What do you need to know when your child is having loose stools?

 Childhood diarrhoea

Q1. What is diarrhea?

Diarrhoea in children has been defined in many ways in various literatures (according to frequency of stool, weight of stool or consistency).  Though the number of stool per day varies greatly from newborn to older children according to age, dietary habit and many other factors, usually more than 3 episode per day with recent change in consistency (ie. loose stool) is considered best to define diarrhea in children. 

Q2. How is ‘diarrhea in children’ different from adults?

Acute diarrhea and resultant dehydration is the second most common cause of death (after Pneumonia) in children below 5 years in India.

• Children has a relatively large body surface area and less amount of total body water content,

• Children are mostly unlikely to take sufficient water to replace the lost water during acute diarrhea.

 Thereby, these two factors make children more prone to dehydration (loss of water from body) easily than adults. 

Q3. What are the types of diarrhea in children?

According to the underlying mechanism, there are 4 types of diarrhea.

1. Secretory: eg Cholera

2. Osmotic: eg fruit juice ingestion

3. Motility: Bacterial overgrowth

4. Short gut syndrome

Though not very relevant in case of acute diarrhea, it may be of concern for your physician for a case of persistent (>2 week duration) diarrhea. 

Q4.  What are the causes of diarrhea in children? 

In majority of cases, it is due to viral infection (eg Rotavirus, adenovirus etc). Few cases can be due to some other agents like bacteria (Shigella, Salmonella etc) or parasite (eg Giardia, Cryptospora) or some non-infective causes (eg Hirschprung colitis). 

Q5. What is the role of antibiotics in childhood diarrhea?

• As the most cases of diarrhea is due to self-limited viral infection only, antibiotics are unnecessary and injudicious use may lead to side-effects including antibiotic associated diarrhea and antibiotic resistance. Usually the child improves after 4-7 days of illness. However in certain circumstances (severe abdominal pain / blood or mucus in stool/ fever/ Immunocompromised child), antibiotics may be prescribed by your physician for a short duration. 

Q6. What to do when your child is having diarrhea (sudden onset loose stools frequently)? 

The first thing to remember is – don’t panic. Most cases are self-limited and resolve spontaneously within one week. However, the most important job as a parent or caretaker is

• Notice the child carefully, specially for danger signs (explained later) (change of behavior, thirst, water intake, number of stools per day, blood in stool etc; Preferably can keep some photographs or videos to show your physician as it helps in many cases)

• Give your child supportive measures: 

1. WHO-ORS (this is the best and single most important strategy which has significantly decreased diarrheal mortality over the last few decades). 

• How to prepare?

 Mix as per instruction on the sachet (usually 1 sachet total to be dissolve in one liter of drinking water, then shake it and offer your child to drink)

• Amount to be given: 

Give as plenty as possible, offer the child frequently at every 15-20 minute interval. Also give 100-200ml after each episode of loose stool additionally [<2yr: 1-2 tsf Q1-2min; older: frequent sips directly from cup] [extra ORS: <2yr 50-100ml/episode of motion & >2yr 100-200ml/episode of motion]

• How to make sugar salt water at home?

It is a substitute for WHO-ORS which can be used if WHO-ORS is not available readily. Prepared by 1 liter water with 6 Level teaspoon sugar and ½  level teaspoon salt.

2. Zinc therapy:  many randomised  trials showed the benefit of this simple therapy: decreases the severity, duration and frequency of diarrhea, helps in remodelling of gut epithelium and it is advisable to complete the two weeks course completely even if diarrhoea resolves before-hand. 

• Preparation: Zinc acetate (20mg/5ml)

• <6month age: 10mg/Day  for 14 days

• >6month age: 20mg/Day for 14 days

3. It is always good to get reviewed by a pediatrician nearby if you think that the child is not behaving well and your assessment is not adequate. 

Q7.   What dietary modification is needed?

The following factors should be kept in mind when your child is having acute onset of loose stools.

• Do not give: 

• Soft drinks (Carbonated drinks- cold drinks)

• Sweetened tea/ fruit juices/ coffee

• Can consider giving the following:

• No Salt: clean water/ coconut water/unsalted rice water/unsalted yogurt drink/ weak tea/ unsalted fresh fruit juice

• With salt: salt-sugar water/ salted soup/ salted soup/ salted yogurt drink/ salted rice water

• Continue feeding: Breast milk/ Smashed banana/ Khichdi/ bland diet etc

Q8.   What are the danger signs (or warning signs) for acute diarrhea in children?

