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Chronic diarrhea (alternate spelling: diarrhoea) of infancy, also called toddler's diarrhea, is a common condition typically affecting up to 1.7 billion children between ages 6–30 months worldwide every year, usually resolving by age 4. According to the
World Health Organization The World Health Organization (WHO) is a list of specialized agencies of the United Nations, specialized agency of the United Nations which coordinates responses to international public health issues and emergencies. It is headquartered in Gen ...
(WHO), diarrheal disease is the second greatest cause of death in children 5 years and younger. Diarrheal disease takes the lives of 525,000 or more children per year.
Diarrhea Diarrhea (American English), also spelled diarrhoea or diarrhœa (British English), is the condition of having at least three loose, liquid, or watery bowel movements in a day. It often lasts for a few days and can result in dehydration d ...
is characterized as the condition of passing of three or more loose or watery bowel movements within a day sometimes with undigested food visible. Diarrhea is separated into three clinical categories; acute diarrhea may last multiple hours or days, acute bloody diarrhea, also known as
dysentery Dysentery ( , ), historically known as the bloody flux, is a type of gastroenteritis that results in bloody diarrhea. Other symptoms may include fever, abdominal pain, and a feeling of incomplete defecation. Complications may include dehyd ...
, and finally, chronic or persistent diarrhea which lasts 2–4 weeks or more. There is normal growth with no evidence of malnutrition in the child experiencing persistent diarrhea. In chronic diarrhea there is no evidence of blood in the stool and there is no sign of
infection An infection is the invasion of tissue (biology), tissues by pathogens, their multiplication, and the reaction of host (biology), host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmis ...
. The condition may be related to
irritable bowel syndrome Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by a group of symptoms that commonly include abdominal pain, abdominal bloating, and changes in the consistency of bowel movements. These symptoms may ...
. There are various tests that can be performed to rule out other causes of diarrhea that don't fall under the chronic criteria, including blood test, colonoscopy, and even genetic testing. Most acute or severe cases of diarrhea have treatment guidelines revolving around prescription or non prescription (also known as over the counter or OTC) medications based on the cause, but the treatment protocols for chronic diarrhea focus on replenishing the body with lost fluids and
electrolyte An electrolyte is a substance that conducts electricity through the movement of ions, but not through the movement of electrons. This includes most soluble Salt (chemistry), salts, acids, and Base (chemistry), bases, dissolved in a polar solven ...
s, because there typically isn't a treatable cause.


Signs and Symptoms

Toddler's diarrhea is characterized by three or more watery stools per day that persist for 2–4 weeks or more. Newborns and infants may normally have soft and frequent stools; however, any noticeable changes in stool frequency or form (i.e. watery) can indicate toddler's diarrhea. Other symptoms may include chills, fever, abdominal pain or cramping, nausea, and/or vomiting. Undigested food and/or mucus may also be observed in stools. More serious symptoms may include bloody stools, weight loss, greasy stools, and/or severe abdominal pain. Aside from these signs and symptoms, infants and children present as healthy individuals with appropriate weight gain (considering sufficient calorie intake), active lifestyles, and normal appetites.


Complications

Possible complications associated with toddler's diarrhea include malabsorption and dehydration.
Malabsorption Malabsorption is a state arising from abnormality in absorption of food nutrients across the gastrointestinal (GI) tract. Impairment can be of single or multiple nutrients depending on the abnormality. This may lead to malnutrition and a varie ...
affects the small intestine and results in the impaired absorption of important nutrients from an infant or child's diet, leading to malnutrition. Malabsorption is indicated by symptoms of bloating, appetite changes, weight loss, and/or gas.
Dehydration In physiology, dehydration is a lack of total body water that disrupts metabolic processes. It occurs when free water loss exceeds intake, often resulting from excessive sweating, health conditions, or inadequate consumption of water. Mild deh ...
occurs when there is not enough fluid intake to compensate for increased loss of fluid and electrolytes that may result from chronic diarrhea. Dehydration is indicated by symptoms of thirst, absence of tears when crying, infrequent urination, dry mouth, and/or decreased energy.


