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Home , Abdominal pain, Bloating, Diarrhea, Fructose malabsorption, Malabsorption, Vomiting

Chronic in Children

National Digestive Information Clearinghouse

What is chronic diarrhea? and goes away on its own. Read more about diarrhea in these publications at Diarrhea is loose, watery stools. Chronic, or www.digestive.niddk.nih.gov: long lasting, diarrhea typically lasts for more than 4 weeks. Children with chronic diarrhea • Diarrhea may have loose, watery stools continually, • What I need to know about Diarrhea or diarrhea may come and go. Chronic diarrhea may go away without treatment, or it may be a symptom of a chronic or What causes chronic disorder. Treating the disease or disorder diarrhea in children? can relieve chronic diarrhea. Many diseases and disorders can cause Chronic diarrhea can affect children of any chronic diarrhea in children. Common age: causes include • infants—ages 0 to 12 months • • toddlers—ages 1 to 3 years • functional gastrointestinal (GI) disorders • preschool-age children—ages 3 to 5 years • and intolerances • grade school-age children—ages 5 to • inflammatory bowel disease (IBD) 12 years Infections, food allergies and intolerances, • adolescents—ages 12 to 18 years and IBD may cause chronic diarrhea along with , meaning the small Diarrhea that lasts only a short time is intestine does not absorb from called acute diarrhea. Acute diarrhea, a food. If children do not absorb enough common problem, usually lasts a few days nutrients from the food they eat, they may become malnourished. Functional GI disorders do not cause malabsorption. Infections Functional Gastrointestinal Infections from , , or parasites Disorders sometimes lead to chronic diarrhea. After In functional GI disorders, symptoms are an , some children have problems caused by changes in how the GI tract digesting , such as , or works. The GI tract is a series of hollow , such as or soy proteins. These organs joined in a long, twisting tube from problems can cause prolonged diarrhea— the mouth to the anus—the opening through often for up to 6 weeks—after an infection. which stool leaves the body. The GI tract Also, some bacteria and parasite infections digests, or breaks down, food and processes that cause diarrhea do not go away quickly solid waste. without treatment. Children with a functional GI disorder Read more about infections that have frequent symptoms, yet the GI tract cause diarrhea in these publications at does not become damaged. Functional GI www.digestive.niddk.nih.gov: disorders are not diseases; they are groups of • Viral symptoms that occur together. • Foodborne Illnesses Small intestinal bacterial overgrowth may also cause chronic diarrhea. Normally, few bacteria live in the , and many bacteria live in the . Small intestinal bacterial overgrowth is an increase Mouth in the number of bacteria or a change in the type of bacteria in the small intestine. These bacteria can cause diarrhea, gas, cramping, and . Small intestinal bacterial overgrowth is often related to diseases or disorders that damage the digestive system or affect how it works, such as Crohn’s disease or . Small intestinal bacterial overgrowth is also more common in people Colon who have had abdominal or who Small (shaded) have slow-moving intestines. intestine Large intestine