The following are a few signs, when present, better it is to get the child seen by a pediatrician nearby.

• becomes very thirsty or lethargic, unable to drink

• cold extremities 

• decreased urine output

• repeated episodes of vomiting

• doesn't get better in 3 days

Q9.   Tabulate the management of diarrhoea in gist:

Management of ACUTE Diarrhoea in children
Treatment strategy	Why and How	How to give ?
Hydration	Assess Dehydration: 4 points:  Mental status:  Shrunken eyes Thirst/ drinking Skin pinch	No Dehydration: Plan A SOME Dehydration: Plan B SEVERE Dehydration: Plan C
Nutrition	Assess for malnutrition (to cut off the vicious cycle of diarrhea> malnutrition> prone to diarrhea)	Continue feeding SAM cocktail if severely malnourished (calorie food, electrolytes and vitamin)
Zinc	Decreases the severity, duration and frequency of diarrhea & Also the frequency of diarrhea episodes in the next 3-4 months.	Preparation: Zinc acetate (20mg/5ml) <6month: 10mg/Day  for 14 days >6month: 20mg/Day for 14 days
Antibiotics ?	Mostly viral Bacterial/protozoal: severe abdominal pain / blood or mucus in stool/ fever Immunocompromised	Consider Metronidazole/ Ornidazole-ofloxacin If immunocompromised, consider Stool RM for OPC (ovum parasite cyst)/ stool for Cl difficile PCR; Add Nitazoxanide for 3 days for Giardiasis
Probiotics ?		Not recommended so far in short diarrhoea, needs more evidence based study However few clinicians use in special circumstances with some benefits (Physician’s choice)
Perianal examination	To check for diaper rash sometimes few findings may be noted like anal skin tag (may indicate underlying disease eg. anal tag or perianal fistula in Crohn’s disease)	Apply soothing creams [Rashfree cream (Benzalkonium and zinc oxide), Siloderm ointment(Dimethicone, Zinc oxide, calamine and cetrimide), Cetaphil baby diaper cream]
Monitoring		Frequency of monitoring: depends on the level of dehydration. Parameters: Vitals, dehydration and urine output Looks Puffy?   stop ORS/ give plain water or other fluids Vomiting: wait for 5-10 min, slowly give ORS again, may consider adding antiemetic  (Ondansetron/Domperidone)
Investigations	to be decided on an individual basis, best by a pediatrician.	CBC/ serum electrolytes/ VBG/ Blood culture/  Stool PCR panel If Suspected HUS: w/up for that Stool elastase, Sweat Cl, Anti-TTG Malabsorption: Stool Reducing sugar, Stool fat,  HIV, Ig profile Colonoscopy
	Plan A:	Give extra fluid: (ORS or HOF) freshly prepared fruit juice/ soup/ rice water/ dahl water/ coconut water [extra ORS: <2yr 50-100ml/episode of motion & >2yr 100-200ml/episode of motion] Continue feeding: Breast milk/ Smashed banana/ Khichdi etc Give Zinc Explain Danger signs and when to come back. (appears more sick/ lethargy/ unable to feed/ cold extremity/ decreased urine output/ fever/ blood in stool)
	Plan B:	ORS correction 7.5% over 4 hours 75ml/kg ORS frequently over 4 hours orally / via NG tube/ intravenous
	Plan C:	Intravenous fluid correction 10% IVF: RL or NS (not 5D), 100ml/kg (30ml/kg + 70ml/kg) <1yr: 1 hr + 5 hr >1yr: ½ hr + 2 ½ hr Frequent assessment/monitoring (15-30min)
	HAF (Home available fluids) for diarrhoea	No Salt: clean water/ coconut water/unsalted rice water/unsalted yogurt drink/ weak tea/ unsalted fresh fruit juice With salt: salt-sugar water/ salted soup/ salted soup/ salted yogurt drink/ salted rice water
	DO NOT GIVE	Soft drinks (Carbonated drinks- cold drinks) Sweetened tea/ fruit juices/ coffee

[Author information: Dr Sabyasachi Mistri, MD (Pediatrics), AIIMS, sabyasachimistri@gmail.com ]