Cause

Diarrhea happens when the amount of fluids absorbed in the intestine does not match the amount secreted. The imbalance can be achieved in two ways: an excess of secretion or a lack of absorption. Thus, diarrhea can be categorized into secretory diarrhea, an excess of secretion, or osmotic diarrhea which is a lack of absorption. Usually both categories are present in chronic diarrhea of infants. Secretory diarrhea can be caused by either infectious or non-infectious agents. Infectious agents include bacteria, viruses, and protozoans while non-infectious agents can be hormones, neurotransmitters, cytokines, and others. Osmotic diarrhea occurs when nutrients that are not absorbed exists in the intestines, typically due to damage to the intestines. The nutrients that are unable to be absorbed in the intestines draws water to itself. Some factors that lead to chronic diarrhea of infancy: * Underdeveloped digestive system, nutrients do not spend adequate time in the digestive tract for water to be absorbed which leads to diarrhea. * Imbalanced Diet — a diet that has excess fiber and/or a lack of fat, fat can slow down the digestion process and prolong the amount of time nutrients spend in the tract which increases absorption. Fiber can lead to diarrhea because it shortens the amount of time food spends in the intestines, decreasing absorption. * Inability to absorb carbohydrates The specific source of chronic diarrhea typically depends on the age of the infant/child. Diarrhea is uncommon for newborns; consequently, its presence in newborns could indicate a congenital disorder which would need hospitalization. Rare causes of chronic diarrhea in young children include a group of genetic mutations known as "congenital diarrhea and enteropathies" (CODEs). This group of genetic disorders usually presents in the first weeks of birth as severe and debilitating diarrhea and can lead to malabsorption, growth failure, and difficulty feeding. CODEs are rare genetic changes to a single gene that affects the lining of the intestine or changes to the immune system that also affects the cell function of important nutrient and electrolyte transporters in the intestine such as Cl/HCO3 mutation. Otherwise, socioeconomic factors and access to treatment/healthcare play a significant part in developing chronic diarrhea as an infant. For instance, leading causes of chronic diarrhea in developing countries are infections of the intestine. In developed countries, chronic diarrhea has a diverse range of causes such as chronic infection of the intestines, autoimmune enteropathy, and inability to absorb nutrients via celiac disease, food sensitivities, etc. From age 0–30 days, typical causes are: *
Abetalipoproteinemia Abetalipoproteinemia (also known as: Bassen–Kornzweig syndrome, microsomal triglyceride transfer protein deficiency disease, MTP deficiency, and betalipoprotein deficiency syndrome) is a disorder characterized by abnormal absorption of fat and ...
, a condition caused by a genetic mutation that creates abnormal absorption of fats and some vitamins. * Acrodermatitis enteropathica, a condition in which the intestine cannot absorb zinc. * Autoimmune enteropathy, a rare condition in which the intestines are perceived as a foreign threat by the immune system and are attacked leading to irritation and inflammation. * Microvillous inclusion disease, a condition caused by a genetic mutation leading to severe diarrhea because intestinal cells did not have normal development and thus the intestines are not able to absorb nutrients properly. * Congenital chloride diarrhea, a lifelong condition caused by a genetic mutation that leads to diarrhea with a high concentration of chloride. * Congenital sodium diarrhea, a genetic disorder caused by mutations in electrolyte transporters that disrupt the transport of Na+ across the intestine and results in high levels of Na+ greater than 145 mM in the stool. * Congenital short-bowel syndrome, a condition in which a portion of the small intestine is absent or not functioning properly leading to decreased absorption of both fluids and nutrients. * Congenital lactase deficiency, a condition caused by a genetic mutation in which the body cannot digest
