When To Worry About Childhood Diarrhea

Dr. Richard So, MD:

Welcome to Little Health, a Cleveland Clinic Children's podcast that helps navigate the complexities of child health one chapter at a time. In each session, we'll explore a specific area of pediatric care and feature a new host with specialized expertise. We'll address parental concerns, answer questions, and offer guidance on raising healthy, happy children. Now, here's today's host.

Dr. Senthilkumar Sankararaman, MD:

Diarrhea is very stressful, especially in infants and young children. As your parent, when you are trying to figure out if this diarrhea is due to your passing virus or this is your sign of your bigger digestive issue. I am Dr. Senthilkumar Sankaraman, your pediatric gastroenterologist at the Cleveland Clinic Children's and today we are going to talk about diarrhea in children. We will discuss the causes, common triggers, how to identify red flags and the best ways to help your child recover. Joining me is my friend and colleague, Dr. Lisa Feinberg, who is your senior pediatric gastroenterologist and expert in this field. She's at Cleveland Clinic Children's. Welcome to Little Health, Dr. Feinberg.

Dr. Lisa Feinberg, MD:

Thank you for having me.

Dr. Senthilkumar Sankararaman, MD:

When I was young, the most popular thing my parents or pediatricians do to me or recommend to me is the BRAT diet, which stands for bananas, rice, apple sauce, and toast. But now it seems like a lot of pediatricians are moving away from BRAT diet. Could you help us understand why is that and the pros and cons?

Dr. Lisa Feinberg, MD:

So the BRAT diet, whilst it won't harm you, if you remain on it for too long is obviously not nutritionally replete. It's kind of low in protein, it's mostly carbs and starchy. And in all honesty, like apples for some people can actually exacerbate diarrhea, so I was always a little confused as to why that's on that list. Now, having said that, a lot of these things are comfort foods and kids will eat them when their stomachs are a little upset and there's no harm in transiently leaning on that, but there's also no evidence that shows that it shortens up the duration of the illness, that it firms up the stools more quickly. So as a doctor who chases evidence and who follows not just, you know, historical recommendations, but also where does the data show this actually works? This does not actually change the duration or the severity of your kid's diarrhea.

Dr. Senthilkumar Sankararaman, MD:

So when should parents take their kid to the emergency room? In other words, are there red flags that parents should be looking for when the child has diarrhea so that they can, don't waste time and they can take to the emergency room immediately?

Dr. Lisa Feinberg, MD:

Severe abdominal pain, I always say, "You never need my permission if you are in pain to go to the ER. If your child is having diarrhea, vomiting and looking dry in the mouth or is, you know, not had a good wet diaper in over six hours, that is a trip to the emergency room for dehydration. If you see blood in the stool, that is never a "stay at home and just watch things" moment. You can always feel comfortable knowing that that's a good reason to go in. Those are like the top ones, but if your child is overall well-appearing, keeping things down, seems hydrated, you can always run things by the pediatrician, you can always run things by us. We have so much like availability and bandwidth to help families if they are concerned.

Dr. Senthilkumar Sankararaman, MD:

That's good to hear. Yeah. So the next question is very popular question. What is the role of probiotics? Are they just waste of money? Do they help in recovery for childhood diarrhea? What are your thoughts on that? I

Dr. Lisa Feinberg, MD:

Generally say that for the most part, there's no harm in them. With the caveat that some of my patients who may or may not have immune deficiencies, I'd exercise caution in those recommendations. But typically there's no harm and they do have some role. There is some evidence to show that they can be helpful if let's say you're on an antibiotic and you get diarrhea from that, which is a fairly common complaint. And in fact, I have no small number of patients who see me for diarrhea where they were just on medicine for an ear infection and it depletes the healthy bacteria and can set you up for a more prolonged course of diarrhea that takes longer.

And a probiotic, the healthy bacteria we'd like to have back can help to shorten that. You know, having said that there are some infections that can be triggered by antibiotics that are more serious, we typically see those in kids a little older than toddlerhood. So if your child's diarrhea again is lasting longer than two weeks or getting worse or if you see blood, those would all be reasons to come see us.

Dr. Senthilkumar Sankararaman, MD:

You talked about the diarrhea lingering for weeks. Could it be due to lactose intolerance?

Dr. Lisa Feinberg, MD:

Oh, 100%. And the simple trick of switching to a lactose-free milk should help that enormously. And the lactose intolerance that we'll see after infections often is temporary. So we expect that to improve as your intestines heal up after that acute insult.

