COMMON GASTROINTESTINAL PROBLEMS IN PEDIATRIC PATIENTS

By Marsha Kay, M.D. and Vasundhara Tolia, M.D.

Department of Pediatric Gastroenterology and Nutrition
The Cleveland Clinic Foundation and Division of Gastroenterology, Childrens Hospital
Of Michigan

GASTROESOPHAGEAL REFLUX

What is gastroesophageal reflux?

Gastroesophageal reflux is the bringing up of stomach contents or acid into the esophagus
(the swallowing tube). Almost everyone refluxes at some point during the day especially
after meals. What distinguishes normal reflux from pathologic or abnormal reflux is how
often reflux occurs and if it causes symptoms or damage to the esophagus. Reflux is
being increasingly recognized in children and adolescents. Although the symptoms in
teenagers may be similar to those seen in adults, the symptoms in infants and younger
children may differ enough so that they are not recognized as being due to reflux.

Is it normal if my infant spits up?

Almost all infants reflux or regurgitate a portion of their feeding at one time or another.
What distinguishes normal regurgitation from abnormal regurgitation is how often the
reflux occurs, if it is associated with discomfort, and if it results in other complications.
These complications include poor weight gain known as “failure to thrive”, breathing
difficulties such as infrequent breaths or apnea, asthma symptoms such as wheezing, or a
hoarse voice or cry. Other complications of reflux are aspiration, which is when the
refluxed stomach contents reach the lungs, pneumonia due to aspiration, or inflammation
of the esophagus called esophagitis. Spitting up blood or material that looks like old
“coffee grounds” is rarely seen and requires evaluation by a physician.

Reflux symptoms in infants tend to get better as they get older, usually by 12 to 15
months. This is because as infants get older their stomach is able to empty quicker and
their esophagus lengthens, therefore there is less material in the stomach to regurgitate.
Infants who reflux or regurgitate will not necessarily have problems with reflux as they
get older or as adults.

Is vomiting in my baby always due to gastroesophageal reflux?

There are a number of reasons, other than reflux, that a baby may vomit. Babies may be
allergic to the milk or soy protein that they are getting in their formula and this can result
in irritability, vomiting, poor weight gain and blood in the bowel movements. This is
treated with a change to a specialized formula where the proteins are broken down to
make them less allergenic (allergy causing). Babies can be born with problems where the

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intestine is not formed or positioned properly or is blocked. These types of problems are
usually found in the immediate newborn period but can present later in some infants. A
combination of x-rays and or endoscopy (looking at the lining of the stomach and upper
intestines and/or colon with a long tube with a video camera at the tip) is usually helpful
to make this diagnosis.

Between 4-8 weeks of age infants can develop a condition known as pyloric stenosis.
This results in significant and forceful vomiting and is usually associated with poor
weight gain and possibly weight loss. Parents of infants with this problem describe their
child's vomiting as projectile. Pyloric stenosis is currently treated with surgery. There are
other non-gastrointestinal causes of vomiting in infants and young children including
hormonal problems, kidney problems and problems with increased pressure on the brain.
These are unusual conditions but patients should be tested for these problems if their
physician feels that their symptoms are not typical or they are not responding to
medications.

What are the symptoms of reflux in older children and adolescents?

Reflux symptoms in children are variable. Children may be unable to communicate

typical heartburn symptoms. They may complain of generalized stomachaches,
frequently around the area of the belly button and on occasion may complain of chest
pain. Often children will report a feeling that they need to throw up and on occasion will
describe that they get a taste in their mouth as if they have thrown up. Other children will
report that they feel that the food is coming back up and that they then re-swallow it.
Occasionally they will report a feeling that food is not going down correctly or feels like
it is getting stuck. Some patients may complain of asthma symptoms such as cough or
wheezing that are worsened by reflux. Even though children may not relate reflux
symptoms to eating, obtaining a dietary history for foods and medicines that trigger
reflux is important.

How is the diagnosis of reflux made?

