Basics
Description
- Benign chronic diarrhea in a toddler or a preschool child who appears healthy and is normally active and who is growing, without evidence of systemic illness, infection, malabsorption, or malnutrition
- Also known as chronic nonspecific diarrhea of childhood, toddler's diarrhea, and irritable bowel of childhood
Risk Factors
Genetics
Family members often report nonspecific GI complaints or functional bowel disorders. �
General Prevention
- Limit the consumption and delay the introduction of sorbitol or fructose-rich fruit juices to the infant diet.
- In the treatment of acute gastroenteritis, parents should be instructed to give an oral rehydration solution (ORS) and resume normal feeding early, avoiding diet restrictions.
- Avoid restrictive diets that may cause caloric deprivation.
Pathophysiology
- Carbohydrate malabsorption
- Diarrhea is often preceded by acute gastroenteritis or other viral infection that results in dietary restrictions. Increased oral fluids, including juices, are used to compensate for stool losses and to prevent dehydration.
- Capacity of the small intestine to absorb fructose is limited. Foods that contain equivalent amounts of fructose and glucose are more readily absorbed because of the additive effect of a glucose-dependent fructose cotransport mechanism.
- Excessive consumption of juices high in sorbitol (which inhibits fructose absorption) and those with a high fructose-to-glucose ratio (e.g., apple juice) result in fructose malabsorption and increased intraluminal gas caused by fermentation. The end result is abdominal distension, excessive flatulence, and diarrhea.
- Colonic function: possibly, disruption of colonic ability to ferment unabsorbed carbohydrates into short-chain fatty acids (SCFA), which maintain colonic function and prevent colon-based diarrhea
- Disturbed motility: short mouth-to-anus transit time
- Persistence of immature bowel motility pattern. Failure of initiation of normal postprandial delayed gastric emptying
- Low-fat meals. Meals with high dietary fat delay gastric emptying.
- Excess fluid intake. Infant's colon already operates in high efficiency (in children, higher volume of fluids reach the cecum). Excessive fluids can lead to diarrhea.
- Low-fiber diet. Dietary fiber serves as a bulking agent.
- Excessive fecal bile acids. Rapid transit resulting in excess conjugated bile salt entering the colon. Bacterial degradation produces unconjugated bile salts, which decrease net water absorption in the colon.
Etiology
- Nutritional factors: excessive consumption of fruit juice; high-carbohydrate, low-fat, and low-fiber diet
- Disordered intestinal motility (i.e., variant of irritable bowel syndrome of infancy) with rapid transit
Diagnosis
- The typical age is 12-36 months, but range is 6 months to 5 years.
- Diagnostic criteria (Rome III):
- Daily, painless, recurrent passage of ≥3 large unformed stools
- Symptoms that last >4 weeks
- Onset of symptoms that begins between 6 and 36 months of age
- Passage of stools that occurs during waking hours
- There is no failure to thrive (FTT) if caloric intake is adequate:
- There is no definite diagnostic test. The diagnosis is primarily clinical based on age of onset, the history, symptoms, clinical course, and limited number of laboratory tests. Usually, it is an evident condition and not a diagnosis of exclusion.
History
- Nutritional history is essential, with attention to the 4 Fs (fiber, fluid, fat, and fruit juices) and dietary changes.
- Diarrhea
- For a toddler, it may not be abnormal to have >3 soft and occasionally loose stools a day with visible food remnants.
- Children, typically, have intermittent symptoms, and are often diagnosed with recurrent viral gastroenteritis.
- Stool characteristics
- Stools that smell foul and contain undigested food particles. Presence of blood or mucus suggests another diagnosis.
- Timing of diarrhea
- No stools passed at night, and typically, the first stool of the day is large and has firmer consistency than those occurring later on in the day.
- Recent enteric infection
- Presence of other affected family members, history of travel, day care, and infectious contacts suggests infectious cause.
- Signs and symptoms:
- Thorough history is required because all illnesses in the differential diagnosis are associated with morbidity if diagnosis is delayed.
Physical Exam
- Normal: Children look healthy, eat well, and are growing normally according to serial plots on the growth chart.
- There are no signs of malnutrition or malabsorption. Weight might be influenced by the dietary measures.
- Fecal mass(es) found on abdominal palpation may signal constipation.
Diagnostic Tests & Interpretation
- The following tests would be helpful only if indicated by history and physical exam:
- Cystic fibrosis: sweat test, stool for pancreatic enzymes, and genetic testing
- Celiac disease is common and warrants a serologic testing (antiendomysial antibodies, tissue transglutaminase antibodies with IgA serum levels).
- CBC, iron studies, vitamin levels, serum albumin
- Allergy testing for suspected food proteins (commonly milk, soy, egg, and wheat)
- Inflammatory markers
- Diarrhea as the sole symptom of malabsorption in a normally thriving child is rare.
Lab
- Stool tests and culture: negative for white blood cells, blood, fat, and pathogens including ova, parasites, and Giardia antigen
- Serum electrolytes normal: no dehydration
- Celiac serology: negative
- CBC normal: no anemia
- Food allergen testing: negative
Imaging
Usually unnecessary: Plain abdominal radiograph may demonstrate colonic fecal retention. �
Diagnostic Procedures/Other
- A trial of lactose and fruit juice-free diet done separately is practical and diagnostic.
- Breath hydrogen test has limited benefit and is inferior to a trial of milk avoidance.
- Small bowel biopsy is rarely indicated unless strong evidence suggests another cause (e.g., positive celiac serology).
Differential Diagnosis
- All causes of chronic diarrhea should be considered.
