~ All you need to know…

Written by Dr Nické Theron, Pediatrician.

When Eran was 8months old we woke one night to a cot full of vomit. Things deteriorated from there… Two days of diarrhoea (with stools leaking through everything) and vomiting with a mild fever followed. I am grateful that it was a very mild episode and he was never dehydrated, but I still had a lot of worry and washing! I have spent many nights admitting children to ICU with severe dehydration and I know how fragile they are, but there is a lot you can do at home to prevent a crisis.

Let us look at the how and why of diarrhoea.
According to the WHO the definition of diarrhoea is 3 or more loose or watery stools per day, or any change from the child’s usual stool patterns. Diarrhoea is still one of the top 5 causes of childhood death in children under 5 years in the developing world and should always be taken seriously.

“Looking after a very sick child was the Olympics of parenting.”

Chris Cleave

Diarrhoea can be divided into acute (continues for less than 5-7 days), intermittent (7-28 days) and chronic (>4weeks).

1. Acute diarrhoea in children is mostly caused by viral infections (up to 60-70% of moderate to severe cases of diarrhoea in children under 2years). The children usually have some vomiting, watery stools and a mild fever (38-39°C). Most children with a viral diarrhoea only need supportive treatment and the disease usually clears up spontaneously within a few days.
   Bacterial infections are the cause of diarrhoea in 30% of cases in children between 2-5years. These kids are almost always more toxic (high fevers above 40°C, looks ill, severe stomach pain, blood or mucous in the stools). The diagnosis can be made with stool or blood cultures.
   Another common cause of acute diarrhoea is antibiotic-associated diarrhoea. It usually starts during or shortly after a course of antibiotics such as Amoxicillin or Amoxicillin with clavulanic acid. The diarrhoea is due to a disturbance in the microbiome in the colon as described or could be due to a secondary infection due to overgrowth of a “bad bacteria” because the antibiotic wiped out all the “good bacteria” from the colon.
2. Intermittent diarrhoea (also called persistent diarrhoea if more than 14days) is mostly due to a combination of factors. When you have a severe bout of infectious diarrhoea the inflammation causes damage to the bowel wall, thus decreasing the absorption of sugars and water. Your child could thus have a type of “lactose intolerance” while the bowel wall is being restored and this causes a prolonged episode of diarrhoea.
3. Chronic diarrhoea is diagnosed when your child has diarrhoea for most days for more than 4 weeks. That is not fun for anyone involved. Some rare causes of chronic diarrhoea are parasitic infections, inflammatory bowel diseases, malnutrition, or malabsorption secondary to diseases such as Cystic Fibrosis. Your doctor will probably request tests on the stool itself, and your child might need some blood tests.

Another more common cause is “Functional diarrhoea”, also named “Toddler’s diarrhoea”. This diagnosis is made when a child has more than 4 stools a day for more than 4 weeks, and more serious issues were excluded. It is often caused by a diet high in fruit-sugars or milk-sugars (or other nutrients that are not absorbed), thus pulling more water into the bowels, leading to diarrhoea. Functional diarrhoea should clear up after a visit to a dietitian.

When your baby starts to spew bodily fluids all over the place, I am sure you don’t really care so much about the cause, so let me tell you the things to look out for and when to start worrying.

⚠️If your child has any of the following symptoms when they have diarrhoea, please see a doctor as it could indicate a cause that need specific treatment:

• Blood in the stools (could indicate a bacterial or serious gut disease that needs urgent treatment)
• Mucous in the stools (usually indicative of a bacterial or parasitic infection)
• Severe stomach pain, especially when it is concentrated in one area
• Other infections that accompanies the diarrhoea such as pneumonia or ear infections
• History of eating wild mushrooms or any other form of toxins

The severity of the diarrhoea and vomiting, and associated fluid loss, can vary greatly.

⚠️Here are some complications to look out for:
• Dehydration is the biggest complication associated with diarrhoea, so be sure to look out for the following symptoms:
Mild dehydration starts with the child feeling thirsty or drinking fluids eagerly, a dry mouth and passing slightly less urine. This can still be managed at home.
If your child loses more fluids, they could also have sunken eyes and a sunken fontanelle (soft spot on their head). They can be irritated and pass very little urine. At this stage (moderate dehydration) it is better to see a doctor to make sure you can keep up with the fluid intake.
If the fluid losses continue without replacement, children become sleepy or unresponsive, they pass no urine and they go into a state of shock where there is insufficient blood circulation to the important organs of the body. This is a medical emergency (severe dehydration) and they need intravenous fluids to catch up with the losses.
• Hyponatremia or Hypokalemia (too little salts in the blood) is another possible complication of severe diarrhoea because of the movement of water and salts over the bowel wall. This can cause muscle weakness, cramps, headaches, confusion, convulsions and heart dysrhythmias.
• Hypoglycaemia (low blood sugar) could complicate diarrhoea as the little ones often does not want to eat and does not absorb food well while their bowels are ill. This could also cause irritability, convulsions and loss of consciousness.

