Case

The parents of a 14 month old boy bring their son to your office with a 2 month history of 2-6 loose, non-foul smelling watery stools per day. At times there is undigested food in the bowel movement. The parents have gone through multiple diet changes and now the boy is only eating a low fat , no dairy products, lots of fruit juices, and minimal protein diet. He has had an extensive workup including negative stool cultures for bacteria and viruses, negative stool for ova and parasites, and no polys or blood in the stool. How would you approach this problem?

Toddler diarrhea is a common pediatric condition. In infants it is referred to as chronic diarrhea of infancy and in older children as irritable bowel syndrome. Common clinical characteristics include:

1. Age between 6-30 months. Most are better by 4 years of age
2. 2-6 watery stools per day. There can be periods of days without stools. Many stools contain undigested material and may drip down the child's leg from the diaper.
3. Normal weight, height, and head circumference growth curves without falling off
4. No evidence of infection
5. Stools are hematest negative
6. The child looks well and there is no evidence of malnutrition and no history of abdominal pain
7. Growth may be compromised if the diet manipulations that have been tried to control the diarrhea have not been enough calories. 
8. There is often a history of colic, gastroesophogeal reflux, and family history of irritable bowel syndrome. 

1. Malabsorption secondary to pancreatic insufficiency or intestinal mucosal injury
1. Children are frequently irritable and have loss of appetite
2. Stools are foul smelling and greasy
3. Poor weight gain and abdominal distention. 
4. The child is often weak and displays decreased activity.
5. Anemia, hypoproteinemia, vitamin deficiencies.
2. Allergies to Food
1. Vomiting, diarrhea, and blood in stool
2. + family history of atopy
3. Failure to gain and grow
4. History of eczema, reactive airway disease, urticaria, and allergic rhinitis
5. Loss of protein in the gut may lead to hypoproteinemia and edema
3. Lactose Intolerance
1. Genetic lactase deficiency is rare in young children and will manifest later on in life
2. Secondary lactase deficiency following gastroenteritis is usually transient and is improvedwithin 2 weeks
4. Giardia Infection
1. Foul smelling watery stools
2. Gassy and abdominal distention
3. Can develop into chronic condition and diagnosed by inspecting stool or duodenal fluid for cysts. 
4. Usually waterborne but can be from person to person transmission 
5. Cryptosporidium
1. Watery, foul smelling stools that may be mucousy. 
2. Crampy abdominal pain
3. + oocysts in stool specimen
6. Waterborne or animal or person to person transmission.

1. Increased colonic transit time and decreased inhibition of post-prandial transit time
2. Decreased fat in diet because of diarrhea that is needed to decrease transit time
3. Fluid load is increased because of fear of dehydration and this aggravates the condition
4. Increase sugar in diet that acts as an osmotic diuretic and causes more water in the gut.

1. Increase fat in the diet
2. Decrease fluid in the diet
3. Avoid fructose and sorbitol- decrease fruit juices
4. Increase dietary fiber
5. Normal diet for age
6. Reassurance- this is difficult because parents have been to many physicians and are convinced that their child has a serious illness. It is important after making your recommendations to follow-up soon to reassure again and watch weight and height gains.
7. There is no role for medications.
8. The parents should be told that there is no serious sequelae and this is not a precursor to inflammatory bowel disease, chronic diarrhea as adults, or cancer
9. Most children are better by 4 years of age, and are better by the time they become potty trained.

1. Treem, William. Chronic Nonspecific Diarrhea of Childhood. Clinical Pediatrics. July, 1992.
2. Vanderhoof JA. Chronic Diarrhea. Pediatrics in Review. 1998; 19:418-422.
3. Liacouras and Baldassano Is it toddler's diarrhea?  Contemporary Pediatirics  Sept 1998