Diarrhea

Definition

• Diarrhea is the sudden increase in the frequency and looseness of stools
• The main risk of diarrhea is dehydration
• Loose or runny stools do not cause dehydration
• Frequent, watery stools can cause dehydration

Causes 

• Viral gastroenteritis (viral infection of the stomach and intestines) is the usual cause
• Bacteria (e.g., salmonella or shigella) cause some diarrhea
• Food poisoning: Rapid onset of vomiting and diarrhea within hours after eating a food contaminated with toxins (e.g., cream dishes that are not properly refrigerated). The symptoms usually resolve in less than 24 hours without a need for medical care.
• Giardia (a parasite) occasionally, especially in child care centers

Dehydration: How to Recognize 

• Dehydration means that the body has lost excessive fluids, usually from vomiting and/or diarrhea. An associated weight loss of more than 3% is required. In general, mild diarrhea, mild vomiting or a mild decrease in fluid intake does not cause dehydration.
• Dehydration is the most important complication of diarrhea.
• The following are signs of dehydration:
  • Decreased urination (no urine in more than 8 hours for infants and no urine in more than 12 hours for older children) occurs early in the process of dehydration. So does a dark yellow, concentrated yellow. If the urine is light straw colored, your child is not dehydrated.
  • Dry tongue and inside of the mouth. Dry lips are not helpful.
  • Dry eyes with decreased or absent tears
  • In infants, a depressed or sunken soft spot
  • Delayed capillary refill longer than 2 seconds. This refers to the return of a pink color to the thumbnail after you press it and make it pale. Ask your doctor to teach you how to do this test.
  • Irritable, tired out or acting ill. If your child is alert, happy and playful, he or she is not dehydrated.
  • A child with severe dehydration becomes too weak to stand or very dizzy if tries to stand.
   

Return to School 

• Your child can return to child care or school after the stools are formed and the fever is gone. The school-aged child can return if the diarrhea is mild and the child has good control over loose stools.

Definition of Diarrhea in Breastfed Infants 

• The stools of a breastfed infant are normal unless they contain mucus or blood or develop a new bad odor.
• The looseness (normally runny and seedy), color (normally yellow) and frequency of stools (normally more than 6/day) are not much help. Breastfed babies may normally even pass some green stools surrounded by a water ring (normal bile can come out green if intestinal transit time is rapid enough).
• During the first 1 to 2 months of life, the breastfed baby may normally pass a stool after each feeding. (However, if an infant's stools abruptly increase in number and looseness and persist for 3 or more stools, the baby probably has diarrhea.)
• Other clues to diarrhea are poor eating, acting sick, or a fever.

Definition of Diarrhea in Formula-Fed Infants 

• Formula-fed babies pass 1 to 8 stools per day during the first week, then 1 to 4 per day until 2 months of age.
• The stools are yellow in color and peanut butter in consistency.
• Formula-fed newborns have true diarrhea if the stools abruptly increase in number or looseness and persist for 3 or more stools, become watery or very runny, contain mucus or blood or develop a new bad odor.
• Other clues to diarrhea are poor eating, acting sick or a fever.
• After 2 months of age, most infants pass 1 or 2 stools per day (or 1 every other day) and no longer appear to have mild diarrhea.

When to Call Your Doctor for Diarrhea

Call Your Doctor Now (night or day) If

Call Your Doctor Within 24 Hours (between 9 am and 4 pm) If

Call Your Doctor During Weekday Office Hours If

Parent Care at Home If

Home Care Advice for Diarrhea

1. Reassurance:
   • Most diarrhea is caused by a viral infection of the intestines.
   • Diarrhea is the body's way of getting rid of the germs.
   • Here are some tips on how to keep ahead of the fluid losses.
    
2. Mild Diarrhea:
   • Continue regular diet.
   • Eat more starchy foods (e.g., cereal, crackers, rice).
   • Drink more fluids. Formula or milk are good balanced fluids for diarrhea. (EXCEPTION: avoid all fruit juices and soft drinks because they make diarrhea worse).
    
3. Formula-Fed Infants WITH frequent, watery diarrhea: Start Oral Rehydration Solutions (ORS)
   • ORS (e.g., Pedialyte or the store brand) is a special electrolyte solution that can prevent dehydration. It's readily available in supermarkets and drug stores.
   • Start ORS for frequent, watery diarrhea (Note: Formula is fine for average diarrhea).
   • Use ORS alone for 4 to 6 hours to prevent dehydration. Offer unlimited amounts.
   • If ORS not available, use formula prepared in the usual way (unlimited amounts) until you can get some.
   • Avoid Jello water, sports drinks, or fruit juice.
    
