Tag Archives: stool



Diarrhea is the sudden increase in the frequency and looseness of stools

* The main risk of diarrhea is dehydration

* Loose or runny stools do not cause dehydration

* Frequent, watery stools can cause dehydration


* Viral gastroenteritis (viral infection of the stomach and intestines) is the usual cause

* Bacteria (eg, Salmonella, Shigella) cause some diarrhea. The main food-borne bacteria are Campylobacter, Salmonella, and Escherichia coli.

* Food Poisoning: Rapid onset of vomiting and diarrhea within hours after eating a food contaminated with toxins (eg, cream dishes that are not properly refrigerated). Symptoms usually resolve in fewer than 24 hours without a need for medical care.

* Giardia (a parasite) occasionally, especially in child care centres.

How to Recognize Dehydration:

* Dehydration means that the body has lost excessive fluids, usually from vomiting or diarrhea. An associated weight loss of more than 3% is required. In general, mild diarrhea, mild vomiting, or a mild decrease in fluid intake does not cause dehydration.

* Dehydration is the most important complication of diarrhea

* The following are signs of dehydration:

– Decreased urination (no urine in more than 8 hours) occurs early in the process of dehydration. So does a dark-yellow, concentrated yellow. If the urine is light straw coloured, your child is not dehydrated.

– Dry tongue and inside of the mouth. Dry lips are not helpful.

– Dry eyes with decreased or absent tears

– In infants, a depressed or sunken soft spot

– Delayed capillary refill longer than 2 seconds. This refers to the return of a pink color to the thumbnail after you press it and make it pale. Ask your child’s doctor to teach you how to do this test.

– Irritable, tired out, or acting ill. If your child is alert, happy, and playful, he is not dehydrated.

– A child with severe dehydration becomes too weak to stand or very dizzy if he tries to stand.

Definition of Diarrhea in Breastfed Infants:

• The stools of a breastfed infant are normal unless they contain mucus or blood, or develop a new bad odor.

* The looseness (normally runny and seedy), color (normally yellow), and frequency of stools (normally more than 6 a day) are not much help. Breastfed babies may normally even pass some green stools surrounded by a water ring (normal bile can come out green if intestinal transit time is rapid enough).

* During the first 1 to 2 months of life, the breastfed baby may normally pass a stool after each feeding. (However, if an infant’s stools abruptly increase in number and looseness and persist for 3 or more stools, the baby probably has diarrhea)

* Other clues to diarrhea are poor eating, acting sick, or fever.

Definition of Diarrhea in Formula-Fed Infants:

* Formula-fed babies pass 1 to 8 stools per day during the first week, then 1 to 4 per day until 2 months of age.

* The stools are yellow in colour and peanut butter in consistency

* Formula-fed newborns have true diarrhea if the stools abruptly increase in number or looseness and persist for 3 or more stools, become watery or very runny, contain mucus or blood, or develop a new bad odour.

* Other clues to diarrhea are poor eating, acting sick, or fever

* After 2 months of age, most infants pass 1 or 2 stools per day (or 1 every other day) and no longer appear to have mild diarrhea.

Return to School: Your child can return to child care or school after the stools are formed and the fever is gone. The school-aged child can return if the diarrhea is mild and the child has good control over loose stools.

Call 911 Now (Your Child May Need an Ambulance) If:

Not moving or too weak to stand

Call Your Doctor Now (or in Alberta, Canada call 780-408-LINK) If:

* Your child looks or acts very sick

* Signs of dehydration (eg, no urine longer than 8 hours, no tears with crying, very dry mouth)

* Blood in the stool

* Weak immune system (eg, sickle cell disease, HIV, chemotherapy, organ transplant, chronic steroids)

* Abdominal pain present longer than 2 hours

* Vomiting clear liquids 3 or more times

* Child is younger than 1 month with 3 or more diarrhea stools (mucus, bad odor, increased looseness)

* Passed more than 8 diarrhea stools in the last 8 hours

* Severe diarrhea while taking a medicine that could cause diarrhea (eg, antibiotics)