‘Do not be anxious about anything, but in every situation, by prayer and petition, with thanksgiving, present your requests to God.’

Phil 4:6

Treatment of Diarrhoea

“Prevention is better than cure” is one of my favourite mantras.

The World Health Organisation has a few recommendations to prevent diarrhoea:

• Breastfeeding
• Consumption of safe food and water. (We often take this step for granted, but many people do not have access to clean water. However, we should all boil any water given to a baby under the age of 6months (especially as part of their formula) and rinse fruit and vegetables well before eating it. Take note of the expiry dates on expendable foods and keep meat separately in the fridge.
• Handwashing for everyone.
• Sterilizing bottles and dummies given to babies under the age of 6months
• Immunizations against the Rota Virus has sharply decreased the number of babies admitted with severe diarrhoea and dehydration.

Unfortunately it is almost inevitable that your children will get poonamies or vulcanic vomiting at some point.

Let me give you a strategy for when the poo hits the fan:

• Offer fluids regularly. The main aim of treatment is to prevent or treat dehydration. The best fluids to use are a combination of pre-mixed electrolytes (such as Rehydrat), diluted with boiled, cooled water. These sachets have the correct ratio of sugars to carry the salts and water back into the body. Another study compared the use of diluted apple juice (1:1 diluted with water) to these sachets and found that in children with mild dehydration the outcomes were the same, making diluted apple juice a good alternative. Using water with no supplements could lead to low salt-levels in the blood, using chicken broth could lead to dangerously high levels of salts in the blood.
• To prevent or treat mild dehydration (see previous post), you should give your child between 50-100mls of fluids/kg over 4 hours. Eg: Your child weighs 12kg. You should give 600-1200ml over 4 hours (150-300ml/hr). It works best if you give a spoonful/ a few sips every 5-10min. Big volumes can make them vomit again.
• If your child has signs of moderate/severe dehydration, or they keep on vomiting the fluids that you give them, please go to the Emergency Unit asap.
• Continue to offer food during snacks and mealtimes
• It is important to continue breastfeeding and giving regular foods (even dairy products) during a bout of diarrhoea. Your child might not have a good appetite, so offer them foods that they usually like, and do not worry if they only take a few bites. It is important to keep the lining of the bowels healthy, or the diarrhoea might be prolonged.
• Anti-diarrhoea medications: Never give children medication to stop the diarrhoea. This causes a build-up of the toxin/virus/bacteria in the bowels, causing it to push into the bloodstream, and this can make them really sick. Anti-vomiting medication is also dangerous as it can make them sleepy (thus they drink less) or have dangerous side-effects in children. Medications like Diosmectite (Smecta) can be really efficient as it binds the toxin/virus/bacteria and expells it. It also improves the consistency of the poo. It is not absorbed, thus is safe to give to babies over 6months. It does taste quite horrible, but we have managed to give it to Eran with a syringe while blowing on his face to distract him/ help him swallow.
• Antibiotics: As most episodes of diarrhoea are caused by viruses, antibiotics are mostly not necessary. If your child has high fevers or bloody diarrhoea there is mostly a bacteria involved which needs to be treated with antibiotics as prescribed by your doctor.
• Supplements:
• ~ Zinc: Several studies have proven that Zinc supplements can decrease the severity and duration of diarrhoea in children under 5 years. Eg Zinplex syrup.
• ~ Probiotics: The use of probiotics can help to restore the microbiome of the bowel and thus help to get the diarrhoea under control. Reuteri drops are safe to give even from birth and although researchers cannot prove which dose or strain gives the best results, we know it should not cause any harm.

And then, most importantly, give them a lot of TLC!

“The secret of the care of the patient is in caring for the patient.’

Dr. Francis Peabody

I hope these tips will help to get your kiddies eating and playing again sooner rather than later!

Let me know what food / fluids works best for you when your child has diarrhoea?

Resources

1. Jenkins R, Whyte LA; “Pathophysiology of diarrhoea”; Paediatrics and Child Health Volume 22, Issue 10, October 2012, Pages 443-447
2. Elliot EJ; “Acute gastroenteritis in children”; BMJ; 2007 Jan 6; 334(7583):35-40
3. http://www.uptodate.com
4. WHO; “Preventing diarrhoea through better water, sanitation and hygiene: exposures and impacts in low- and middle-income countries”
5. Freedman SB, Willan AR, Boutis K, Schuh S; “Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial.”; JAMA. 2016;315(18):1966.
6. Lukacik M, Thomas RL, Aranda JV; “A meta-analysis of the effects of oral zinc in the treatment of acute and persistent diarrhea.”; Pediatrics. 2008;121(2):326.
7. Lazzerini M, Ronfani L; “Oral zinc for treating diarrhoea in children.”; Cochrane Database Syst Rev. 201