Diarrhoea (Chronic)

Chronic Diarrhoea in Children

1) Key messages:

• Chronic diarrhoea is the daily passage of watery stools lasting more than 4 weeks.
• In resource-rich countries, functional diarrhoea related to gut motility (including toddler diarrhoea and irritable bowel syndrome) is most common.
• Coeliac disease has a prevalence of about 1 in 100 with two peaks: in the first two years and between 10 and 20 years of age.
• Toddler diarrhoea can start anytime post 6 months and persist till the 5th birthday. Undigested food (eg peas) in stool is common
• Crohn’s disease, while typically presenting in older children and young adults, can manifest in younger children with watery diarrhoea and abdominal cramps.

2) What to do:

• History: Look for the duration and frequency of diarrhoea, presence of blood, mucus, undigested food, associated symptoms (pain, bloating, weight loss, vomiting), family history, diet and any systemic symptoms.
• Examinations: Ensure to check for signs of malnutrition, dehydration, anaemia, abdominal tenderness, and any systemic signs.
• Investigations to consider: FBC, coeliac serology, stool MC+S. Keep in mind that Faecal calprotectin tests are not validated for children under 4 years (well children can have high levels)
• Management:
• Toddler’s Diarrhoea: avoid excessive fluid intake, especially sugary drinks. Consider increasing dietary fat.
• Irritable Bowel Syndrome(IBS): Recognize abdominal pain relief after stool/gas passage. Manage stress and consider dietary modifications.
• Weight loss, vomiting or blood in stools is not in keeping with IBS or toddlers diarrhoea
• Food Allergy/Intolerance: Identify potential food triggers but beware of strict avoidance without a plan for reintroduction (this applies for for non IgE mediated cows milk allergy and lactose intolerance)
• Post Gastroenteritis: If formula fed a few weeks on lactose free formula may be helpful for some for transient secondary lactose intolerance. Regardless this should resolve by 3 months; monitor

3) When to refer:

• All children with chronic diarrhoea, unless assessment points to primary/secondary lactose intolerance or toddler diarrhoea where the child is thriving and systemically well
• Urgent referral for children with growth faltering or systemically unwell

References

Birmingham Children’s outpatient guidance on Chronic Diarrhoea