DIARRHOEA IN KIDS

~ 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

IRON DEFICIENCY

PART 1

Written by Dr Nické Theron, Pediatrician.

This is a topic that I have been avoiding for a while because there is so much conflicting advice and evidence available. I started giving our son iron supplementation from 6months but because it tasted horrible and stained all his clothes and he struggled with constipation, I stopped at around 10months. After attending the European Academy of Pediatrics congress in September I was reminded about how important iron is for brain development, and I felt very guilty that I did not give Eran enough iron-supplements. But was it really necessary? When should babies and toddlers use iron-supplements and what sort of iron should they use? Read on to learn with me:

Iron is a vital mineral in our bodies. It is used in red-blood cells to carry oxygen and to help manage the storage and usage of oxygen in the muscles. Iron also plays a very important role in brain development in babies and toddlers, regulating the structure as well as the hormonal messengers of the brain. The immune system also needs iron to function well. Luckily the body regulates iron very closely, and as red blood cells break down it is recycled and used again. We do however loose a small amount of iron daily from our skins and gut, and during menstruation. If we do not take in enough iron to counter-act these losses, it leads to iron deficiency.

Adults need to absorb about 5% of their daily iron needs from food. Children need to absorb up to 30% due to their rapid growth and development. This already places them at a high risk for iron deficiency.

“Iron deficiency” occurs when there is not enough iron in the “stores” of the liver. (Mostly measured by doing a “Ferritin level” on a blood test). If there is no treatment it will progress to “Iron deficiency anaemia” where the iron-levels in the red blood cells are also dropping, leading to fewer and smaller red blood cells. (Measured by testing the “Hemoglobin level” or a “Full Blood Count”). It is mostly only when a child becomes pale and tired that the problem is picked up. However there is already a big effect on brain-development, behaviour and growth long before the “Iron deficiency anaemia” causes symptoms. Sadly iron deficiency is the most common nutrient deficiency in the world, and the effect it has on children’s behaviour and development is scary.

“As iron sharpens iron, so one person sharpens another”

Proverbs 27:17

Children who have a high risk of iron deficiency are:

  • Mother has an iron deficiency during pregnancy (the baby will still take the iron it needs, but there is not enough iron to totally fill all the stores)
  • Mother has hypertension or diabetes mellitus during pregnancy (the iron in the mother’s body is not as easily available for baby / the baby has a higher need for iron)
  • Premature babies (iron stores are filled during the last few months of pregnancy, so premature babies miss out on this. They also have a smaller blood volume and undergo many blood-tests while in NICU).
  • Low-birth-weight babies (multiple reasons for high risk)
  • Early cord clamping (allowing more blood to flow to the baby from the placenta increases the amount of iron they start out with)
  • Insufficient dietary intake during early infancy
  • Early introduction (<1 year) of unmodified cow’s milk or consuming large amounts of cow’s milk (>500ml) after 1year of age. (Early introduction may cause an increase of blood loss from the bowels as the bowels are not ready for the large proteins / via allergic reactions. Cow’s milk contains very little iron, thus the risk is high if your baby does not eat enough other iron-containing foods)
  • Exclusive breastfeeding for longer than 6months (breastmilk has a very low iron content. See below. It is important to start iron-rich supplemental food from 6months).
  • Picky-eaters, children with multiple food allergies, children following specific diets.
  • Obese children
  • Children with malnutrition, chronic diseases or bowel-diseases.

I would like to explain a little more about the iron-needs in babies. Term, healthy infants usually has enough iron in their bodies for the first 5-6months of life (they have a relatively high “hemoglobin” at birth and their stores are filled during the 3rd trimester). Their iron-needs are thus quite low during the first few months. Breastmilk contains very little iron (+- 0.3mg/L) but it is very easily absorbed (up to 50%). Formula milk is usually supplemented with up to 12mg/L iron, but it is not as available to be absorbed (4-6%).

After 6months of age the iron requirements increase rapidly, and thus breastmilk alone is not enough to sustain the iron-needs in babies. They need to take in extra iron in some form. Iron-rich foods and iron-fortified foods such as cereals has been shown to be more effective than medical supplements in the long term to sustain normal iron stores. (If your baby already has a deficiency it is easier to fill up the stores with medical supplements, see next article).

So how do you prevent iron-deficiency?

  • The American Association of Pediatrics recommends that all healthy term babies who are exclusively breastfed should receive supplemental iron (1mg/kg/day) routinely from the age of 4months until they eat sufficient quantities of iron-rich food. (At least 2 meals per day containing iron rich food or iron-fortified food). The European society feels that there is no need for general iron supplementation in healthy babies and children as long as there are no other risk factors.
  • Formula-fed babies should receive enough iron in the formula for the first 6months and thus do not need further supplementation.
  • All premature babies should receive iron supplementation from the age of 2weeks until 1year (2-4mg/kg/day).

You can give the supplements as part of a multivitamin (eg Vidaylin with iron) or separately (eg Ferro-drops or Ferrimed). Seeing that there are some risks involved in using iron supplements in otherwise healthy children (some studies show that babies with normal iron stores that were supplemented with iron did not grow as well in length as those that were not supplemented) I think it is very important to discuss this topic with your pediatrician at the 6week check-up to make an informed decision with them after looking at all the risk factors for YOUR baby.

Iron deficiency has serious implications in your child’s development and should be carefully managed and monitored. In the next article I will discuss the effects of iron deficiency anemia and the treatment thereof.

Resources:

  1. Lonnerdal B, Georgieff MK, Hernell O; “Developmental physiology of iron absorption, homeostasis and metabolism in the healthy term infant”; J Pediatr 2015 Oct; 167(4 0): S8-S14
  2. Baker RD, Greer FR, The Committee on Nutrition; “Diagnosis and Prevention of Iron Deficiency Anemia in Infants and Young Children (0-3years of age)”; American Academy of PediatricsClinical Report
  3. Friel J, Qasem W, Cai C; “Iron and the Breastfed infant”; Antioxidants (Basel). 2018 Apr; 7(4): 54
  4. ESPGHAN guidelines for Iron Requirements of Infants and Toddlers
  5. http://www.uptodate.com