Rectum Anus

The organs of the GI tract

2 Chronic Diarrhea in Children Two functional GI disorders that cause are not able to report symptoms of or chronic diarrhea in children are toddler’s discomfort. Read more in these publications diarrhea and (IBS). at www.digestive.niddk.nih.gov: Toddler’s diarrhea. Toddler’s diarrhea— • Irritable Bowel Syndrome also called functional diarrhea or chronic • Irritable Bowel Syndrome in Children nonspecific diarrhea of childhood—is a common cause of chronic diarrhea in • What I need to know about Irritable toddlers and preschool-age children. Bowel Syndrome Children with this disorder pass three or more loose stools a day and do not have any Food Allergies and Intolerances other symptoms. They typically are growing Food allergies, celiac disease, lactose well and gaining weight, and are healthy. intolerance, and dietary intolerance are common causes of chronic diarrhea. Toddler’s diarrhea develops between the ages of 6 months and 3 years, and it usually goes Food allergies. A food is a reaction away on its own by the time children begin by the , the body’s natural grade school. Researchers think a with defense system, to one or more proteins too much —such as the sugar found in in certain . The immune system fruit —relative to the amount of and normally protects the body from infection fiber may cause toddler’s diarrhea. by identifying and destroying bacteria, viruses, and other potentially harmful foreign IBS. The most common symptoms of IBS substances that can cause illness. In food are or discomfort, often allergies, however, the immune system reported as cramping, along with changes responds abnormally to certain foods. in bowel habits, such as diarrhea. The pain or discomfort of IBS typically gets better Cow’s milk and soy allergies are the most with the passage of stool or gas. IBS does common food allergies that affect the not cause symptoms such as weight loss, GI tract in children. Food allergies usually , or in the stool. appear in the first year of life. Many children outgrow cow’s milk and soy allergies by Possible causes include problems with nerves age 3. Allergies to other foods, such as in the intestines, problems with nerve signals cereal grains, eggs, or seafood, may also between the brain and the intestines, changes affect the GI tract. in how food moves through the intestines, and hypersensitivity to pain. Psychological Symptoms of food allergies may include problems, such as and , or diarrhea, vomiting, and weight loss or poor food sensitivity may also play a role. weight gain. Some children have mild symptoms, while others have severe or life- IBS is a common cause of chronic diarrhea threatening symptoms. For example, some in grade school-age children and adolescents. children have severe vomiting and diarrhea Health care providers rarely diagnose IBS in that lead to , which means the younger children because younger children body lacks enough fluid and — minerals in , including , , and —to function properly.

3 Chronic Diarrhea in Children Celiac disease. Celiac disease is an • low levels of important nutrients such as autoimmune disease in which people cannot and tolerate . A chronic reaction to gluten Read more in these publications at damages the lining of their small intestine www.digestive.niddk.nih.gov: and prevents absorption of nutrients. Gluten is a found in , , and barley • Celiac Disease and in and supplements, • What I need to know about Celiac lip balms, communion wafers, and certain Disease . . Lactose intolerance is Children of any age can experience digestive a condition in which people have digestive symptoms of celiac disease or have symptoms symptoms—such as , gas, and in other parts of the body. Digestive diarrhea—after consuming milk or milk symptoms can include products. Lactose is a sugar found in milk or • chronic diarrhea milk products. , an produced by the small intestine, breaks down lactose • abdominal bloating into two simpler forms of sugar: and • stomach pain . The bloodstream then absorbs • gas these simpler . • vomiting Some children have a lactase deficiency, meaning the small intestine produces low • levels of lactase and cannot digest much • pale, foul-smelling, or fatty stool lactose. Lactase deficiency may cause lactose malabsorption. In children with lactose Malabsorption of nutrients during the years malabsorption, undigested lactose passes to when nutrition is critical to a child’s normal the colon, where bacteria break down the growth and development can result in other lactose and create fluid and gas. health problems. These problems may include Not all children with lactase deficiency and lactose malabsorption have digestive • in infants symptoms. Experts use the term lactose • slowed growth and short stature intolerance when lactase deficiency and lactose malabsorption cause digestive • weight loss symptoms. • irritability or mood changes The most common type of lactase deficiency • delayed develops over time, beginning after about • dental enamel defects of the permanent age 2, when the body begins to produce teeth less lactase. Children who have lactase deficiency may not experience symptoms of • , a condition in which red blood lactose intolerance until late adolescence or cells are fewer or smaller than normal, adulthood. which prevents the body’s cells from getting enough oxygen

