Persistent Diarrhea in Post-Institutionalized (PI) Children

Persistent diarrhea is extremely common in PI children and can be caused by many factors. Very often several factors are present at the same time. Frequently persistent diarrhea is just an uncomfortable condition, but sometimes it can be a sign of a serious health problem. In most of the cases, it is a combination of different factors, which is determining the necessity and urgency of actions. Children with persistent diarrhea are more prone to have gastro-intestinal tract complications during or after any stressful situations (emotional, infectious and so on)

DEFINITION. Diarrhea is a defecation pattern with unusual quality, quantity and/or frequency (more frequent) of stools for this individual. Therefore, a pattern of two to three stools per day does not arbitrarily constitute a diarrhea, if this is a usual healthy pattern for that particular person. The same is valid for a constipation, when for some people stools every other day can be absolutely normal. Taking in consideration that we can not be sure what exactly stooling pattern is "normal" or usual for this particular child, it is advisable to remain relatively cautious.

PROTECTIVE factors: relatively good condition of the child at the time of adoption, good and steady weight gain, very good appetite ("vacuum cleaner"), frequent mushy stools without abnormally bad smell, stool is normal color and composition, not a lot of gas. Child is usually healthy, does not have un-usually frequent and prolonged infections. Presence of the protective factors does not exclude medical problem with the digestion, but they can protect this individual from complications.

NEGATIVE factors: extremely malnourished child, poor or no weight gain (note that "normal" weight gain along the percentiles of the standard growth chart can be considered as a poor weight gain for a malnourished PI baby), poor appetite, watery, explosive, foul smelling, discolored (too light, too dark, green and so on) stools, a lot of gas, child is uncomfortable. Persistent congestion, frequent and hard to treat ear and sinus infections, allergies (nose, skin, eyes), frequent and prolonged "chest colds". Multiple and prolonged use of antibiotics. Unexplained anemia. Poorly healing scratches and wounds. Presence of the negative factors makes the probability of the medical problem higher.

SOME CAUSES FOR PERSISTENT DIARRHEA IN PI CHILDREN:

1. OVEREATING is a very common in PI children of any age. Children are usually always hungry, gulping the food and asking for more. They grow very well "across the percentiles" and do complete their catch-up growth within the first months after adoption. Diarrhea secondary to overeating is a diagnosis of exclusion and can be made ONLY after all other treatable causes of diarrhea are ruled out. All the bloodwork is usually normal, stool cultures are negative and the best medicine in this situation is a "tincture of time". Probiotics can help, as well as foods, high in fiber. Minimal dietary adjustments can be beneficial (see below) but mostly children can and should eat everything.

2. TODDLERS DIARRHEA is a term describing persistent diarrhea in a toddler, who is drinking a lot of juices. Juices have nothing good in them except of the sugars and the American Academy of Pediatrics recommends to limit juice consumption to 4-6 oz per day in any child. Again, toddlers diarrhea is a diagnosis of exclusion and can be made ONLY after all other treatable causes of diarrhea are ruled out. Restriction of juice consumption is usually enough to make the diarrhea more tolerable, but it can take some time for a child to develop the "adult type stool"

3. Diarrhea secondary to MILK PROTEIN ALLERGY and LACTOSE INTOLERANCE is not unusual either. It can be transient after antibiotic treatments, gastro-intestinal infections or in a child, seriously sick with any other disease. Some people can not tolerated milk protein and/or sugar because of the permanent deficiency of specific enzymes, which help us to digest different types of food. In Caucasian population and children under 2 years of age the milk protein allergy is more frequent than the lactose intolerance. Milk protein allergy can be treated by the use of the sour milk products (yogurt, buttermilk, sour cream, most types of cheese) and use of the soy products. In severe cases rice milk can be an answer. Lactose intolerance is more frequent in African-Americans and children over 2 years of age. Lactose-free diet and lactate supplements are usually more than enough to control the symptoms. Fat-free or low-fat milk has nothing to do with treatment of those conditions because only fat is being removed from the milk, leaving the protein and sugar intact.

4. For many years the diagnosis of DYSBACTERIOSIS was not taken seriously in the United States, but now more and more parents and pediatricians are becoming aware of that problem. Dysbacteriosis means the dis-balance in the composition in the intestinal flora (bacteria, which are helping us to digest food, fight the infections, absorb vitamins and so on). Dysbateriosis can be temporary (after infections) or persistent. Healthy nutrition and appropriate doses of the probiotic medications are crucial for successful treatment.