- Infection: bacterial, viral, and parasite (giardiasis, cryptosporidiosis)
- Celiac disease
- Malabsorption: carbohydrate: postinfectious secondary lactose intolerance, sucrase-isomaltase deficiency
- Pancreatic: cystic fibrosis, Shwachman-Diamond syndrome, Johannson-Blizzard syndrome, chronic pancreatitis
- Bile acid disorders: chronic cholestasis, terminal ileum disease, bacterial overgrowth
- Immunologic: cow's milk and soy protein intolerance, food allergy, immunodeficiency
- Food allergies
- Miscellaneous: antibiotic-associated diarrhea, laxatives, fecal retention constipation, UTI, abetalipoproteinemia, inflammatory bowel disease, short-bowel syndrome, hormone-secreting tumors, Munchausen by proxy
- Common conditions that may cause diarrhea without FTT: constipation, lactose intolerance, and persistent infective diarrhea
- Constipation-related diarrhea is frequently overlooked. Consider it if diarrhea alternates with hard stools.
Treatment
Medication
- Medications are unwarranted for a condition primarily caused by food that does not hamper growth.
- Metronidazole may be beneficial for patients with undetected giardiasis.
- Loperamide is effective in normalizing bowel patterns, but only for duration of therapy.
- Studies have shown that certain probiotic preparations such as Lactobacillus rhamnosus and Saccharomyces boulardii may be effective at reducing symptoms.
Additional Treatment
General Measures
Daily diet and defecation diary may document a specific food responsible for loose stools. �
Additional Therapies
Reassure parents that there is no underlying GI disease, infection, or inflammation. �
Issues for Referral
- Failure of response to diet
- Weight loss despite adequate intake
- Presence of other symptoms (e.g., anorexia, irritability, fever, vomiting)
- Fat, blood, and mucus in the stool
Ongoing Care
Follow-up Recommendations
- Improvement with dietary changes confirms the diagnosis and reassures the parents.
- Follow up phone call to parents within a few days of instituting diet. If no improvement within 2 weeks despite good compliance with dietary recommendations, then reconsider diagnosis; consider more diagnostic tests and referral to a specialist.
Patient Monitoring
- Follow growth parameters.
- Monitor symptoms indicating nonfunctional illness.
Diet
- The child's feeding pattern should be normalized according to the 4 Fs:
- Overconsumption of fruit juices should be discouraged, especially those that contain sorbitol and a high fructose-to-glucose ratio (e.g., apple juice, pear nectar).
- Cloudy apple juice or white grape juice may be safe as alternatives.
- Fiber intake should be normalized by introduction of whole-grain bread and fruits.
- Increase dietary fat to at least 35-40% of total energy intake. Substitution of low-fat milk with whole milk may be sufficient.
- Restrict fluid intake to <90 mL/kg/24 h if history is significant for fluid consumption >150 mL/kg/24 h.
- Improvement occurs within a few days to a couple of weeks after initiating the earlier discussed therapy.
Prognosis
- Good
- Symptoms resolve by school age.
- Long-term benefit of low-carbohydrate diet: contributes to balanced nutrition and the prevention of obesity
Complications
Although children tend not to suffer from the symptoms, parents are often worried and frustrated and require frequent reassurance. �
Additional Reading
- Hoekstra �JH. Toddler diarrhoea: more a nutritional disorder than a disease. Arch Dis Child. 1998;79(1):2-5. �[View Abstract]
- Huffman �S. Toddler's diarrhea. J Pediatr Health Care. 1999;13(1):32-33. �[View Abstract]
- Hyman �PE, Milla �PJ, Benninga �MA, et al. Childhood functional GI disorders: neonate/toddler. Gastroenterology. 2006;130(5):1519-1526. �[View Abstract]
- Judd �RH. Chronic nonspecific diarrhea. Pediatr Rev. 1996;17(11):379-384. �[View Abstract]
- Kneepkens �CM, Hoekstra �JH. Chronic nonspecific diarrhea of childhood: pathophysiology and management. Pediatr Clin North Am. 1996;43(2):375-390. �[View Abstract]
- Moukarzel �AA, Lesicka �H, Ament �ME. Irritable bowel syndrome and nonspecific diarrhea in infancy and childhood: relationship with juice carbohydrate malabsorption. Clin Pediatr. 2002;41(3):145-150. �[View Abstract]
- Vernacchio �L, Vezina �RM, Mitchell �AA, et al. Characteristics of persistent diarrhea in a community-based cohort of young US children. J Pediatr Gastroenterol Nutr. 2006;43(1):52-58. �[View Abstract]
Codes
ICD09
- 564.5 Functional diarrhea
- 579.8 Other specified intestinal malabsorption
ICD10
- K59.1 Functional diarrhea
- K90.4 Malabsorption due to intolerance, not elsewhere classified
SNOMED
- 39963006 toddler diarrhea (disorder)
- 235720008 malabsorption due to intolerance to carbohydrate (disorder)
FAQ
- Q: How do I know that my toddler's diarrhea is not serious?
- A: Growth is usually normal and your child looks and feels well. His or her activity and development seem unaffected by the diarrhea. The change of diet results in improvement.
- Q: What are the components of a successful treatment plan?
- A: Attention to the 4 Fs in the diet: decreased fruit juice intake, increased fat intake, decreased fluid, and increased fiber intake
- Q: Are probiotics useful in the treatment of toddler's diarrhea?
- A: There is no adequate data to support such a recommendation, but evidence is emerging that probiotics may be effective in treating "irritable bowel syndrome like diarrhea and bloating."�
- Q: When should care by a pediatric gastroenterologist be sought?
- A: If no response after 2 weeks of compliance with dietary therapy, if growth is delayed, or if other GI or systemic complaints are present, seek a pediatric gastroenterologist's care.
- Q: Did my child get diarrhea because he goes to child care or because he is not clean?
- A. No. Functional diarrhea is not caused by infection.