lactose Lactose is a disaccharide composed of galactose and glucose and has the molecular formula C12H22O11. Lactose makes up around 2–8% of milk (by mass). The name comes from (Genitive case, gen. ), the Latin word for milk, plus the suffix ''-o ...
properly. * Glucose-galactose malabsorption, a genetic disorder caused by changes in a protein critical for the transport of glucose and
galactose Galactose (, ''wikt:galacto-, galacto-'' + ''wikt:-ose#Suffix 2, -ose'', ), sometimes abbreviated Gal, is a monosaccharide sugar that is about as sweetness, sweet as glucose, and about 65% as sweet as sucrose. It is an aldohexose and a C-4 epime ...
across the intestine which leads to impaired glucose/galactose absorption, dehydration, and severe diarrhea in young children. Typically, the severe diarrhea improves with a diet low in glucose/galactose and the tolerability to glucose/galactose improves with age. *
Hirschsprung's disease Hirschsprung's disease (HD or HSCR) is a birth defect in which nerves are missing from parts of the intestine. The most prominent symptom is constipation. Other symptoms may include vomiting, abdominal pain, diarrhea and slow growth. Most child ...
(HSCR), a gut motility disorder characterized by a lack of nerve cells in the large intestine which are needed to move the stool through the digestive tract. In infants, HSCR typically presents when a newborn is unable to pass the first feces, or
meconium Meconium is the earliest stool of a mammalian infant resulting from defecation. Unlike later feces, meconium is composed of materials ingested during the time the infant spends in the uterus: intestinal epithelial cells, lanugo, mucus, am ...
within 48 hours of birth. Other symptoms include blockage of the intestine, fever, rapid release of stool and flatulence upon rectal examination, and may present with diarrhea in infants. * Intestinal pseudo-obstruction (IPO), a gut motility disorder characterized by the inability to contract intestinal walls with symptoms similar to intestinal obstruction but lack a distinguishable cause of obstruction. Signs and symptoms include abdominal pain, dilated or enlarged bowel, constipation and may include diarrhea. Although rare in infants, IPO is a type of congenital disorder that may present with diarrhea in infants. * Primary bile acid malabsorption, a gut defect in the reabsorption of bile acids in the small intestine which results in increased levels of bile acids in the colon leading to watery diarrhea and bloating. * Chronic infection of
C. difficile ''Clostridioides difficile'' ( syn. ''Clostridium difficile'') is a bacterium known for causing serious diarrheal infections, and may also cause colon cancer. It is known also as ''C. difficile'', or ''C. diff'' (), and is a Gram-positive spec ...
, G. lamblia ** C. difficile — bacteria that can be the source of diarrhea. ** G. lamblia — a parasite that can be the source diarrhea. From 1–12 months, typical causes of chronic diarrhea are the following: * Acrodermatitis enteropathica, a condition in which the intestine cannot absorb zinc. *
Cystic fibrosis Cystic fibrosis (CF) is a genetic disorder inherited in an autosomal recessive manner that impairs the normal clearance of Sputum, mucus from the lungs, which facilitates the colonization and infection of the lungs by bacteria, notably ''Staphy ...
, a condition caused by a genetic mutation that can lead to injury to the body's organs including the lungs and those in the digestive system. * Apple juice and pear nectar, the digestive tract of children have difficulty absorbing significant quantities of sugars and carbohydrates which certain fruit juices can have. *
Celiac Disease Coeliac disease (British English) or celiac disease (American English) is a long-term autoimmune disorder, primarily affecting the small intestine. Patients develop intolerance to gluten, which is present in foods such as wheat, rye, spel ...
, a disorder in which there is an immune response to eating gluten which can eventually cause damage to the small intestine over time and impedes absorption. * Food allergy. Most instances of chronic diarrhea in infancy are caused by infectious and post infectious disease of the intestine as well as food sensitivities or allergies.