4 Chronic Diarrhea in Children Infants rarely have lactose intolerance at Another type of fructose intolerance, birth. People sometimes mistake cow’s milk hereditary fructose intolerance, is not related allergy, which can cause diarrhea in infants, to . Hereditary for lactose intolerance. Congenital lactase fructose intolerance is an extremely rare deficiency—an extremely rare inherited inherited . Children with genetic disorder in which the small intestine this disorder lack an enzyme needed to break produces little or no lactase enzyme at down fructose. Symptoms of hereditary birth—can cause lactose intolerance in fructose intolerance may include abdominal infants. Premature infants may experience pain, vomiting, and diarrhea. This disorder lactose intolerance for a short time after can also damage the liver and kidneys. birth. Children of any age may develop temporary lactose intolerance after a viral Inflammatory Bowel Disease diarrheal episode or other infection. Inflammatory bowel disease causes and inflammation in the intestines. The Read more in these publications at two main types of IBD are ulcerative www.digestive.niddk.nih.gov: and Crohn’s disease. These disorders can • Lactose Intolerance affect children at any age; however, they commonly begin in the grade school years • What I need to know about Lactose or in adolescence. The causes of IBD are Intolerance unknown. Researchers believe they result Dietary fructose intolerance. Dietary from an abnormal immune system reaction. fructose intolerance is a condition in which . Ulcerative colitis is a people have digestive symptoms—such as disease that causes inflammation, or swelling, bloating, gas, and diarrhea—after consuming and ulcers in the inner lining of the large foods that contain fructose. Fructose is intestine. The large intestine includes a sugar found in fruits, fruit , and the colon and the —the lower end . Fructose is also added to many foods of the large intestine leading to the anus. and soft as a sweetener called high Normally, the large intestine absorbs fructose . from stool and changes it from a liquid to a Fructose malabsorption causes dietary solid. In ulcerative colitis, the inflammation fructose intolerance. The small intestine causes loss of the lining of the large intestine, absorbs fructose, and, when a person leading to , production of pus, consumes more fructose than the small diarrhea, and abdominal discomfort. intestine can absorb, fructose malabsorption Read more in Ulcerative Colitis at results. Unabsorbed fructose passes to www.digestive.niddk.nih.gov. the colon, where bacteria break down the fructose and create fluid and gas. The amount of fructose that a child’s small intestine can absorb varies. The capacity of the small intestine to absorb fructose increases with age. Some children may be able to tolerate more fructose as they get older.

5 Chronic Diarrhea in Children Crohn’s disease. Crohn’s disease is a disease that causes inflammation and irritation of any part of the GI tract. The end part of Consult a Health Care the small intestine, called the ileum, is most Provider commonly affected. In Crohn’s disease, A child’s parent or caretaker should inflammation can extend through the entire consult a health care provider if the wall of the GI tract, leading to possible child complications. Swelling can cause pain and can make the intestine empty frequently, • has diarrhea for more than resulting in diarrhea. 24 hours • is younger than 6 months old Read more in these publications at www.digestive.niddk.nih.gov: • has received treatment and the diarrhea persists • Crohn’s Disease Children with any of the following • What I need to know about Crohn’s symptoms should see a health care Disease provider right away: What other symptoms may • signs of malabsorption—bloating and swelling of the , accompany chronic diarrhea changes in appetite, and weight loss in children? or poor weight gain Symptoms that accompany chronic diarrhea • severe abdominal or rectal pain in children depend on the cause of the diarrhea. Symptoms can include • a of 102 degrees or higher • cramping • stools containing blood or pus • abdominal pain Read more in these publications at www.digestive.niddk.nih.gov: • or vomiting • Diarrhea • fever • What I need to know about Diarrhea • chills • bloody stools Children with chronic diarrhea who have malabsorption can experience • bloating and swelling, also called distention, of the abdomen • changes in appetite • weight loss or poor weight gain