* Fever above 104°F (40°C) and not improved 2 hours after fever medicine

* Child is younger than 12 weeks with fever above 100.4°F (38.0°C) rectally (CAUTION: Do NOT give your baby any fever medicine before being seen)

Call Your Doctor Within 24 Hours (Between 9:00 am and 4:00 pm) If:

* You think your child needs to be seen

* Pus in the stool present for more than 2 days

* Loss of bowel control in a toilet-trained child occurs 3 or more times

* Fever present for more than 3 days

* Close contact with person or animal who has bacterial diarrhea

* Contact with reptile (snake, lizard, turtle) in previous 14 days

* Travel to country at risk for bacterial diarrhea within past month

Call Your Doctor During Weekday Office Hours If:

* You have other questions or concerns

* Diarrhea persists more than 2 weeks

* Loose stools are a chronic problem

Parent Care at Home If:

Mild diarrhea (probably viral gastroenteritis) and you don’t think your child needs to be seen

Home Care Advice for Diarrhea:

1. Reassurance:

* Most diarrhea is caused by a viral infection of the intestines

* Diarrhea is the body’s way of getting rid of the germs

* Here are some tips on how to keep ahead of the fluid losses

2. Mild Diarrhea:

* Continue regular diet

* Eat more starchy foods (eg, cereal, crackers, rice)

* Drink more fluids. Formula or milk are good balanced fluids for diarrhea (EXCEPTION: Avoid all fruit juices and soft drinks because they make diarrhea worse)

3. Formula-Fed Infants With Frequent, Watery Diarrhea: Start Oral Rehydration Solution (ORS)

* ORS (eg, Pedialyte, store brand) is a special electrolyte solution that can prevent dehydration. It’s readily available in supermarkets and drugstores.

* Start ORS for frequent, watery diarrhea (Note: formula is fine for average diarrhea)

* Use ORS alone for 4-6 hours to prevent dehydration. Offer unlimited amounts.

* If ORS is not available, use formula prepared in the usual way (unlimited amounts) until you can get some.

* Avoid Jell-O water, sports drinks, and fruit juice

4. Returning to Formula:

* Go back to formula by 6 hours at the latest (Reason: child needs the calories)

* Use formula prepared in the usual way (Reason: it contains adequate water)

* Offer formula more frequently than you normally do

* Lactose: Regular formula is fine for most diarrhea. Lactose-free formulas (soy formula) are only needed for watery diarrhea persisting more than 3 days.

* Extra ORS: Also give 2 to 4 oz (30 to 120 mL) of ORS after every large, watery stool

5. Solids:

Infants Older Than 4 Months: Continue solids (eg, rice cereal, strained bananas, mashed potatoes).

6. Breastfed Infants With Frequent, Watery Diarrhea:

* Continue breastfeeding at more frequent intervals. Continue solids as for formula fed.

* Offer 2 to 4 oz (60 to 120 mL) ORS (eg, Pedialyte) after every large, watery stool (especially if urine is dark) in addition to breastfeeding.

7. Children Older Than 1 Year With Frequent, Watery Diarrhea:

* Fluids: Offer unlimited fluids. If taking solids, give water or half-strength Gatorade. If child refuses solids, give milk or formula.

* Avoid all fruit juices and soft drinks (Reason: make diarrhea worse)

* ORS (eg, Pedialyte) is rarely needed, but for severe diarrhea, also give 4 to 8 oz (120 to 240 mL) of ORS after every large, watery stool.

* Solids: Starchy foods are absorbed best. Give dried cereals, oatmeal, bread, crackers, noodles, mashed potatoes, or rice. Pretzels or salty crackers can help meet sodium needs.

8. Probiotics:

* Probiotics contain healthy bacteria (lactobacilli) that can replace unhealthy bacteria in the gastrointestinal tract.