Dr. Senthilkumar Sankararaman, MD:

What I'm hearing from you seems like when the kid gets better, starting their regular baseline food seems more logical and safer.

Dr. Lisa Feinberg,MD:

Absolutely. And culturally speaking, I mean, the BRAT diet is a very Westernized diet. A lot of people who are from elsewhere in the world have other traditional comfort food sort of things. In the house I grew up in, it was chicken soup, ginger ale, and noodles.

Dr. Senthilkumar Sankararaman, MD:

So how about if the infant is breastfed, can the mom continue breastfeeding during diarrhea?

Dr. Lisa Feinberg, MD:

Oh, 100%. And in fact, the breast milk does even contain antibodies and there is evidence that clearly shows that those will help to fight off an infection.

Dr. Senthilkumar Sankararaman, MD:

That's awesome. That's good. Are there any medications that parent can use for their child with diarrhea?

Dr. Lisa Feinberg, MD:

There are several over-the-counter options out there. I usually am more of a let's ride this out and do supportive care and make sure you're keeping your child hydrated while we wait for this to resolve. But yeah, some of the over the counter options, I know some families will use loperamide to help to slow the amount of stool coming out of their child. Now, I exercise caution with these recommendations because a lot of times it's to hurry up and get your child seeming better so that they can go back to preschool or daycare, but they're still going to be infectious even if their stools are not loose anymore because of the medication. So I tend to shy away from those recommendations.

Dr. Senthilkumar Sankararaman, MD:

And sometimes it can prolong the course of the infections also, right?

Dr. Lisa Feinberg, MD:

It does. Yeah. The, the... You want to get that out of you. You want, you want your body to let it jettison - [That makes sense.] the pathogens.

Dr. Senthilkumar Sankararaman, MD:

Yeah. And we often recommend the electrolyte solutions, pediatric electrolyte solutions, but lot of kids don't like it. So in that scenario, parents often ask us about, "Can I give one of the sodas or can I give vitamin water or sports drink?" What is your take on that?

Dr. Lisa Feinberg, MD:

So many of those vitamin waters and the sports drinks, particularly the lower calorie or the sweeter ones, will have non-absorbable sugars in them, which can even make the diarrhea worse. If your child is not a fan of pediatric electrolyte solution, water is a better option than the sweetened or artificially sweetened beverages. There are recipes out there for something called oral rehydration solution and you can make that at home and it is considerably less expensive. So that too is an option.

Dr. Senthilkumar Sankararaman, MD:

Good. Thank you. And other question I often get from parents is when a child has diarrhea, is it not bowel rest the best option because that may reduce the frequency of diarrhea versus pushing more like electrolyte solutions to the kid? Help us understand like why we need to push the electrolyte solutions.

Dr. Lisa Feinberg, MD:

Well, we want to make sure that we are getting fluids to make up for what is coming out and the ongoing losses. So we absolutely wanna keep those balances. And in all honesty, I usually tell parents, feed through a diarrheal illness. Yes, you might see bits of food in their poop. It might not be the funnest, but if your child is willing to eat and is hungry, they are still absorbing nutrients in the small intestine even if they are potentially losing water in the colon and the nutrients that they are absorbing will help their body to fight infections and heal more quickly.

Dr. Senthilkumar Sankararaman, MD:

So some of the kids, especially kids going to school or preschool or daycare often get diarrheal infections. Is it a sign of immunodeficiency or like when parents need to worry about something, a bigger problem?

Dr. Lisa Feinberg, MD:

Catching germs is not a sign of immunodeficiency. Kids who have immunodeficiency will typically catch germs but have a harder time getting over them or will become sicker when they have them. So if your child has several diarrheal illnesses over the course of a school year, that's okay. It's only if they are protracted prolonged, or if they are severe enough that they are needing admissions or things like that. So catching bugs not a problem, catching bugs and having longer and harder illnesses, more the issue.

Dr. Senthilkumar Sankararaman, MD:

And I also think like other signs and symptoms could also be present such as not gaining weight. [Oh, yes.] Yeah. Or bloody stools and things like that.

Dr. Lisa Feinberg, MD:

Yes. Yes, absolutely.

Dr. Senthilkumar Sankararaman, MD:

When does parent need to worry about something bigger like inflammatory bowel disease?