6 Chronic Diarrhea in Children How do health care Physical exam. After taking a medical history, a health care provider will perform a providers determine the physical exam, which may help determine the cause of chronic diarrhea cause of chronic diarrhea. During a physical in children? exam, a health care provider usually To determine the cause of chronic diarrhea • examines a child’s body in children, the health care provider will take • uses a stethoscope to listen to bodily a complete medical and family history and sounds conduct a physical exam, and may perform tests. • taps on specific areas of the child’s body Medical and family history. Taking a Tests. The health care provider may perform medical and family history is one of the first one or more of the following tests: things a health care provider may do to help • . A stool test is the analysis determine the cause of chronic diarrhea. of a sample of stool. The health He or she will ask for information about care provider will give the parent or symptoms, such as caretaker a container for catching • how long the child has had diarrhea and storing the stool. The parent or caretaker returns the sample to the • the amount of stool passed health care provider or a commercial • the frequency of diarrhea facility that will send the sample to a lab • the appearance of the stool for analysis. Stool tests can show the presence of blood, bacteria, or parasites • the presence of other symptoms that or signs of diseases and disorders. accompany diarrhea The health care provider may also do The health care provider will ask about the a rectal exam, sometimes during the child’s diet and may recommend keeping physical exam. For a rectal exam, the a diary of the child’s diet and bowel habits. health care provider inserts a gloved, If the health care provider suspects a lubricated finger into the rectum to or intolerance, he or she may check for blood in the stool. recommend changing the child’s diet to see if • . A blood test involves symptoms improve. drawing blood at a health care The health care provider may also ask provider’s office or a commercial facility about family medical history. Some of the and sending the sample to a lab for conditions that cause chronic diarrhea, such analysis. The blood test can show signs as celiac disease and lactose intolerance, run of certain diseases and disorders that in families. can cause chronic diarrhea in children, including –– high levels of white blood cells, which may be a sign of inflammation or infection somewhere in the body –– anemia, which may be a sign of bleeding in the GI tract or of malabsorption

7 Chronic Diarrhea in Children –– the presence of certain antibodies–– endoscope transmits a video image to proteins that react against the body’s a monitor, allowing close examination own cells or tissues––which may be a of the intestinal lining. A child may sign of celiac disease receive a liquid anesthetic that is gargled or sprayed on the back of the • breath test. This test throat. A health care provider will place measures the amount of hydrogen in a an intravenous (IV) needle in a vein in child’s breath. Normally, only a small the arm if general is given. amount of hydrogen is detectable in the breath. However, bacteria break down The health care provider may use sugars—such as lactose and fructose— instruments passed through the that are not digested by the small endoscope to perform a or intestine and produce high levels of collect fluid. A biopsy is a procedure hydrogen. In small intestinal bacterial that involves taking a piece of tissue overgrowth, bacteria break down sugars for examination with a microscope. A in the small intestine and produce pathologist—a doctor who specializes hydrogen. in diagnosing diseases—examines the tissues in a lab. This test can show For this test, the child breathes into a problems in the upper GI tract that may balloonlike container that measures cause chronic diarrhea. For example, a hydrogen. Then, the child drinks a biopsy of the small intestine can show lactose-loaded beverage, and the child’s signs of celiac disease. A health care breath is analyzed at regular intervals provider may use a fluid sample from to measure the amount of hydrogen. the small intestine to check for bacteria In most cases, a health care provider to diagnose small intestinal bacterial performs this test at a hospital, on an overgrowth. outpatient basis. A health care provider may use a to check • Flexible or . for signs of lactose intolerance, fructose While these tests are similar, a health intolerance, or small intestinal bacterial care provider uses a colonoscopy overgrowth. to view the rectum and entire colon and a flexible sigmoidoscopy to view • Upper GI . This procedure just the rectum and lower colon. A involves using an endoscope—a small, gastroenterologist performs these flexible tube with a light—to see the tests at a hospital or an outpatient upper GI tract, which includes the center. For both tests, the health care esophagus, stomach, and duodenum, provider will give written bowel prep the first part of the small intestine. instructions for the child to follow at A gastroenterologist—a doctor who home. The health care provider may specializes in digestive diseases— ask that the child follow a clear liquid performs the test at a hospital or an diet the day before either test. The outpatient center. The endoscope child may require a for 4 days is carefully fed down the esophagus before either test or only the day before and into the stomach and duodenum. either test. The child may require an A small camera mounted on the the day before either test. These

