Diarrhea, Toddler's

Basic Information

Definition

Toddler's diarrhea is a common benign diarrheal disorder that presents in the toddler with three to six large, loose, watery stools per day for more than 3 weeks, but without evidence of systemic illness, failure to thrive, or other gastrointestinal disorder. Diarrhea should be present for at least 3 weeks (and preferably 4 weeks) to be considered “chronic” and may be episodic rather than continuous.

Synonyms

• Chronic nonspecific diarrhea (CNSD)

• Irritable colon of childhood

• Sloppy stool syndrome

ICD‐9‐CM Code

• 787.91 Diarrhea

Epidemiology & Demographics

• •Toddler's diarrhea is thought to be common, but the exact prevalence is unknown.
• •It is the most common type of chronic diarrhea referred to pediatric gastroenterologists.
• •Typical age is 12 to 36 months (range 6 months to 5 years).
• •Symptoms resolve in 90% of children by 40 months of age.
• •May be a variant of irritable bowel syndrome.

Clinical Presentation

History

• •Recent travel, drinking water sources, antecedent illness, infectious contacts, day care, new foods
• •Use of antibiotics, laxatives, prescribed or over‐the‐counter drugs that may contain sorbitol, home remedies, alternative therapies
• •Family history of gastrointestinal diseases
• •An accurate description of the stool appearance and pattern
• •
  Dietary history to ascertain total calories and fat consumed daily, quantities of milk and juice consumed daily, and any trials of elimination diets or currently eliminated foods

  • ○
    It is possible for a child to have toddler's diarrhea and have poor weight gain merely because he or she was placed on a hypercaloric diet by the caretakers in an attempt to control the diarrhea.
• •
  Specifically, with toddler's diarrhea, the history will reveal the following:

  • ○
    Onset is at 6 months or later.
  • ○
    No stools occur overnight.
  • ○
    Stooling is most common in the morning.
  • ○
    There may be oscillation between normal and watery stools.
  • ○
    Stools are sloppy—generally watery but occasionally with mucus.
  • ○
    Stools often contain recognizable undigested food particles.
  • ○
    There is no associated nausea, vomiting, abdominal pain, flatulence, blood in the stool, fevers, weakness, decreased activity, anorexia, dermatologic problems, weight loss, poor growth, or other symptoms of systemic disease.
  • ○
    Although there may have been an antecedent illness, children with toddler's diarrhea exhibit no evidence of current enteric infection or malabsorption.
  • ○
    They continue to show normal growth and development unless caloric intake has been inadequate.

Physical Examination

• •The physical examination and growth parameters are normal with toddler's diarrhea.
• •The single most important aspect of the physical examination is accurate measurement of weight, height, and head circumference. Serial plots are needed.
• •Abdominal and rectal examinations are entirely normal.
• •Look for signs of dehydration—none are present in toddler's diarrhea.
• •
  Check for evidence of malnutrition or malabsorption—none of the following are present in toddler's diarrhea:

  • ○
    Lack of subcutaneous fat
  • ○
    Eczematous rash of essential fatty acid deficiency and zinc deficiency
  • ○
    Glossitis
  • ○
    Easy bruising
  • ○
    Skin, hair, or nail abnormalities
  • ○
    Tired or ill‐appearing
  • ○
    Decreased reflexes
• •Examine the perianal area—there may be evidence of irritation from toddler's diarrhea, but true perianal disease, abscesses, fistulas, or rectal prolapse would indicate another disorder.

Etiology

• •
  Toddler's diarrhea is a multifactorial problem. The following are contributing factors:

  • ○
    Excessive fluid intake
  • ○
    Disordered intestinal motility—resulting in rapid transit time
  • ○
    Carbohydrate malabsorption from excessive fruit and fruit juice consumption
  • ○
    Sorbitol
  • ○
    Fructose, when the concentration exceeds glucose concentration
  • ○
    Dietary fat restriction
  • ○
    Elevated colonic bile salts concentration

Diagnosis

Differential Diagnosis

• •
  Enteric infection

  • ○
    Parasite
  • ○
    Protracted viral gastroenteritis (several viruses can rarely promote chronic diarrhea)
  • ○
    Rare for any bacterial infection to be chronic but has been reported (usually in younger infants with Salmonella, Shigella, Yersinia, Campylobacter, Aeromonas, and Plesiomonas)
• •
  Intestinal malabsorption

  • ○
    Postviral enteritis (caused by flattened villi after an infection with rotavirus, adenovirus, astrovirus, or coronavirus)
  • ○
    Inflammatory bowel disease
  • ○
    Celiac disease
• •
  History of onset or change in bowel habits; diarrhea present before 3 months of age, including the following:

  • ○
    Congenital microvillous atrophy
  • ○
    Disaccharidase abnormalities
  • ○
    Milk and soy allergies
  • ○
    Hollow visceral myopathy
• •Protein intolerance: usually unknown mechanism (e.g., animal proteins, soy proteins)
• •Food allergy: will usually have other gastrointestinal symptoms, such as oral pruritus, vomiting, or abdominal pain, in addition to diarrhea; may also have systemic symptoms such as skin rash, bronchospasm, or anaphylaxis
• •
  Lactose intolerance

  • ○
    Primary acquired (late onset): lactase levels decrease through late childhood
  • ○
    Secondary acquired: caused by mucosal injury
  • ○
    Congenital: exceedingly rare
• •Medication‐induced
• •Encopresis
• •Immune system disorders: eosinophilic enteritis, acquired immunodeficiency syndrome, immunoglobulin A (IgA) deficiency, autoimmune enteropathy
• •Acrodermatitis enteropathica (zinc deficiency)
• •Anatomic abnormalities: short intestine, malrotation
• •Fat malabsorption: cystic fibrosis, Shwachman‐Diamond syndrome, pancreatitis
• •Endocrine disorders: hyperthyroidism, diabetes
• •
  Hormone‐secreting tumors

  • ○
    APUDomas: These tumors originate in the APUD cells (amine precursor uptake and decarboxylation of amino acids) of the gastroenteropancreatic endocrine system.
  • ○
    Cell origin is adrenal or extra‐adrenal neurogenic sites.
• •Hirschsprung's disease
• •Vasculitis: hemolytic uremic syndrome, Henoch‐Schönlein purpura
• •Pseudoobstruction
• •Appendicitis
• •Munchausen syndrome by proxy

Laboratory Tests

• •
  A fresh stool sample may be the only body fluid needed and can be examined.

  • ○
    pH, reducing substances, neutral fat, occult blood
  • ○
    Ova and parasites, Giardia antigen
  • ○
    Leukocytes, eosinophils
  • ○
    Clostridium difficile toxin
• •
  All of these stool studies are normal in toddler's diarrhea.

  • ○
    Occult blood could be present if there is a perianal rash or excoriation from the frequent stools.
• •Other laboratory tests should be done only if indicated because of an abnormality found on fresh stool sample or because a different diagnosis is suspected based on history or physical examination.

Treatment

Nonpharmacologic Therapy

• •Provide parental reassurance
• •Reduce juice consumption
• •Eliminate soda and non‐juice sweet drinks
• •Normalize fluid consumption (to about 100 mL/kg/day)
• •Reduce dietary sorbitol and free fructose
• •Normalize diet (especially fats) if parents are restricting
• •Increase dietary fat content to 35% to 40% of total calories (usually more than 4 g/kg/day)
• •Increase dietary fiber

Acute General Rx

• •Usually, no medical treatment is needed; resist the temptation and parental pressure to use medication.
• •
  Green stools may contain abnormally high quantities of bile acid.

  • ○
    Treatment with the bile salt‐binding medications cholestyramine and bismuth subsalicylate has reduced stool frequency and water content in some patients.
• •Psyllium (2 to 3 g twice daily for 2 weeks) or Citrucel (1 to 2 tsp/day) may offer some cohesiveness to stools.
• •Metronidazole will help the patient with undetected Giardia.
• •Do not prescribe antispasmodic agents or antidiarrheal agents (e.g., loperamide) because these are not helpful.

Complementary & Alternative Medicine

• One study suggests that ingestion of yeast can benefit some patients with toddler's diarrhea by altering the intestinal microflora and thereby decreasing the chance of bacterial overgrowth.

Disposition

• •Although an extensive workup is not necessary, these children should be followed at least three times a year.
• •If any additional signs or symptoms of gastrointestinal disease occur, or if the child has poor weight gain or weight loss, further evaluation will be necessary.

Pearls & Considerations

Comments

• •Normally, postprandial activity interrupts and replaces the migrating motor complex (MMC) the moment food enters the digestive system, slowing the transit of food through the intestine and allowing more time for the absorption of fluid, electrolytes, and nutrients. In children with toddler's diarrhea, food may fail to interrupt MMC activity, perhaps because of delayed gut motor development.
• •Excess bile salts can enter the colon from rapid transit time and are thought to contribute to diarrhea because bacterial degradation of the salts produces bile acids and hydroxylated fatty acids, which may act as secretogogues in the colon.

Prevention

• See “Nonpharmacologic Therapy.”

Patient/Family Education

• •Explain the common nature and cause
• •Show parents the child's normal growth parameters
• •
  Provide a list of fruits (and juices) low in sorbitol and low in free fructose (equal concentrations of fructose and glucose or more glucose)

  • ○
    Several fruits (and juices) have no sorbitol and also have a favorable fructose:glucose ratio; examples include:

    • ▪
      Citrus fruits
    • ▪
      Cranberries
    • ▪
      Grapes
    • ▪
      Pineapples
    • ▪
      Raspberries
    • ▪
      Blackberries
    • ▪
      Strawberries