Diagnosis

Diagnosis of toddler's diarrhea involves the evaluation of history of present illness, any relevant past medical history, and physical examination to determine any causative factors to inform treatment regimens and further recommendations. Evaluation of
history of present illness Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symp ...
includes: * Stool characterization (i.e. appearance, consistency, frequency, etc.) * Time frame and duration (important for differentiation between acute and chronic diarrhea) * Food/drink allergies or restrictions (e.g.
lactose intolerance Lactose intolerance is caused by a lessened ability or a complete inability to digest lactose, a sugar found in dairy products. Humans vary in the amount of lactose they can tolerate before symptoms develop. Symptoms may include abdominal pain ...
) * Medications, especially antibiotics * Infection exposure (e.g. travel) Evaluation of
past medical history In a medical encounter, a past medical history (abbreviated PMH) is the total sum of a patient's health status prior to the presenting problem. Questions to include Different sources include different questions to be asked while conducting a P ...
includes: * Family history * Conditions such as
inflammatory bowel disease Inflammatory bowel disease (IBD) is a group of inflammatory conditions of the colon and small intestine, with Crohn's disease and ulcerative colitis (UC) being the principal types. Crohn's disease affects the small intestine and large intestine ...
,
cystic fibrosis Cystic fibrosis (CF) is a genetic disorder inherited in an autosomal recessive manner that impairs the normal clearance of Sputum, mucus from the lungs, which facilitates the colonization and infection of the lungs by bacteria, notably ''Staphy ...
, and
celiac disease Coeliac disease (British English) or celiac disease (American English) is a long-term autoimmune disorder, primarily affecting the small intestine. Patients develop intolerance to gluten, which is present in foods such as wheat, rye, spel ...
Physical examination involves: *
Abdominal examination An abdominal examination is a portion of the physical examination which a physician or nurse uses to clinically observe the abdomen of a patient for signs of disease. The abdominal examination is conventionally split into four different stages: ...
(tenderness, distention, and/or bowel sounds) * Genital examination (rashes, anal fissures, and/or ulcerative
lesion A lesion is any damage or abnormal change in the tissue of an organism, usually caused by injury or diseases. The term ''Lesion'' is derived from the Latin meaning "injury". Lesions may occur in both plants and animals. Types There is no de ...
s) * General assessment and
vital signs Vital signs (also known as vitals) are a group of the four to six most crucial medical signs that indicate the status of the body's vital (life-sustaining) functions. These measurements are taken to help assess the general physical health of ...
(any signs of
dehydration In physiology, dehydration is a lack of total body water that disrupts metabolic processes. It occurs when free water loss exceeds intake, often resulting from excessive sweating, health conditions, or inadequate consumption of water. Mild deh ...
such as
tachycardia Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal ...
and low blood pressure) * Examination of extremities and head (any signs of
dehydration In physiology, dehydration is a lack of total body water that disrupts metabolic processes. It occurs when free water loss exceeds intake, often resulting from excessive sweating, health conditions, or inadequate consumption of water. Mild deh ...
such as dry
mucous membrane A mucous membrane or mucosa is a membrane that lines various cavities in the body of an organism and covers the surface of internal organs. It consists of one or more layers of epithelial cells overlying a layer of loose connective tissue. It ...
s and skin turgor)


Diagnostic Tests

The following tests can also be performed to assist in the diagnosis of toddler's diarrhea and evaluation of any associated complications/underlying conditions: *
Stool test A stool test is a medical diagnostic technique that involves the collection and analysis of fecal matter. Microbial analysis (culturing), microscopy and chemical tests are among the tests performed on stool samples. Collection Stool samples shou ...
s provide further information about bleeding, infectious agents, and/or anatomical problems. *
Blood test A blood test is a medical laboratory, laboratory analysis performed on a blood sample that is usually extracted from a vein in the arm using a hypodermic needle, or via fingerprick. Multiple tests for specific blood components, such as a glucose ...
s allow assessment of inflammatory markers and/or other criterion for causative diseases. *
X-ray An X-ray (also known in many languages as Röntgen radiation) is a form of high-energy electromagnetic radiation with a wavelength shorter than those of ultraviolet rays and longer than those of gamma rays. Roughly, X-rays have a wavelength ran ...
s provide evaluations of any problems that may originate in the gastrointestinal tract/liver/etc. * Upper
endoscopy An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are insert ...
or
colonoscopy Colonoscopy () or coloscopy () is a medical procedure involving the Endoscopy, endoscopic examination of the large bowel (colon) and the distal portion of the small bowel. This examination is performed using either a Charge-coupled device, CCD ...
allows visualization of the gastrointestinal tract to assess location of inflammation. * Breath hydrogen tests are utilized to determine lactose,
fructose Fructose (), or fruit sugar, is a Ketose, ketonic monosaccharide, simple sugar found in many plants, where it is often bonded to glucose to form the disaccharide sucrose. It is one of the three dietary monosaccharides, along with glucose and gal ...
, and/or
sucrose intolerance Sucrose intolerance or genetic sucrase-isomaltase deficiency (GSID) is the condition in which sucrase-isomaltase, an enzyme needed for proper metabolism of sucrose (sugar) and starch (e.g., grains), is not produced or the enzyme produced is either ...
.
Small intestinal bacterial overgrowth Small intestinal bacterial overgrowth (SIBO), also termed bacterial overgrowth, or small bowel bacterial overgrowth syndrome (SBBOS), is a disorder of excessive bacterial growth in the small intestine. Unlike the colon (or large bowel), which is r ...
(SIBO) may also be indicated by this test.


