Physician: Recurrent Diarrhea

Ruling out all the possible causes

Sonia Billadeau January 31, 2014
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My 20-month-old internationally adopted child has a problem with persistent diarrhea. His post-adoption medial workup was completely negative. I do not understand why his bowels are so loose if there is nothing medically wrong with him?

Unfortunately, chronic diarrhea is a very common problem found in many post-institutionalized children. Causes can vary from mild dietary intolerances, to psychological situations, to serious medical problems. In pediatric medicine, children have usually one medical diagnosis at a time. In the orphan child who has lived in an institution for several months, many unrecognized or ignored medical conditions can occur concurrently.

The normal stooling pattern for children is 1-2 times per day. When this frequency increases to multiple times per day, with massive amounts of copious, foul-smelling stools with little consistency, diarrhea would be a diagnosis of concern, regardless of the fact that the initial evaluation was negative. We need to re-look at the patient’s history and order appropriate medical tests.

Reasons for recurrent diarrhea in the internationally adopted child could be many, but the most common reason still is dietary changes. If the correct diagnosis is made quickly and appropriately, then the proper medical therapy can be implemented which will undoubtedly resolve the symptoms of diarrhea.

In the internationally adopted child, overeating is another common reason for recurrent diarrhea. Adopted children are known to be fixated with food post-arrival. Sometimes they seem to be bottomless pits. They eat everything in sight, as if it won’t be available in the morning. One must remember that food for these children was scarce in the orphanage. When it was available, it did not look or taste very good. Now with the availability of good tasting food, children just cannot control themselves. In their little minds, they fear that it may not be available tomorrow, so they just eat it.

Catch-up growth in these children is always very dramatic. Medical concerns are always diminished in a growing child. Sometimes probiotics, such as a product called Florastar, may help to overcome some of the complaints caused by dietary changes.

Toddlers’ Diarrhea is another common cause of recurrent loose bowel movement in the general pediatric world. It is even more common in the adopted child because, like with food, they tend to drink large amounts of juice. Apple juice, a common drink given to the pediatric population, is notorious for causing Toddlers’ Diarrhea. The recommended therapy of choice is to limit the amount of juice intake.

The diarrhea caused from dietary intake is called Osmotic Diarrhea. Both of the above mentioned causes of diarrhea–Toddlers’ and Osmotic– could only be made once other medical concerns are ruled out accordingly.

Some medical concerns that need to be looked into a with child with chronic diarrhea who was adopted internationally:

Giardia Enteritis is a parasitic infection of the bowel commonly found in children who lived in crowded orphanages. Infected children in the developing parts of the world are generally not treated for this organism because of the high recurrence rate. In the U.S., once diagnosis is confirmed with positive stool specimens for ova and parasitic infection, or with a positive Giardia antigen, therapy is started immediately in order to eradicate the organism, and to keep the infection from spreading to the family and the schools. This parasitic infection is generally treated with either Metronidazole or Alinia.

Metronidazole is an older drug that does work well, but it is not easily attainable. The medication must be compounded by the pharmacist; it is foul tasting and needs to be administered four times daily. A newer and better tasting medication called Alina is now available for children. The company states that an infected child needs to be treated once a day for a total of three days. Unfortunately, there have been many failures with such a short course of treatment. Some internationally adopted children, especially those adopted from Russia, may carry a resistant form of Giardia and may require a longer course of therapy from the very beginning in order to fully eradicate the organism.

Milk protein allergy is another common cause for recurrent diarrhea. In children under 2 years of age, cow’s milk protein allergy is common. Adopted children in the orphanages are given different types of milk products, such as Kefir, soymilk, and sometimes goat milk. It is not until they arrive to the U.S. that the adoptive parents introduce whole milk to their diets and intolerance to milk protein is discovered. Eliminating cow’s milk from their diet and supplementing it with soy or rice milk is an easy way to manage this condition.

Lactose intolerance can also be a cause of diarrhea in the internationally adopted child. Lactose intolerance is common, especially in adopted children from China. There is a deficiency in the enzyme called lactase that is used in the process of digesting milk products. A lactose-free diet and the use of lactate supplements when enjoying a milk product should be sufficient to control the symptoms of the child.

Sorbitol, which is a preservative found in a medication frequently used in children that have a positive PPD reaction, can also cause explosive diarrhea. This medication is called Isoniazide. I have had cases where treating the child’s positive tuberculosis screen caused explosive, foul-smelling diarrhea. This probably caused more discomfort to the patient and the family than the exposure to tuberculosis itself.

A simple remedy to this problem is to have the pharmacist compound the Isonizide using a sorbitol-free preservative. The elimination of the sorbitol from the compound resolves the diarrhea quickly.

More serious conditions that can cause recurrent diarrhea are Celiac disease, Cystic Fibrosis, and Malabsorption Syndrome. These conditions generally present themselves with chronic diarrhea in a child that does not thrive at all. The one thing that many internationally adopted children seem to do almost universally is thrive post-adoption– if they do not have any underlying medical conditions. When a child does not thrive post-adoption, this should be a red flag that something else may be going on with this child.

Once a qualified physician or adoption specialist determines the cause for the child’s recurrent diarrhea, only then can appropriate therapy be implemented.

One should try to stay away from food products that may upset the child’s bowels:

  1. Raw fruits and vegetables
  2. Juice, soda, and milk
  3. Greasy and fried fast-food products
  4. Spicy foods
  5. Sauces
  6. Sweets

Things that can help to alleviate the upset stomach:

  1. Warm liquids
  2. Pasta
  3. Rice cereal
  4. Crackers
  5. BRAT Diet: Bananas, Rice. Applesauce, Toast

Disclaimer

The information and advice provided is intended to be general information, NOT as advice on how to deal with a particular child’s situation and or problem. If your child has a specific problem you need to ask your pediatrician about it– only after a careful history and physical exam can a medical diagnosis and/or treatment plan be made. This website does not constitute a physician-patient relationship.

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Sonia Billadeau


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