* Yogurt is the easiest source of probiotics. If your child is older than 12 months, give 2 to 6 oz (60 to 180 mL) of yogurt twice daily (Note: today, almost all yogurts are “active culture”)

* Probiotic supplements in granules, tablets, or capsules are also available in health food stores.

9. Diaper Rash: Wash buttocks after each stool to prevent a bad diaper rash. Consider applying a protective ointment (eg, petroleum jelly) around the anus to protect the skin.

10. Contagiousness: Your child can return to child care or school after the stools are formed and the fever is gone. The school-aged child can return if the diarrhea is mild and the child has good control over loose stools.

11. Expected Course: Viral diarrhea lasts 5 to 14 days. Severe diarrhea only occurs on the first 1 or 2 days, but loose stools can persist for 1 to 2 weeks.

12. Call Your Doctor If:

* Signs of dehydration occur

* Diarrhea persists more than 2 weeks

* Your child becomes worse

Based on recommendations/advice in “My Child is Sick; Expert Advice for Managing Common Illnesses and Injuries”, 14th Edition, by Barton D. Schmitt

“Stuck in a tunnel”: the common problem that is constipation

One of the most common problems I encounter in the pediatric office, are problems with regards to bowel movements. It is very frustrating as a parent to see your baby, toddler or child in pain while trying to push out that stool. You just wish you could do something for them. Constipation can present as abdominal pain, skipping days of bowel movements (or weeks in extreme case) or even as diarrhea. In this article I will discuss the most common causes of constipation, how to treat it, and how to maximize everything you can do to prevent it from happening (again).

What is constipation?

Constipation is defined as having a bowel movement fewer than 3x a week. Often the stools will be dry and hard, but this does not always need to be the case. Stools come in all shapes and forms (just look at the picture; Types 4 and 5 are considered “normal”). In fact, in cases of really bad constipation stools can actually become quite liquid, and soiling may occur.

What are conditions/situations that make constipation appear most often?

Babies can have irregular bowel movements, and only have a bowel movement once every 4-5 days. As long as they are not bothered by it, that is ok. Some babies will have a bowel movement with every diaper change, some will skip 4 or 5 days.

When transitioning to solid feeds (often with the introduction of rice cereal) some babies may get constipated.

Another common time one can encounter constipation, is when your child is getting potty-trained. We are teaching them to hold their bowel movement until they reach their potty. Some kids love to have the power to hold their stools, and will try to hold it for as long as possible. Others are only inclined to have a bowel movement in their own home, and will hold it while at daycare, school or out camping. This ultimately leads to the most common vicious cycle in constipation: they will hold it, making the stool harder and bigger. When they do eventually have a bowel movement, it will cause them pain because it is too large. The next time they have to go to the washroom they will hold it even more because (like any human being) they do not want to experience pain again. This eventually turns into a vicious cycle, and at this point a doctor’s visit is often required to help resolve the constipation.

If one is prone to constipation, then a time when one is dehydrated (for example after a stomach flu with lots of vomiting and/or diarrhea) or when your child is hardly eating or drinking because they feel sick, could be the start of constipation.

All of these forms of constipation are called “habitual constipation”. There are also medical conditions that can cause constipation. These are rare, but in persistent cases of constipation, your primary care physician should rule them out and/or refer your child to a specialist. Again these are rare, but here is a list of some of the most common, rare causes: celiac disease (a gluten-allergy), hypothyroidism (thyroid is working too slow), Hirschsprungs disease (last part of intestine is missing nerves) and (exceedingly rare) Cystic Fibrosis (there is usually a family history of this, and many more other symptoms). With Hirschsprungs disease it will often manifest itself in the first week of life, when it will take very long for your baby to have their first bowel movement after birth (the so-called “meconium stool”). If your baby’s first meconium occurred > 48 hrs after birth, and they continue to suffer from constipation that is hard to treat, you should talk to your child’s physician about ruling out this disease.

How do we treat constipation?

