DIARRHEA

Symptom Definition

• Diarrhea is the sudden increase in the frequency and looseness of BMs (bowel movements, stools).
• Mild diarrhea is the passage of a few loose or mushy BMs.
• Severe diarrhea is the passage of many watery BMs.

Causes

• Viral gastroenteritis (viral infection of the stomach and intestines) is the usual cause
• Bacteria (e.g., Salmonella or Shigella) cause some diarrhea
• Giardia (a parasite) occasionally, especially in child care centers

Definition of Diarrhea in Breastfed Infants

• The BMs 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 BMs (normally more than 6/day) are not much help.  Breastfed babies may normally even pass some green BMs surrounded by a water ring (normal bile can come out green if GI transit time is rapid enough).
• During the first 1 to 2 months of life, the breastfed baby may normally pass a BM after each feeding.  (However, if an infant's BMs 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 BMs 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.

Return to School

• Your child can return to day 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.

See More Appropriate Topic (instead of this one) If

• The vomiting is worse than the diarrhea, see VOMITING.
• Blood present and no diarrhea, see STOOLS, BLOOD IN.

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WHEN TO CALL YOUR DOCTOR

Call 911 now (your child may need an ambulance) if:

• Not moving or too weak to stand.

Call your doctor now (night or day) if:

• Your child looks or acts very sick.
• Signs of dehydration (e.g. no urine in over 8 hours, no tears with crying and very dry mouth).
• Blood in the stool.
• Fever above 105°F (40.6° C).
• Age less than 12 weeks with fever above 100.4°F (38° C) rectally. (Caution: Do NOT give your baby any fever medicine before being seen.)
• Abdominal pain present more than 2 hours.
• Vomiting clear liquids 3 or more times.
• Age less than 1 month with 3 or more large diarrhea stools.
• Passed more than 8 diarrhea stools in the last 8 hours.
• Severe diarrhea while taking a medicine that could cause diarrhea (e.g., antibiotics).

Call your doctor within 24 hours (between 9am and 4pm) if:

• You think your child needs to be seen.
• Mucus or pus in the stool for more than 2 days.
• Loss of bowel control in a toilet trained child occurs 3 or more times.
• Fever longer than 3 days.
• Close contact with person and animal who has bacterial diarrhea.
• Contact with reptile (snake, lizard, turtle) in previous 14 days.
• Travel to country at risk for bacterial diarrhea within past month

Call your doctor during weekday office hours if:

• You have other questions or concerns
• Diarrhea persists over 2 weeks or is a recurrent problem.

Parent care at home if:

• Mild diarrhea, probably viral gastroenteritis and you don't think your child needs to be seen.

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HOME CARE ADVICE

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. (EXCEPTION: avoid all fruit juices and soft drinks because they make diarrhea worse).
3. Formula-Fed Infants (less than 1 year old) 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 oz. 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 oz. 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 is rarely needed, but for severe diarrhea, also give 4-8 oz. of ORS after every large watery stool.
• Solids: Starchy foods are absorbed best.  Give dried cereals, oatmeal, bread, crackers, noodles, mashed potatoes, rice, carrots, applesauce, strained bananas, etc.  Pretzels or salty crackers can help meet sodium needs.
• Yogurt: If over 12 months old, give 2-6 oz. of active culture yogurt twice a day. (Reason: restores healthy bacteria to GI tract).
8. 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.
9. Contagiousness: Your child can return to day 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.
10. 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.
11. 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 worsens or develops any of the "Call Your Doctor" symptoms.

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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.
2. Anidi I, Bazargan M, James FW. Knowledge and management of diarrhea among underserved minority parents/caregivers. Ambulatory Pediatrics. 2002;2:201-206.
3. 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.
4. 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.
5. Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006;11(8):527-531.
6. Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003;52(RR-16):1-16.
7. Fonsecca BK, Holdgate A, Craig JC. Enteral vs intravenous rehydration therapy for children with gastroenteritis. Arch Pediatr Adolesc Med. 2004; 158:483-490.
8. Gastanaduy AS and Begue RE. Acute gastroenteritis. Clin Pediatr. 1999;38(1):1-12.
9. Gorelick MH, Shaw KN, Murphy KO. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics. 1997;99(5):E6.
10. Lasche J and Duggan C. Managing acute diarrhea: What every pediatrician needs to know. Contemp Pediatr. 1999;16(2):74-83.
11. 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.
12. Ozuah PO, Avner JR, Stein REK. Oral rehydration, emergency physicians, and practice parameters: A national survey. Pediatrics. 2002;109:259-261.
13. Porter SC, Fleisher GR, Kohane IS, Mandl KD. The value of parental report for diagnosis and management of dehydration in the emergency department. Ann Emerg Med. 2003;41:196-205.
14. Richards LM, et al. Management of acute diarrhea in children: Lessons learned. Pediatr Infect Dis J. 1993;12:5-9.
15. Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated? JAMA. 2004;291:2746-2754.
16. Van Niel CW, Feudtner C, Garrison MM, Christakis DA. Lactobacillus therapy for acute infectious diarrhea in children: A meta-analysis. Pediatrics. 2002;109:678-684.

Disclaimer: This information is not intended 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.

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• Stools, Blood in
• Vomiting

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SelfCareNet, Inc. Copyright © 2000-2007 Barton Schmitt, M.D. FAAP

Reviewed 7/2007

Revised 8/2007