Chronic Diarrhoea (Paediatric)

Chronic diarrhoea is the passage of 3 or more loose or liquid stools in a 24-hour period (or more than is normal for the individual) for more than 4 weeks.

Causes of chronic diarrhoea	Clinical features
Idiopathic chronic diarrhoea	Self-limiting with no identifiable cause
Toddlers’ diarrhoea	Age 1-5 years, up to 10 bowel movements per day, undigested food in stool, otherwise well child, normal growth
Irritable bowel syndrome	Abdominal pain, bloating, flatulence, normal growth
Overflow diarrhoea	Sticky, soiling/smearing, features of constipation
Transient post- infectious lactose intolerance	Usually after an infectious gastrointestinal illness, bloating, flatulence and loose often explosive stools
Coeliac disease	Faltering growth, distended abdomen, anaemia, abdominal pain, vomiting, diarrhoea or constipation
Inflammatory bowel disease	Abdominal pain, faltering growth / weight loss, clinical features of anaemia, diarrhoea (+/- blood), nocturnal stooling

Chronic diarrhoea can also be a feature of rarer disorders such as parasitic infections, hyperthyroidism, pancreatic insufficiency, immunodeficiencies and metabolic diseases.

History:

Red Flags (refer to Medical Paediatrics)

– Faltering growth or weight loss
– Persistent blood in stools
– Regular nocturnal stooling
– Persistent pyrexia
– Skin, joint or eye manifestations suggesting possible IBD or immunodeficiency
– Family history (1^st degree relative) of IBD/ Lynch syndrome

Presence of other GI symptoms e.g. abdominal pain/oral ulcers/upper GI symptoms
Previous stool pattern
Triggers including foods, psychosocial stressors or preceding acute gastroenteritis
Diet and fluid intake
Travel and allergy history
Family history of coeliac or other GI diseases

Examination:

Assessment of growth: please include weight & height in referral
Hydration and clinical evidence of nutrient deficiency (e.g. conjunctivae, skin, nails)
Abdominal examination
Visually inspect the mouth and anus

Investigations:

In most cases of chronic diarrhoea, provided growth is good and in the absence of red flags, no further investigation is required. Provide follow-up to review trend of symptoms and growth.

Investigations should be done in the presence of red flags or may be considered to provide reassurance.

Stool samples:
- MC&S (C.difficile toxin will be automatically added by the lab if the sample is loose) +/- parasites (if history of travel)
- Enteric viruses
Blood tests may include FBC, ESR, U&Es, LFTs, CRP, TFTs, coeliac screen.
Faecal Calprotectin if 5 years or older and there is a strong clinical suspicion of IBD
- Poor clinical utility below the age of 5 years
- If not already sent, send stool MC&S and enteric viruses at the same time
- Faecal calprotectin may be falsely raised in children
  - taking NSAIDs
  - who have had a gastrointestinal infection within the last 4 weeks
  - with polyps.

A clinically significant faecal calprotectin is usually >200ug/g. If between 50-200ug/g then, if relevant (i.e. symptoms persist), it should be repeated after 1 month.

D.M, A.B, C.H, R.R & P.H – 29-05-26

Who to Refer

Refer any child to gastroenterology if there is a strong suspicion of IBD
Refer any child with a positive serology for coeliac disease to paediatric coeliac service
Refer any child with red flags (who does not have tests suggestive of coeliac disease or IBD) to medical paediatrics

Toddlers’ diarrhoea:

Provide reassurance that it is very common, it is not a serious problem (due to rapid colonic transit time / colonic immaturity & insufficient time for water reabsorption), and it will usually resolve by the age of 5 years.
Dietary changes families can implement to help:
- Avoid low fat diet
- Avoid / reduce refined sugars & sweeteners (i.e. sweets, fruit juices, diluting juice)
- Avoid / reduce processed foods
- Avoid excessive fluid intake
- Avoid excessive fibre intake

Irritable bowel syndrome – diarrhoea subtype:

Dietary changes as listed under toddlers’ diarrhoea can be helpful.
Additionally, avoiding large meals, taking your time to eat and avoiding common triggers e.g. fatty foods, caffeine, fizzy drinks, artificial sweeteners.
Exercise regularly.
Address anxiety and use relaxation techniques (see IBS/FAP resources section).
Trial of food exclusion for suspected triggers e.g. wheat or dairy may be helpful, but reintroduction following a period of elimination (around 4 weeks) is important to confirm or refute. Excessively restrictive diets may be harmful. Unlike in adults, FODMAP diets are not routinely recommended. Consider Food, mood and symptom diary (see below).
Medications have weak evidence but may be considered if lifestyle changes are not effective. There is clear dosing in the BNFc for the following medications:
- Fybogel or Loperomide for chronic diarrhoea
- Buscopan or Mebeverine (immediate release) antispasmodics for pain
- Peppermint oil for bloating (over 15 years)

Post-infectious lactose intolerance:

Usually transient, lasting around 6-8 weeks but may last up to 6 months.
Diagnosis and treatment is with a lactose-free diet, with reintroduction plan after 8 weeks. Paed-GI-Lactose-Free-Diet-Sheet-v1.0-Aug2019.pdf

There is weak evidence to support the use of probiotics for chronic gastrointestinal disorders, please see the link in the resources section for further information.

Information for primary care: