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You are playing happily with your baby when you suddenly detect a rather unpleasant odor emanating from the diaper area. When you open up the diaper to change it, instead of the usual soft yellow stool, you find a greenish-brown, runny, foul-smelling mess that's all over both baby and his clothes. Sound fun? Not when it keeps happening 10 more times that day! There are many causes of loose stools, most of which are not serious. Most diarrhea illnesses are more of a nuisance than a medical problem and clear up easily with extra fluids and minor changes in the diet. The main concern with diarrhea is dehydration. Your baby's body contains just the right balance of salts (called electrolytes) and water. Healthy intestines and kidneys regulate this balance, causing the body to lose water and electrolytes, or dehydrate. Add vomiting and you further increase the risk of dehydration. Here are some guidelines to help you know when to worry and what to do.

There are two components to the definition of diarrhea:

• Frequency – it is normal for an infant to have stools up to 10 times a day, although most don't attain this goal. The frequency will slow down as baby gets older, but even some toddlers and preschoolers still go several times a day. An increase in frequency of one-and-a-half or two times your child's normal pattern is considered abnormal.
• Consistency – again, it's important to know what your child's stools usually look like. If the stools become looser, watery, mucusy, green, or runnier than usual, this is considered a significant change.

• Newborns often stool 8 – 10 times a day, sometimes passing small, watery stools mixed with yellow, seedy pieces. They also may have several stools each day that are runnier and more mucusy than usual. These are all normal variations and are not a cause for concern.
• Infants may occasionally have one or several stools that are much more loose and foul smelling than usual. This is probably due to a variation in diet or may be for no reason at all. It is not a cause for concern.
• Some infants may have persistent loose, runny stools that never seem to firm up into a normal stool. This can go on for one or two weeks. As long as your child is thriving, not acting sick, and your pediatrician reassures you that your child is well, then there is little reason for concern.

1. Intestinal infections – most of these are not serious, not treatable, and will resolve on their own with time:
   • Rotavirus – one of the most common causes of diarrhea, especially during late fall and winter months. It causes very foul smelling, watery, green or brown diarrhea that can persist for weeks. Fever and vomiting are common at the onset of the illness.
   • Other viruses – there are a variety of these, none of which are serious.
   • Bacteria – these include E. Coli, Salmonella, and several others. Vomiting and fever may be present at the onset. Blood in the diarrhea is a common finding with bacterial infections. Even these infections rarely require antibiotic treatment.
   • Parasites – there are a variety of these. They are usually caught from contaminated water (e.g. Giardia) or during travel to foreign countries. The telltale sign of a parasite is very watery diarrhea that lasts beyond two weeks.
   • CONTAGIOUS – these are all generally contagious as long as the diarrhea continues.

2. Food intolerance or sensitivity – your child may simply be eating something that is difficult for his intestines to digest. These foods vary from person to person.
   • Lactose intolerance – this is the most common example of food intolerance. Symptoms include gassy pain, stomach cramps, nausea, and diarrhea after eating dairy products (which contain the sugar, lactose).
   • Sugar or chemical additives and coloring – these have been known to upset some little ones' intestines.

3. Food allergy – there are many signs of food allergies, and mucusy, sometimes bloody, diarrhea is one of them. It is different from food intolerance in that the allergic symptoms affect several parts of the body – intestines, skin, respiratory.
   • Milk protein allergy – this is an example of one of the most common food allergies. Your child may start to develop diarrhea, rash on the face, body, and diaper area, runny nose, cough, or wheezing. Notice that here the child is allergic to the protein in dairy products, where as with the dairy intolerance above, his intestines have a difficult time digesting the milk sugar, lactose.

4. Normal intestinal variations – as discussed above, your child may simply be going through a normal phase of loose stools. It may be related to a change in diet, but doesn't always mean there is an allergy or intolerance.

1. Determine the cause. Look over the above causes to help you decide what might be causing it.
   • If the diarrhea is accompanied by fever and maybe vomiting, then it is probably an intestinal viral or bacterial infection.
   • If you have just started your one-year-old on milk, then it is probably milk allergy or intolerance.
   • If you have been adding a variety of foods to your infants diet recently, then it may be a sensitivity to one of these.
   • Your child may be overdosing on high-fiber fruits or vegetables or diarrhea-causing juices like apple or pear.
   • Is your child vomiting? If yes, then click on Vomiting to learn how to get through the vomiting phase of the illness.
   • Is your child dehydrated? Children rarely get significantly dehydrated from diarrhea alone. Click here to help you determine this.

2. Eliminate irritating foods. Here are some liquids and foods known to increase diarrhea. Refrain from these until whatever is causing the diarrhea has resolved:
   • Dairy products, except yogurt
   • Cow's milk-based formula – if the diarrhea is severe and has lasted more than 3 days, we suggest you switch to a soy formula for two weeks while the intestines have time to heal. Intestines that have been damaged by severe diarrhea cannot digest cow's milk.
   • Apple juice, pear juice and cherry juice – the high sorbitol sugar content of these juices can worsen diarrhea. White grape juice is a good alternative.
   • Note – it is virtually never necessary to temporarily stop breastfeeding during the course of a diarrhea illness.

3. Determine the severity of the diarrhea and dehydration. Is baby playful and wet (eyes, mouth, diaper)? Perhaps except for more frequent messy diapers, you wouldn't know anything was amiss. In this case you don't have to change anything (except more diapers), and observe what direction the stools take.

