Diarrhea

DEFINITION

• Diarrhea is the sudden increase in the frequency and looseness of stools
• The main risk of diarrhea is dehydration
• Loose or runny stools do not cause dehydration
• Frequent, watery stools can cause dehydration

Causes  

• Viral gastroenteritis (viral infection of the stomach and intestines) is the usual cause
• Bacteria (e.g., Salmonella or Shigella) cause some diarrhea.
• Food-poisoning: the main food-borne bacteria are Campylobacter, Salmonella and E.coli.
• 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 (Caution: Do NOT give your baby any fever medicine before being seen.)
• Abdominal pain present over 2 hours
• Vomiting clear liquids 3 or more times Age under 1 month with 3 or more diarrhea stools (mucus, bad odor, increased looseness)
• Passed more than 8 diarrhea stools in the last 8 hours
• Severe diarrhea while taking a medicine that could cause diarrhea (e.g., antibiotics)
• You think your child needs to be seen urgently

Call Your Doctor Within 24 Hours (between 9 am and 4 pm) If

• You think your child needs to be seen, but not urgently
• 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 or 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

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.

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).

Formula-Fed Infants 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.

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.

Solids

• Infants over 4 months old: Continue solids (e.g., rice cereal, strained bananas, mashed potatoes, etc).

Breastfed Infants WITH frequent, watery diarrhea:

• Continue breastfeeding at more frequent intervals. Continue solids as for formula-fed.
• Offer 2-4 oz. ORS (e.g.: Pedialyte) after every large watery stool (especially if urine is dark) in addition to breastfeedings.

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 (e.g.: Pedialyte) 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, etc. Pretzels or salty crackers can help meet sodium needs.

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 2 to 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.

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.

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.

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.

Call Your Doctor If:

• Signs of dehydration occur
• Diarrhea persists over 2 weeks
• Your child becomes worse

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.

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Author and Senior Reviewer: Barton D. Schmitt, M.D.
Last Reviewed: 11/14/2011
Last Revised: 11/14/2011
Content Set: Pediatric HouseCalls Symptom Checker
Copyright 1994-2012 Barton D. Schmitt, M.D.