1.Offer fluids regularly:
The main aim of treatment is to prevent or treat dehydration.
- The best fluids to use are a combination of pre-mixed electrolytes (such as Rehydrat), diluted with boiled, cooled water. These sachets have the correct ratio of sugars to carry the salts and water back into the body. Another study compared the use of diluted apple juice2 (1:1 diluted with water) to these sachets and found that in children with mild dehydration the outcomes were the same, making diluted apple juice a good alternative. Using water with no supplements could lead to low salt-levels in the blood, using chicken broth could lead to dangerously high levels of salts in the blood.
- To treat mild dehydration (see previous post), you should give your child between 50-100mls of fluids/kg over 4 hours. Eg: Your child weighs 12kg. You should give 600-1200ml over 4 hours (150-300ml/hr). It works best if you give a spoonful/ a few sips every 5-10min. Big volumes can make them vomit again. I was surprised at how hard it can be to let your 8month old take a few mouthfuls of fluids if he is just simply refusing. Try to make it fun, do it with him, use a syringe / a straw / a cup with his favourite movie-character on. Just keep on offering!
- To prevent further dehydration, you should give them 10ml/kg after each loose stool or vomit. Eg: Your child weighs 12kg, you should give 120ml of fluids after each loose stool. If the stools are just pouring out every few minutes and you cannot keep up, rather go to the Emergency Unit for help.
- If your child has signs of moderate/severe dehydration, or they keep on vomiting the fluids that you give them, please go to the Emergency Unit asap.
2. Continue to offer food during snacks and mealtimes
It is important to continue breastfeeding and giving regular foods (even dairy products) during a bout of diarrhoea. Your child might not have a good appetite, so offer them foods that they usually like, and do not worry if they only take a few bites. It is important to keep the lining of the bowels healthy, or the diarrhoea might be prolonged.
3. Anti-diarrhoea medications
Never give children medication to stop the diarrhoea. This causes a build-up of the toxin/virus/bacteria in the bowels, causing it to diffuse into the bloodstream, and this can make them really sick. Anti-vomiting medication is also dangerous as it can make them sleepy (thus they drink less) or have dangerous side-effects in children.
Medications like Diosmectite (Smecta) can be really efficient as it binds the toxin/virus/bacteria and expells it. It also improves the consistency of the poo. It is not absorbed, thus is safe to give to babies over 6months. It does taste quite horrible, but we have managed to give it to Eran with a syringe while blowing on his face to distract him/ help him swallow.
As most episodes of diarrhoea are caused by viruses, antibiotics are mostly not necessary. If your child has high fevers or bloody diarrhoea there is mostly a bacteria involved which needs to be treated with antibiotics as prescribed by your doctor.
- Zinc: Several studies3,4 have proven that Zinc supplements can decrease the severity and duration of diarrhoea in children under 5 years. Give your child a Zinc 10mg/day (under 6 months) or 20mg/day (6 months-5 years) in a supplement such as Zinplex syrup.
- Probiotics: The use of probiotics can help to restore the microbiome of the bowel and thus help to get the diarrhoea under control. Reuteri drops are safe to give even from birth and although researchers cannot prove which dose or strain gives the best results, we know it should not cause any harm.
“the secret of the care of the patient is in caring for the patient”Dr. Francis Peabody
I hope these tips will help to get your kiddies eating and playing again sooner rather than later! Let me know what food / fluids works best for you when your child has diarrhoea?
- WHO; “Preventing diarrhoea through better water, sanitation and hygiene: exposures and impacts in low- and middle-income countries”
- Freedman SB, Willan AR, Boutis K, Schuh S; “Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial.”; JAMA. 2016;315(18):1966.
- Lukacik M, Thomas RL, Aranda JV; “A meta-analysis of the effects of oral zinc in the treatment of acute and persistent diarrhea.”; Pediatrics. 2008;121(2):326.
- Lazzerini M, Ronfani L; “Oral zinc for treating diarrhoea in children.”; Cochrane Database Syst Rev. 201