Genetic Testing

Most commonly, chronic diarrhea in infants and children are classified as acquired diarrhea, identified with the general diagnostic tests mentioned above. The other classification of chronic diarrhea, congenital diarrheas and enteropathies (CODEs), are rare diagnoses of exclusion. With recent advances in genome sequencing, the addition of targeted
genetic testing Genetic testing, also known as DNA testing, is used to identify changes in DNA sequence or chromosome structure. Genetic testing can also include measuring the results of genetic changes, such as RNA analysis as an output of gene expression, or ...
to diagnostic algorithms has been proposed to allow faster diagnoses and earlier treatment of CODEs. While certain genes and mutations have been associated with various CODEs, further research and studies are necessary to support the role of diagnostic genetic testing.


Treatment

According to doctors of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), treating the cause of chronic diarrhea in infants is primarily through diet (e.g. avoiding foods their bodies don't tolerate such as
gluten Gluten is a structural protein naturally found in certain Cereal, cereal grains. The term ''gluten'' usually refers to the elastic network of a wheat grain's proteins, gliadin and glutenin primarily, that forms readily with the addition of water ...
,
lactose Lactose is a disaccharide composed of galactose and glucose and has the molecular formula C12H22O11. Lactose makes up around 2–8% of milk (by mass). The name comes from (Genitive case, gen. ), the Latin word for milk, plus the suffix ''-o ...
,
fructose Fructose (), or fruit sugar, is a Ketose, ketonic monosaccharide, simple sugar found in many plants, where it is often bonded to glucose to form the disaccharide sucrose. It is one of the three dietary monosaccharides, along with glucose and gal ...
, and
sucrose Sucrose, a disaccharide, is a sugar composed of glucose and fructose subunits. It is produced naturally in plants and is the main constituent of white sugar. It has the molecular formula . For human consumption, sucrose is extracted and refined ...
).
Dietary fiber Dietary fiber (fibre in English in the Commonwealth of Nations, Commonwealth English) or roughage is the portion of plant-derived food that cannot be completely broken down by human digestive enzymes. Dietary fibers are diverse in chemical co ...
and fat can be increased and fluid intake, especially fruit juice intake, decreased. With these considerations, NIDDK doctors recommend that children consume a normal balanced diet based on their age to avoid malnutrition or growth restriction. Non-prescription medications such as
loperamide Loperamide, sold under the brand name Imodium, among others,Drugs.co Page accessed 4 September 2015 is a medication of the opioid receptor agonist class used to decrease the frequency of diarrhea. It is often used for this purpose in irritable ...
are not recommended by the Centers for Disease Control and Prevention for children below 6 years of age as they don't address the underlying cause of the condition. According to Benjamin Ortiz, M.D., a pediatrician in the Food and Drug Administration's Office of Pediatric Therapeutics,
bismuth subsalicylate Bismuth subsalicylate, sold generically as pink bismuth and under brand names including Pepto-Bismol, Pepti-Calm, and BisBacter, is a medication used to treat temporary discomfort of the stomach and gastrointestinal tract. This includes an upset ...
is not recommended in children below 12 years of age because its contents, including magnesium, aluminum, and bismuth, are not readily cleared from their bodies, making them more susceptible to harm. Studies have shown that certain
probiotic Probiotics are live microorganisms that provide health benefits when consumed, generally by improving or restoring the microbiota in the gut. Probiotics are considered generally safe to consume, but may cause bacteria– host interactions ...
preparations such as '' Lactobacillus rhamnosus'' (a
bacterium Bacteria (; : bacterium) are ubiquitous, mostly free-living organisms often consisting of one biological cell. They constitute a large domain of prokaryotic microorganisms. Typically a few micrometres in length, bacteria were among the ...
) and '' Saccharomyces boulardii'' (a
yeast Yeasts are eukaryotic, single-celled microorganisms classified as members of the fungus kingdom (biology), kingdom. The first yeast originated hundreds of millions of years ago, and at least 1,500 species are currently recognized. They are est ...
) may be effective at reducing the duration and severity of diarrhea in acute settings as a result of
gastroenteritis Gastroenteritis, also known as infectious diarrhea, is an inflammation of the Human gastrointestinal tract, gastrointestinal tract including the stomach and intestine. Symptoms may include diarrhea, vomiting, and abdominal pain. Fever, lack of ...
, while other studies have found that the use of probiotics doesn't have an effect on the length of diarrhea in toddlers. While treatments for chronic diarrhea of infancy aren't clear cut, it is crucial to address the complications of dehydration that may arise from chronic diarrhea with the American Academy of Pediatrics (AAP) guidelines recommendation of
oral rehydration therapy Oral rehydration therapy (ORT) also officially known as Oral Rehydration Solution is a type of fluid replacement used to prevent and treat dehydration, especially due to diarrhea. It involves drinking water with modest amounts of sugar and salt ...
(ORT). Oral rehydration solution (ORS), recommended by both AAP and the World Health Organization (WHO), must be composed of 50-90mEq/L sodium and 2% glucose or other complex carbohydrates. ORS is easily found in the US because it is available without a prescription. The typical amount of ORS administered is 50mL/kg over a 4-hour time period for mild dehydration and 100mL/kg over a 4-hour time period for moderate dehydration with an extra 10mL/kg for every loose stool. Repeat this administration regimen for as long as the signs and symptoms of dehydration continue. It is important to take measures early on to maintain hydration. Along with ORT, WHO recommends a 10-14 day course of 20 mg zinc tablet supplementation, stating it will shorten the length of diarrhea and potentially improving harmful outcomes. The NIDDK recommends a visit to the doctor when a child experiences stools containing pus or blood (black, tarry, or coffee ground-like appearance), signs of dehydration, diarrhea longer than 24 hours, or a fever of 102 degrees or more.


