Appointments: 01277 695688
Dr Nigel Meadows
Clinic for both general paediatric problems
and all aspects of paediatric gastroenterology

Chronic Diarrhoea

Acute diarhoea is common in children of all ages, and is usually short lived. The most common agents responsible are viruses. Treatment is to ensure adequate hydration with the use of rehydration solutions. It is important to realise that this does not stop the diarrhoea, drug treatment is not normally required. Advice is available by N.I.C.E guidelines on Vomiting and Diarhhoea in Children under 5 years.

Chronic diarrhoea in contrast lasts for 2 weeks, it often in children under a year, seems to have followed an acute infection. Congenital diarrhoea beginning from birth, and associated with poor growth or weight loss, is rare, and needs expert evaluation to exclude congenital abnormalities of the small intestine. All children with chronic diarrhoea and faltering growth need referral for review.

Toddler's Diarrhoea

This is a common cause of diarrhoea in young children. It often presents in the latter part of the first year, and may continue till the age of 3 years. It is distressing for parents as the stool frequency can be many times a day with very runny stool, that seems to run down the child's legs, and burns on contact. Food may also appear unchanged in the child's poo, such as peas and carrots, giving the alternate name as Peas and Carrots syndrome! The essential thing of this syndrome is there is no faltering and growth, and is otherwise well.

The cause of this condition is unknown, but there is often IBS in members of the family. Simple measures often help, and medicine is not needed. The excess intake of fluid particularly with things such as squashes will aggravate the diarrhoea, and reduce the child's appetite. It is important to review fluid intake. The increase in fat in the diet is also often helpful, using things like olive oil and cream in cooking or adding to pasta. It is important to realise this will improve, albeit gradually.

Cow's Milk Allergy

There is no doubt that some children have diarhoea due to an intolerance to the protein in cow's milk, and occasionally soya. In young infants it seems to have followed an acute infection. There may be other manifestation of allergy such as a rash, or family history, but this may be absent and not essential for the diagnosis.

Many of these children will be diagnosed at the time of biopsy. An upper GI endoscopy and biopsy should be considered in all children with faltering growth and diarrhoea.

Treatment is the use of a hypoallergenic milk. Consideration in this situation is often made to a MEWS diet, namely the avoidance of milk, egg, wheat and soya. In children this must be supervised by a dietician to ensure that the diet is adequate for growth.

Coeliac Disease

This is an important cause of chronic diarrhoea and poor weight gain. The condition is a reaction to gluten in cereal products namely wheat, oats, barley and rye. Symptoms will not occur if they are not part of the diet, and so do not arise until after weaning. There is a very strong genetic component to the disease, with a congenital inheritance for the predisposition to the development of the condition. There is also a connection with diabetes mellitus and thyroid disease. The disease is lifelong, and can occur at any age, but as yet we do not know the trigger for the development of the disease.

The symptoms of Coeliac disease may be vague and include diarrhoea, abdominal pain, and lethargy. Many children and their parents notice quite profound depression that lifts after treatment.

Investigation of coeliac disease is initially by blood test. This is a measurement of the Tissue transglutamase level (TTG). It must be remembered that this is an IgA antibody. IgA deficiency is common in the population, and so immunoglobulins are measured at the same time. If the levels are low the TTG is unreliable. The current dilemma has been reviewed by BSPGHAN, and they have provided a good guideline. In general in the situation if there are very high TTG levels a biopsy may be unnecessary. An alternate approach is to look at the genetic predisposition using HLA testing in blood.

Biopsy of the duodenum at endoscopy is diagnostic. The villi are flattened (finger like projections on the small bowel), there is infiltration of lymphocytes in the epithelium (lining of the small bowel).

It is very important that children suspected of having coeliac disease are not put on a gluten free diet until the diagnosis is confirmed.

A dietician must monitor treatment. In children they are routinely reviewed to ensure that weight gain is normal and they are compliant of the diet.

It is advisable that all children join the Coeliac society, who in addition provide update on gluten free products.