   To make sure the diarrhea, is not causing dehydration, weigh your child daily, preferably undressed and in the morning before feeding, using the most accurate scale you can obtain. As a general guide: no weight loss – no worries, and no need to call your doctor yet. Both the degree and the rapidity of weight loss determine the severity of dehydration. If your baby has not lost significant weight, she is not becoming dehydrated. However, if your child loses 5 percent of her baseline body weight (for example, a weight loss of one pound in a twenty-pound baby), she has experienced mild to moderate dehydration, and this merits a phone call to your doctor. A rapid weight loss is more of a concern than a gradual one. A twenty-pound infant who loses a pound of body weight over the period of a day is much more worrisome than one who loses the same amount of weight over a week's time. But infants usually appear very sick if they are losing weight rapidly; they do not act as sick if their weight loss has been gradual. Ten percent weight loss, especially if occurring within a few days, suggest serious dehydration, and you should call your doctor immediately, preferable even before this degree of weight loss occurs.

4. Keep a diarrhea record. To keep track of your baby's illness, make a diarrhea chart. This record helps your doctor advise you on how soon to resume baby's regular diet and whether or not baby is becoming dehydrated. Charting helps you do your part in the medical partnership with your doctor. Here's a sample chart:

   DAY	WEIGHT	NUMBER AND NATURE OF STOOLS	TREATMENT	COURSE OF ILLNESS
   1	20 pounds	8, green, watery	40 ounces Pedialyte	Vomiting stopped, slight fever stools same.
   2	19.5 pounds	6, no change	20 ounces Pedialyte, resumed full-strength formula (20 ounces and rice cereal and bits of banana and yogurt	Fever gone, baby perkier.

5. What to feed your child. Rule of thumb for G.I. upsets: Feed half as much twice as often. Offer food and fluids more frequently but in smaller amounts. Try sips and chips: frequent sipping and ice chips or white grape juice, or Popsicles made with oral electrolyte solution. Let your child suck on these all day long.

   Mild diarrhea – defined as 2 – 4 loose stools in a 24-hour period.

   • BRAT diet – this is an age old, time-tested diet.
     2. Bananas
     3. Rice or rice cereal
     4. Apple sauce
     5. Toast, unbuttered
     6. Yogurt (See Intestinal Healing Properties of )Yogurt
     
   • Breastmilk or formula
   • White grape juice or oral electrolyte solution such as Pedialyte. Popsicles also work well.

   Moderate diarrhea – defined as 4 – 8 loose or watery stools per day, but child is generally not acting sick.

   • BRATY diet, but only very small amounts
   • Breastmilk or half-strength formula (formula mixed half and half with an oral electrolyte solution such as Pedialyte)
   • White grape juice, oral electrolyte solution or popsicles.

   Severe diarrhea – defined as 10 or looser, watery, foul stools and child is acting sick. Consult your pediatrician.

   • BRATY diet, but only very small amounts
   • Breastmilk. Do not give formula until child improves or as directed by your pediatrician.
   • White grape juice, oral electrolyte solution or popsicles.

6. Probiotics - You may have heard of Acidophilus, a healthy bacterium that lives in our intestines and often added to yogurt. You can buy another probiotic with Lactobacillus bacteria in from any vitamin or drug store. One brand I recommend is Culturelleฎ, one caplet daily. For young children, parents can empty the caplet into any cold food or beverage. Research has shown that taking this probiotic can shorten the duration and severity of diarrhea.

A diarrhea illness can often persist for a few weeks. Intestines heal slowly after the initial illness. The loose stools from temporary lactose intolerance can continue to be a nuisance for 3 – 4 weeks as the intestines recover. As long as baby is generally well and has no fever, abdominal pain, your child is in the recovery stage and can gradually resume a normal diet. Avoid cow's milk as a beverage until the diarrhea subsides, but yogurt is all right. During the one-to-six-week recovery period from an intestinal infection your doctor may advise using a nonlactose soy formula, since the healing intestines may not tolerate lactose. If baby's diarrhea relapses when resuming solids, back off a bit and start more bland foods, such as rice, rice cereal, and bananas. For a general guide, as your baby's stools become more solid, so may the diet.

Here are several signs that warrant an appointment with your doctor within a day:

• Bloody diarrhea. This can be a sign of a bacterial illness or an allergy. Contact your doctor.
• Moderate to severe dehydration – click on Dehydration for guidelines.
• Severe diarrhea as defined above. Child is acting lethargic (defined as limp, and less responsive to touch or words, won't focus on you).
• Increased abdominal pain.
• Continued weight loss.

Because diarrhea usually is due to an untreatable viral or bacterial infection, it is therefore usually not necessary to test the stools to determine the cause. By the time anyone really starts to worry and think about testing, the diarrhea resolves. Your doctor may want to test the diarrhea if it is bloody or continues for more than 2 or 3 weeks. Here are the common tests your doctor may consider. They require you to pick up a special sterile container from the lab first. Ask the lab for any special instructions on collecting or storing the specimen before you bring it in:

• Routine culture – this will look for a variety of intestinal bacterial infections such as Salmonella and E-coli.
• Ova and Parasites (O and P) – the lab will look for a variety of parasites in the stool sample.
• Rotavirus antigen – this will detect the most common cause of diarrhea infection in infants and young children. Usually your doctor can diagnose this infection without needing this test.
• Giardia antigen – this is a parasite, and is a fairly common cause of abdominal pain and diarrhea. It won't be found on O and P test.
• Hemocult test – this checks for hidden blood in the diarrhea, which can help your doctor determine the cause.