Diarrhea

Pediatric HouseCalls Online

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.

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 over 8 hours, no tears with crying and very dry mouth).
• Blood in the stool.
• Fever over 104° F (40° C) and not improved 2 hours after fever medicine.
• Age under 12 weeks with fever above 100.4°F (38.0° C) rectally.
• Abdominal pain present over 2 hours.
• Vomiting clear liquids 3 or more times.
• Age under 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 9 am and 4 pm) If

• You think your child needs to be seen.
• Pus in the stool present for over 2 days.
• Loss of bowel control in a toilet trained child occurs 3 or more times.
• Fever present for more 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

• Loose stools are a chronic problem

Parent Care at Home If

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

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.  (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 bananast, 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 2to 6 oz.(60 to 180 ml) of yogurt twice daily. (Note: Today, almost all yogurts are "active culture".)
   • Probiotic supplements in granules, tablets or capsules are also available in health food stores.
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 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.
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 "Call Your Doctor" symptoms. 

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.

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

Last Reviewed: 1/19/2009

Last Revised: 6/12/2008

Content Set: Pediatric HouseCalls Online

Copyright 1994-2009 Barton D. Schmitt, M.D.