Dr. Lisa Feinberg, MD:

Those children typically grow very poorly. The other thing is blood in stool is always a big red flag. So if a child has a more serious illness, they tend to not grow real well. And this is another reason that like when we see our patients, we like to have several plots of weight and height to follow that overall trend. A kid with very tall parents who's very tiny gives us pause or a kid who's been of average height and then sort of slowly drops down on those percentiles makes us think. So it's not just, you know, what is your child's poop looking like or, you know, how often does your child poop, but it's also how well is your whole child?

Dr. Senthilkumar Sankararaman, MD:

Good. And same line, could this could be a celiac disease?

Dr. Lisa Feinberg, MD:

It absolutely can. Celiac disease is one of those things we always hear about in our education about how it's that tip of the iceberg thing. It's also associated with other autoimmune things. So we see a, no small number of patients who are diagnosed with other things as well and it's celiac disease is sort of picked up as screening. But no, celiac disease can cause diarrhea and most of my patients who have diarrhea that again, persists. It's that two week mark. A kid with celiac disease isn't gonna have diarrhea, then not have diarrhea, then have diarrhea again. It stays. So in patients with chronic diarrhea, investigating for celiac disease is always a reasonable thing to do.

Dr. Senthilkumar Sankararaman, MD:

As a gastroenterologist, this is the fun part for me to ask you. What does poop color mean?

Dr. Lisa Feinberg, MD:

Well, um -

Dr. Senthilkumar Sankararaman, MD:

Can we take, is there any take parents can understand or kind of like try to see or try to kind of like get something out of it?

Dr. Lisa Feinberg, MD:

So pretty much anything you see on a camo palate is good. So greens, browns, yellows, all those lovely earth tones, olives, things like that. The colors that we as gastroenterologists really hate to see, red or maroons, black, because that would be digested blood. Or if your child has white or very light, light tan stools, that could be a problem. Although again, sometimes these viral illnesses will cause a temporary lightening of the stool and that has to do in part because, you know, things are just diluted and watered down. Those green colors come from our digestive juices that come from the liver. It's called bile. If you're having a lot of diarrhea that could get thinned out to a palish green or a lighter, like a darker yellow and that while not normal is not necessarily scary.

Dr. Senthilkumar Sankararaman, MD:

So what I'm hearing from you, if it seems like acute episodes are diarrhea lasting for a few days in your child otherwise growing really well, eating well, not getting dehydrated, hiting the milestones appropriately, seems like those diarrhea can be effectively managed by parents with the help of pediatricians, but if the diarrhea is more prolonged or the kid having, not gaining weight appropriately or losing weight or any additional concerns as you rightly mentioned, like blood in the stool or like fever, things like that, those red flag symptoms seems like that should definitely prompt your referral to pediatric gastroenterologists.

Dr. Lisa Feinberg, MD:

Absolutely. Absolutely.

Dr. Senthilkumar Sankararaman, MD:

Any other things you want to share with us for our audience?

Dr. Lisa Feinberg, MD:

Again, just to say if ever you have any concerns, we are happy to work along with your pediatricians to help your child in any way that we can.

Dr. Senthilkumar Sankararaman, MD:

Switching gears a little bit, what is your favorite food?

Dr. Lisa Feinberg, MD:

That's a toughie because I do love to eat. I would have to say asparagus.

Dr. Senthilkumar Sankararaman, MD:

Okay, good. Very unusual one I get. Yeah. It's

Dr. Lisa Feinberg, MD:

Been my favorite since I was actually a small child.

Dr. Senthilkumar Sankararaman, MD:

Okay, good. And what is your favorite thing to do or favorite things to do in Cleveland?

Dr. Lisa Feinberg, MD:

Things to do in Cleveland. Love the Metro Parks. There are some beautiful trails out there. I'd love to get my outside on.

Dr. Senthilkumar Sankararaman, MD:

Good, good. Thank you. Thank you so much for your time. Thank you so much for all those valuable advices you gave.

Dr. Lisa Feinberg, MD:

It's been a pleasure. Thank you so much.

Dr. Senthilkumar Sankararaman, MD:

So we hope we made those stressful moments associated with diarrhea feel a little bit more manageable and you feel more confident helping your child's recovery. If you would like to schedule an appointment with your pediatric gastroenterologist at the Cleveland Clinic Children's, please call 216.444.KIDS. That is 216.444.5437. Thank you so much.

Dr. Richard So, MD:

Thanks for listening to Little Health. We hope you enjoyed this episode. To keep the little health tips coming, subscribe wherever you get your podcasts or visit clevelandclinicchildrens.org/littlehealth.