4. Returning to Formula
   • Go back to formula by 6 hours at the latest. (Reason: needs the calories)
   • Use formula prepared in the usual way. (Reason: It contains adequate water).
   • Offer the formula more frequently than you normally do.
   • Lactose: Regular formula is fine for most diarrhea. Lactose-free formulas (soy formula) are only needed for watery diarrhea persisting over 3 days.
   • Extra ORS: also give 2–4 ounces (60–120 ml) of ORS after every large watery stool.
    
5. Solids
   • Infants over 4 months old: Continue solids (e.g., rice cereal, strained bananas, mashed potatoes, etc).
    
6. Breastfed Infants WITH frequent, watery diarrhea:
   • Continue breastfeeding at more frequent intervals. Continue solids as for formula-fed.
   • Offer 2–4 ounces (60–120 ml) ORS after every large watery stool (especially if urine is dark) in addition to breastfeedings.
    
7. Older Children (over 1 year old) WITH frequent, watery diarrhea:
   • Fluids: Offer unlimited fluids. If taking solids, give water or half-strength Gatorade. If refuses solids, give milk or formula.
   • Avoid all fruit juices and soft drinks. (Reason: makes diarrhea worse)
   • ORS (Pedialyte) is rarely needed, but for severe diarrhea, also give 4–8 ounces (120–240 ml) of ORS after every large watery stool.
   • Solids: Starchy foods are absorbed best. Give dried cereals, oatmeal, bread, crackers, noodles, mashed potatoes, rice, etc. Pretzels or salty crackers can help meet sodium needs.
    
8. Probiotics:
   • Probiotics contain healthy bacteria (Lactobacilli) that can replace unhealthy bacteria in the GI tract.
   • YOGURT is the easiest source of probiotics. If over 12 months old, give 2 to 6 oz (60 to 180 ml) of yogurt twice daily. (Note: Today, almost all yogurts are "active culture".
    
9. Diaper Rash: Wash buttocks after each stool to prevent a bad diaper rash. Consider applying a protective ointment (e.g., petroleum jelly) around the anus to protect the skin.
10. Contagiousness: Your child can return to child care or school after the stools are formed and the fever is gone. The school-aged child can return if the diarrhea is mild and the child has good control over loose stools.
11. Expected Course: Viral diarrhea lasts 5-14 days. Severe diarrhea only occurs on the first 1 or 2 days, but loose stools can persist for 1 to 2 weeks.
12. Call Your Doctor If:
    • Signs of dehydration occur
    • Diarrhea persists over 2 weeks
    • Your child becomes worse
     

And remember, contact your doctor if your child develops any of the "When to Call Your Doctor" symptoms.

References

1. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis Practice parameter: The management of acute gastroenteritis in young children. Pediatrics. 1996;97:424-431
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3. Anidi I, Bazargan M, James FW. Knowledge and management of diarrhea among underserved minority parents/caregivers. Ambulatory Pediatrics. 2002;2:201-206.
4. Armon K, Elliott EJ. Acute gastroenteritis. In: Moyer V, Davis RL, Elliott E, et al, eds. Evidence Based Pediatrics and Child Health.London, England: BMJ Publishing Group; 2000. p. 273-286
5. Atherly-John YC, Cunningham SJ, Crain EF. A randomized trial of oral versus intravenous rehydration in a pediatric emergency department. Arch Pediatr Adolesc Med. 2002;156:1240-1243.
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15. Meyers A, et al. Safety and effectiveness of homemade and reconstituted packet cereal-based oral rehydration solutions. Pediatrics. e-pages 1997;100(5):www.pediatrics.org.
16. Ozuah PO, Avner JR, Stein REK. Oral rehydration, emergency physicians, and practice parameters: A national survey. Pediatrics. 2002;109:259-261.
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Disclaimer

This information is not intended to be a substitute for professional medical advice. It is provided for educational purposes only. You assume full responsibility for how you choose to use this information.

Author and Senior Reviewer: Barton D. Schmitt, M.D.

Last Reviewed: 8/1/2010

Last Revised: 10/19/2010 6:27:50 PM

Copyright 1994-2011 Barton D. Schmitt, M.D.