8 Chronic Diarrhea in Children medications cause diarrhea, so the child • Functional GI disorders. For toddler’s should stay close to a bathroom during diarrhea, treatment is usually not the bowel prep. needed. Most children outgrow toddler’s diarrhea by the time they start In most cases, light anesthesia, and school. In many children, limiting fruit possibly pain , helps the child juice intake and increasing the amount relax. For either test, the child will lie of fiber and fat in the diet may improve on a table while the gastroenterologist symptoms of toddler’s diarrhea. inserts a flexible tube into the anus. A small camera on the tube A health care provider may treat IBS sends a video image of the intestinal with lining to a computer screen. The –– changes in diet. gastroenterologist may also perform a biopsy by taking a small piece of tissue –– medication. from the intestinal lining. The child –– —live microorganisms, will not feel the biopsy. These tests can usually bacteria, that are similar to show problems in the rectum or colon, microorganisms normally found in such as signs of IBD. the GI tract. Studies have found that probiotics, specifically Bifidobacteria Cramping or bloating may occur during and certain combinations, the first hour after these tests. The child improve symptoms of IBS when should recover fully by the next day and taken in large enough amounts. be able to return to a normal diet. However, researchers are still studying the use of probiotics to treat How is chronic diarrhea IBS. in children treated? –– psychological therapy. The treatment for chronic diarrhea will depend on the cause. Some common causes of chronic diarrhea are treated as follows: To help ensure coordinated and safe • Infections. If a child has prolonged care, people should discuss their use of problems digesting certain complementary and alternative medical carbohydrates or proteins after an acute practices, including their use of dietary infection, a health care provider may supplements and probiotics, with their recommend changes in diet. A child health care provider. Read more at may need or medications www.nccam.nih.gov/health/probiotics. that target parasites to treat infections that do not go away on their own. A health care provider may also prescribe antibiotics to treat small intestinal bacterial overgrowth.

9 Chronic Diarrhea in Children • Food allergies and intolerances. A health care provider will recommend Points to Remember changes in diet to manage symptoms of food allergies and intolerances. To • Diarrhea is loose, watery stools. treat food allergies, the child’s parent or Chronic, or long lasting, diarrhea caretaker should remove the food that typically lasts for more than 4 weeks. triggers the allergy from the child’s diet. • Many diseases and disorders can For children with celiac disease, cause chronic diarrhea in children. following a gluten-free diet will stop Common causes include infections, symptoms, heal existing intestinal functional gastrointestinal (GI) damage, and prevent further damage. disorders, food allergies and intolerances, and inflammatory The child’s parent or caretaker can bowel disease (IBD). manage the symptoms of lactose • Symptoms that accompany chronic intolerance with changes in the child’s diarrhea in children depend on the diet and by using products that contain cause of the diarrhea. Symptoms the lactase enzyme. Most children with can include cramping, abdominal lactose intolerance can tolerate some pain, nausea or vomiting, fever, amount of lactose in their diet. The chills, or bloody stools. amount of change needed in the diet depends on how much lactose a child • Children with chronic diarrhea who can consume without symptoms. have malabsorption can experience bloating and swelling of the For children with dietary fructose abdomen, changes in appetite, or intolerance, reducing the amount weight loss or poor weight gain. of fructose in the diet can relieve symptoms. • Children with any of the following symptoms should see a health • IBD. A health care provider may use care provider right away: signs medications, surgery, and changes in of malabsorption, severe diet to treat IBD. abdominal or rectal pain, a fever of 102 degrees or higher, or stools Eating, Diet, and Nutrition containing blood or pus. A health care provider may recommend • To determine the cause of chronic changing a child’s diet to treat the cause of diarrhea, the health care provider chronic diarrhea. Making sure that children will take a complete medical receive proper nutrition is important for and family history and conduct a growth and development. A child’s parent physical exam, and may perform or caretaker should talk with a health care tests. provider about changing the child’s diet to • The treatment for chronic diarrhea treat chronic diarrhea. will depend on the cause. • A child’s parent or caretaker should talk with a health care provider about changing the child’s diet to treat chronic diarrhea.

