Most children experience several episodes of diarrhea. Most will be mild and self limited. However, depending on the pathogen and severity of infection, some will take days or even weeks to completely resolve. This is because every intestinal cell that was attacked by the virus has to be replaced by a new cell. Recovery occurs as the intestinal lining is restored.

During this time, the intestinal lining is injured by the virus, nutrients might be not completely absorbed. Cow's milk and apple juice can be incompletely digested in the small intestine and reach the colon. These undigested sugars can aggravate the diarrhea and make it more irritating to the skin. Infants often get a red, raw diaper rash.

It is of utmost importance to replace lost fluids, otherwise a child can get progressively weaker and start to experience electrolyte disturbances. If a child has one or two loose stools, the parents can offer more fluid, however, if more stools ensue, it is important to start pedialyte, kaolyte or other electrolyte solution.

Electrolyte solutions such as Pedialyte were developed in the 1960's and are formulated to replace the lost water and electrolytes. As a rule of thumb, if a child takes 2 ounces of electrolyte solution for each watery stool, he or she will remain in balance.

Diarrhea without vomiting

The goal is to replace fluids by mouth in an amount which is roughly equivalent to that which they are losing in diarrhea. Again, clear, sugary fluids or Pedialyte are good choices. Avoid things that cause loose stools on a good day (such as apple juice and cider) and avoid dairy products, as diarrhea will cause temporary lactose intolerance in most children. (The lactase enzyme which digests lactose sugar in milk/dairy is in the very center of the intestinal tract. With multiple episodes of diarrhea, the lactase gets washed away and may require a few days of being well to replenish itself.)

If your child is tolerating fluids, you can use carbohydrates such as pretzels, crackers, toast, and noodles to "soak up the fluid". Other foods that can help are bananas, decaffeinated teas, rice/rice cakes, and applesauce (the pectin helps to stop diarrhea). In general keep your child's diet boring and bland for a few days, even when their hunger returns. Reintroducing their favorites such as hot dogs and pizza too early may make symptoms reappear.

Common questions and answers:

What if it seems like everything I give goes right through my child?

This may appear to be the case, but is really not what is happening. Remember when you first brought your child home as an infant? Every time you fed him/her, he soiled his diaper. This is because the body has a "gastro-colic" reflex and no tone to the anal sphincter when you are very young. Every time you introduce something into the stomach, the colon starts moving things along and the rectal sphincter relaxes to expel whatever happens to be down there. If things are moving rapidly through the intestinal tract (as in the case of a viral illness), the contents do not sit in the colon/rectum long enough for the body to reabsorb any excess water. This is why it looks like the fluids you are giving by mouth are coming out the other end. Be persistent! Keep pushing the fluids and the body will eventually recover.

What do I give an infant with vomiting/diarrhea?

In general, children under 12 months of age should receive fluid replacement in the form of Pedialyte or one of the other electrolyte replacement solutions on the market. These products have the correct amount of sugar/salt to make sure the baby's "chemistries" don't get out of whack. As above, start with small amounts. If your child is not vomiting, keep offering fluids as tolerated and monitor hydration status as above. If you are breastfeeding, continue to do so with small, frequent feedings. If you are bottle feeding, offer no other foods but Pedialyte (absorbed through the stomach, and the body doesn't have to do any work to digest, so it gives the intestinal tract a "rest") for the first 24 hours. Then switch to a non-milk based or lactose-free formula for a few days. It is often a good idea to do 24 hours of Pedialyte only, followed by 12-24 hours of Pedialyte and lactose-free/soy formula, followed by full strength (mixed according to the directions on the can) lactose-free/soy formula for a few days. If your child is eating solids, you can reintroduce bland/boring things once you know they are tolerating full strength formula.

When should I be concerned?

Seek medical attention if your child appears dehydrated, symptoms persist longer than expected (vomiting continues longer than 12 hours, and/or diarrhea persists longer than 3 days), your child appears very ill/listless, or diarrhea is accompanied by severe abdominal pain/cramps and/or has mucous or blood in it.

What if your child doesn't like pedialyte or kaolyte?

Try one of the flavored forms of pedialyte, (particularly apple). Electrolyte solutions are also available as popsicles and jello. There is also a citrus flavored product called Citrucel.

Sneak it into formula, by adding one ounce of water to one ounce of formula, and then add 3-4 ounces of pedialyte. If you add pedialyte directly to formula, it will be too 'osmotic' and can aggravate the fluid loss. Diluting the formula slightly will prevent this.

Make a sugar based solution: Mix 1/2 tsp of salt (2.5mL) with 8 teaspoons of sugar and one quart of water. This contains the right proportion of sodium and glucose, but doesn't contain potassium. The child will also need to have bananas, carrots, or another potassium containing food. Tip: Make this solution, add a banana and quarter cup of orange juice and put in a blender.

Make a soup based solution: Use a proportion of 1/3 tsp of salt to each quart of water (This will make up for some evaporation of the water during cooking). Add a piece of chicken or other meat preferably with a bone. Add carrots and rice or potatoes and start cooking. You can also add some frozen squash. The resulting chicken/rice/carrot soup will help replace sodium, potassium, water but also contain trace elements like calcium, magnesium and phosphorus.

It's good to give a child rice during diarrhea because it helps balance their intestinal contents. The structure of rice acts like a cotton mop by absorbing bacterial byproducts. Potatoes, carrots, and squash also help firm up the stools. When a child is starting to improve, giving high fiber foods like oatmeal and small amounts of lentils and beans help normalize the GI tract.

Yogurt contains the beneficial bacteria lacto-bacillius. It populates the intestinal tract with 'friendly' bacteria that crowds out the more pathogenic germs. It is recommended that parents start giving children yogurt at the beginning of diarrhea, or whenever they are taking an antibiotic.

When a child needs to go to the ER or be hospitalized

Severe diarrhea with inability to keep up with ongoing losses. Each winter, many infants are hospitalized for IV fluids because of the Rota virus, which gives a particularly watery diarrhea.

Green vomiting

This can be a sign of a medical emergency, intussusception, in which the stressed intestinal tract becomes obstructed in a telescoping like motion.

Bloody Stools

This can be a sign of pathogenic e.coli that can cause complications with blood clotting and kidney function.

Pain with motion or pain in the right abdomen

This can be a sign of appendicitis. After intestinal viruses, the lymph nodes of the intestinal tract become slightly enlarged. Children have relatively larger lymph nodes than adults and they are more crowded in the vicinity of the appendix. Appendicitis is notoriously hard to diagnose in younger children. One of the early symptoms is pain with movement. Another symptom is pain in the middle of the night. The pain of appendicitis typically starts around the belly button and then moves to the right lower quadrant. However, it can have an atypical pattern. The appendix can be slightly deflected and the pain, if it is inflamed, can be referred to another area of the abdomen.

If you think your child is getting sicker

Parents have very good intuition. If your child is acting weak, this can mean that dehydration or an electrolyte imbalance is setting in. A few hours of IV hydration can make a tremendous difference. Diarrhea can be serious. It continues to claim countless lives in third world countries and war zones. I remember reading in a medical journal that in 1900, 20% of the children in New York City died of diarrhea. This was before IV therapy was available and people knew about the need to replace electrolytes as well as fluid.

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