5. TRAVELER'S DIARRHEA, INTESTINAL INFECTIONS (with bacteria and viruses) and INFESTATIONS (with parasites) can case a lot of trouble at any age. Infections with Giardia, Entameba and other pathogens are very common in PI children. Proper testing of everybody involved, sanitary precautions and timely treatment with appropriate doses of appropriate medications is crucial for the success.

6. CHRONIC PEDIATRIC CONDITIONS, like chronic otitis media, allergies and hepatitis can present with persistent diarrhea.

7. HEREDITARY CONDITIONS (Celiac disease, Cystic fibrosis, immune deficiencies, malabsorbtion syndromes and others) can present with diarrhea and failure to thrive. Evaluation and treatment in this case is usually performed in specialized centers by pediatric gastroentherologists and other specialists.

THERAPEUTIC AND DIETARY MANAGEMENT OF PERSISTENT DIARRHEA (Always consult with your doctor first!!!)

FOODS THAT CAN UPSET INTESTINES: Everything too hot or too cold. Large infrequent meals. Raw fruits and vegetables, juices, soda, milk (sometimes), chicken/beef soup, greasy fast food, fried foods, spicy foods, tomato souses, sweets. Some dried fruits, including prunes, figs, dates.

FOODS THAT CAN HEAL INTESTINES: everything neutral, warm, coating, blended. Small frequent meals. Easy to digest (light) products. Pasta, rice, hot cereal (oatmeal, farina, buckwheat) with little or no milk/or cream, some baked or cooked vegetables and/or fruits, breads. Teas and "compots" (see below). BRAT diet ( Banana, Rice cereal, Applesauce, dry Toast), Good natural fats (sweet butter, olive oil, etc). Electrolyte solutions (Pedialyte and others) are good for preventing and treating dehydration, but they would not treat the cause of diarrhea.

SUPPLEMENTS THAT CAN HEAL INTESTINES: (1) vitamins - a lot of vitamins can be lost because of the increased speed of passage of the stool through intestines and because of decreased absorption. Fat soluble vitamins are the most vulnerable in this situation and they can be absorbed only in the presence of fats in the diet. (2) Fats are extremely important in building the cell wall, defense from infections and healing mechanisms. Fats are also known to slow the propulsion of food through the intestinal tract, which can be helpful in the case of BENIGN persistent diarrhea. In the case of severe milk allergy, alternative sources of fat should be sought. (3) Probiotics - good bacteria, which do help us to digest foods and fight the infections. Yogurt is a good source of probiotics, but in the case of severe milk intolerance, those same bacteria in tablet or powder form may be required. (4) Soluble fiber is very important in management of diarrhea, because it absorbs water and thickens stool. (5) Herbs and mild spices can add taste to your child's food and promote healing at the same time. Cooked dill, fennel, celery, parsley, and onions can be safely added to the mashed potatoes, vegetable soups and foods alike.

SUPPLEMENTS WHICH CAN UPSET INTESTINES. Any medication, which claims to stop diarrhea (IMMODIUM and so on) can be potentially harmful.

TEAS and COMPOTS Regular black tea is known to promote healing of the intestines and is frequently used in many cultures to treat diarrhea. The tannic acid (this brownish coloring) has good binding, anti-inflammatory, anti-viral, anti-bacterial, anti-whatever you want capacities. You can safely use caffeine free tea in a child over 6 months of age. Fruit and herbal teas can be used as an alternatives to juices. You can make a fruit tea (compote) yourself from dried fruits from your local supermarket. Be sure NOT to use raisins, prunes, figs, and dates. It is good to start with one fruit at a time. Dice your fruit (dried apples, apricots, peaches, pears) into a glass or ceramic container and pour boiling water over it. It is not necessary to boil it - just let it steep overnight. You can adjust the taste and concentration of the compote according to your child's taste and symptoms.

This article was originally posted at www.welcomegarden.com in February 2003
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The information appearing here is intended for educational purposes only. It should not be used as a substitute for professional medical advice tailored to your child's individual needs. If you have questions or concerns regarding your child's physical or mental health, please seek assistance from a qualified healthcare provider.