10 Chronic Diarrhea in Children Hope through Research Centers for Disease Control and Prevention 1600 Clifton Road The Division of Digestive Diseases and Atlanta, GA 30333 Nutrition at the National Institute of Phone: 1–800–CDC–INFO Diabetes and Digestive and Diseases (1–800–232–4636) (NIDDK) supports basic and clinical TTY: 1–888–232–6348 research into GI diseases, including diarrhea. Internet: www.cdc.gov Clinical trials are research studies involving International Foundation for Functional people. Clinical trials look at safe and Gastrointestinal Disorders effective new ways to prevent, detect, or 700 West Virginia Street, Suite 201 treat disease. Researchers also use clinical Milwaukee, WI 53204 trials to look at other aspects of care, such Phone: 1–888–964–2001 or 414–964–1799 as improving the quality of life for people Fax: 414–964–7176 with chronic illnesses. To learn more about Email: [email protected] clinical trials, why they matter, and how to Internet: www.iffgd.org participate, visit the NIH Clinical Research Trials and You website at www.nih.gov/health/ North American Society for Pediatric clinicaltrials. For information about current , and Nutrition studies, visit www.ClinicalTrials.gov. (NASPGHAN) P.O. Box 6 For More Information Flourtown, PA 19031 Phone: 215–233–0808 American College of Gastroenterology Fax: 215–233–3918 6400 Goldsboro Road, Suite 200 Email: [email protected] Bethesda, MD 20817 Internet: www.naspghan.org Phone: 301–263–9000 Fax: 301–263–9025 Email: [email protected] Acknowledgments Internet: www.gi.org Publications produced by the Clearinghouse are carefully reviewed by both NIDDK American Gastroenterological Association scientists and outside experts. This 4930 Del Ray Avenue publication was reviewed by Mark Donowitz, Bethesda, MD 20814 M.D., Johns Hopkins University School of Phone: 301–654–2055 Medicine, and by NASPGHAN. Fax: 301–654–5920 Email: [email protected] Internet: www.gastro.org

11 Chronic Diarrhea in Children National Digestive Diseases This information was prepared in Information Clearinghouse partnership with the North American Society for Pediatric Gastroenterology, 2 Information Way Hepatology and Nutrition Bethesda, MD 20892–3570 (NASPGHAN); the NASPGHAN Phone: 1–800–891–5389 Foundation for Children’s TTY: 1–866–569–1162 Digestive Health and Nutrition; Fax: 703–738–4929 and the Association of Pediatric Email: [email protected] Gastroenterology and Nutrition Internet: www.digestive.niddk.nih.gov Nurses (APGNN). The information The National Digestive Diseases Information is intended only to provide general Clearinghouse (NDDIC) is a service of the information and not as a definitive National Institute of Diabetes and Digestive basis for diagnosis or treatment in any and Kidney Diseases (NIDDK). The particular case. You should consult NIDDK is part of the National Institutes of your child’s pediatrician about your Health of the U.S. Department of Health child’s specific condition. and Human Services. Established in 1980, the Clearinghouse provides information about digestive diseases to people with digestive disorders and to their families, health care professionals, and the public. The NDDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about digestive diseases.

This publication is not copyrighted. The Clearinghouse You may also find additional information about this encourages users of this publication to duplicate and topic by visiting MedlinePlus at www..gov. distribute as many copies as desired. This publication may contain information about This publication is available at medications and, when taken as prescribed, www.digestive.niddk.nih.gov. the conditions they treat. When prepared, this publication included the most current information available. For updates or for questions about any medications, contact the U.S. Food and Drug Administration toll-free at 1–888–INFO–FDA (1–888–463–6332) or visit www.fda.gov. Consult your health care provider for more information.

NIH Publication No. 14–7714 February 2014

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