If the constipation is mild and only started relatively recently, one can try diet modifications such as increasing fluid intake, eating prunes and/or drinking dilated prune or pear juice (1:1 ratio of prune/pear juice and water). In babies sometimes the old-fashioned trick of brown sugar-water can help (2 oz of water with 1 teaspoon of brown sugar). It is important to note that this should not be given daily. If these conservative measurements are not helping do not wait too long before seeking medical attention.

Your child’s physician may decide to prescribe a stool-softener which will basically attract water into the intestine, making the stool softer (for example lactulose liquid, or Polyethylene glycol powder also known as PEG3350). It is important to stress that one can NOT become dependent on these products.

On occasion it may be necessary to give your child enemas. These are typically given to children who are so full of stool, that they need to “get the cork out” in order to facilitate the rest of the stool to start moving.

“My child has a tendency to get constipated. Is there something I can do to prevent it from happening so often?”

Making sure the children are properly hydrated is by far the most effective way to prevent constipation. Ideally toddlers should drink at least 4 cups of water a day, and older children 6-8 cups of water a day. One of the contributing factors to constipation in toddlers is that they do not drink enough water in the first place. Some parents will put a tiny bit of juice in a cup, and then add lots of water and for some children that works. If that is not effective, sometimes a physician may give the kids a stool softener to help them.

Some parents might buy over-the-counter fibre products such as Benefibre or Metamucil. These products certainly provide extra fibre, however they only help treat the constipation if you drink even more water than your physician told you. This is often not possible for the kids. So, I do NOT recommend using these products. I suggest trying to encourage the kids to eat their fruits and vegetables to provide them with a natural source of fibre. The third step in preventing constipation is exercise. Luckily, most kids are very active so this is something that already occurs naturally.

Lastly, a regulated toilet regime can help your child prevent constipation. I suggest putting your child on the potty or toilet 3x a day for 5 minutes. If they produce, that is wonderful, if they don’t it is ok too. Typically about 15-20 minutes after a meal our bowels are most active. So for example, after breakfast, lunch and dinner would be a good time to put your child on the toilet/potty.

“My doctor/pharmacist told me to use a suppository to help with constipation”

It is true that glycerine suppositories can help getting some stool out of the rectum. I tend not to recommend them in most cases, for 2 main reasons: it only helps to get rid of the stool that is in the rectum (much more stool is left in rest of intestine), and sometimes you can create a small cut (also known as fissure) with the introduction of the suppository. Now your child or baby may experience pain again with a bowel movement, start holding the stool etc. Now we have actually created more problems than help with that suppository.

“My child has a bowel movement every day (albeit a bit hard); he cannot be constipated, can he?”

Oh yes, he can be constipated. The analogy I like to use for this is the accident in the tunnel. Imagine about 3/4 into a tunnel a traffic accident occurred and the 2-lane road has turned into a single lane (don’t worry, nobody got hurt). If you look at the entrance of the tunnel, you will see free-flowing traffic in 2 lanes going into the tunnel. However, if you are standing at the exit of the tunnel, you see cars coming out one by one, slowly in a single lane. Once the site of the accident in the tunnel has been cleared, there will be free-flowing traffic in the tunnel again. At no point did cars stop coming out of the tunnel, it was just slower and it took more time. With this kind of constipation, we need to help your child “clear the site of the accident” so to speak.

“Our doctor has already prescribed a stool softener, but it is not working”

This could indeed be the case, and then more vigorous treatments, possibly further investigations and/or referral to a specialist would be necessary. Alternatively, the dose of the stool softener prescribed was not high enough, or the stool softener was not used for an adequate amount of time.

Dr Raffi’s constipation tips:

1. Make sure your child drinks enough fluids, and eats their fruits and vegetables to provide sufficient fibre intake

2. Have a strict toilet regime

3. Don’t wait too long before seeking medical help (or restart previously prescribed stool softeners) in order not to get stuck in the vicious cycle of holding, experiencing pain and constipation.

4. If constipation persists despite all these therapies, talk to your child’s physician to rule out rare medical causes, and/or refer to a specialist Pediatrician or Pediatric Gastro-Enterologist