Epidemiology

Diarrheal illness in children accounts for 1.5 to 2.5 million deaths per year worldwide. It is responsible for the secondary cause of mortality among children less than 5 years of age surpassing the combined childhood deaths from malaria, measles, and AIDS. In 2009, the World Health Organization (WHO)/United Nations International Children's Emergency Fund (UNICEF) reported 2.5 billion cases of diarrhea in children less than 5 years old. More than half of the cases occurred in Africa and South Asia. It is estimated that Africa and South Asia comprise more than 80% of deaths from diarrhea in children. In fact, about 75% of the childhood deaths from diarrhea come from only 15 countries. According to the World Health Organization (WHO), the proportion of deaths attributable to diarrheal illness among children less than 5 years of age was 13.2% in 2002. Half of these childhood deaths were due to chronic diarrheal causes. Worldwide, studies estimate that diarrheal illness affects 3 to 20% of children under the age of 5 with an incidence of 2.7 episodes of diarrhea per child-year. Developing nations experience higher burden of disease and mortality from chronic diarrhea in children compared to developed nations. In the United States, it is reported that 15 to 20% of young children have an episode of acute diarrhea each year. Compared to worldwide estimates, the United States has a lower incidence rate of chronic diarrhea in young children reported at 0.18 episodes per child year. In pediatrics, diarrhea is a common complaint making up 9% of U.S. hospital visits for children less than 5 years old. In contrast to resource-poor nations, resource-rich nations such as the United States experience less chronic diarrhea severity. In the United States, approximately a quarter of chronic diarrhea cases in young children seek medical care and less than 1% of cases are hospitalized.


References

{{reflist Diarrhea Pediatrics