Reflux is usually diagnosed based on symptoms and physical examination. X-rays are
generally not helpful in diagnosing abnormal reflux although they are often used to
exclude other problems that may mimic reflux. Performing an upper intestinal endoscopy
with biopsies can be helpful to determine if inflammation of the esophagus is present.
The test currently considered most helpful in making the diagnosis of acid reflux is a pH
probe. This probe is a small tube inserted through the nose into the esophagus that
continuously measures how often acid is being regurgitated into the esophagus. There are
normal expected values for children and adults.

What are treatment choices for children and adolescents with gastroesophageal
reflux?

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There are many medications available to treat gastroesophageal reflux. Many of these
medications have been used successfully to treat children. Dosages of medication must be
modified for a child's weight. Also they require monitoring to reduce possible long-term
side effects. Diet is an important part of reflux management and children and teenagers
with reflux should avoid the products listed below. Medications such as aspirin,
ibuprofen and alcohol based products should be avoided if possible in children with
reflux. Rarely a surgical procedure called a fundoplication (or wrap) is required for
severe reflux. This procedure is usually reserved for patients with severe symptoms or
complications of reflux that do not respond to standard medications and dietary
treatment.

Foods to avoid if you have reflux

Spicy, acidic or tomato based foods

Fatty foods
Citrus products including citrus juices
Apple juice (apples are fine)
Caffeinated drinks- cola, tea, coffee, hot chocolate
Chocolate and licorice

LACTOSE INTOLERANCE

What is Lactose Intolerance?

Lactose is the sugar found in milk and dairy products such as cheese and yogurt. After
eating dairy products that contain this sugar, lactase a digestive enzyme of the small
intestine, helps to breakdown this complex sugar into two simple sugars. Normally
lactase breaks down lactose into two components, glucose and galactose. These simple
sugars are then absorbed in the small intestine and ultimately reach the blood stream
where they act as nutrients. The enzyme lactase is located in the lining of the small
intestine known as the intestinal villi.

Lactose is also the sugar found in breast milk and standard infant formulas. Therefore
almost all babies are able to digest and absorb this sugar and it serves as their primary
dietary sugar.

What are other sources of lactose?

In addition to milk and dairy products such as ice cream, yogurt and cheese, lactose can
be found in bread and baked goods, processed breakfast cereals, instant potatoes, some
soups and non-kosher lunch meats, candies, dressings and mixes for pancakes and
biscuits.

Who gets lactose intolerance?

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Rarely babies may be born with a deficiency or absence of the enzyme lactase. This
condition is very rare and is known as primary lactase deficiency. Babies inherit this
condition by getting one gene that causes this problem from each of their parents, even
though both parents may be lactose tolerant. Babies who lack this enzyme may have
severe feeding problems with diarrhea, vomiting and poor growth starting in early
infancy. These babies require a specialized formula with another type of sugar such as
sucrose (present in table sugar), which they are able to digest. The majority of infants
who have feeding problems however are not lactose intolerant.

A cause of temporary lactose intolerance in infants and young children is infection. Older
infants and young children will commonly be infected by a virus known as rotavirus.
Most children will have had at least one episode of this type of infection by the age of
five years, with the majority of cases occurring before two years of age. The symptoms of
rotavirus infection include vomiting, diarrhea (frequent watery stools), and fever. This
type of viral infection commonly causes damage to the lining of the small intestine.
Because this is where the enzyme lactase is located, rotavirus infection often results in
lactose intolerance. This type of lactose intolerance is transient or temporary, however,
and when the lining of the intestine returns to normal within three to four weeks, the
lactose intolerance usually goes away. Another type of infection that causes temporary
lactose intolerance is giardia infection. Giardia is a parasite that is found in well water
and fresh water from lakes and streams and also causes damage to the surface of the
small intestine resulting in temporary lactose intolerance. Treatment of the giardia with
antibiotics will resolve the lactose intolerance.

Many individuals acquire lactose intolerance as they get older. It is estimated that
approximately one half of adults in the United States have acquired lactase deficiency.
This condition is due to a normal decline in the amount of the enzyme lactase present in
the small intestine as we age. Although lactose is an important part of the diet in infants
and young children it represents only 10% of the carbohydrate (sugar) intake in adults.
However, individuals who are lactose intolerant may not be able to tolerate even small
amounts of this sugar in their diet.

Lactose intolerance occurs more frequently in certain families. One of the most important
factors affecting the rate of developing lactose intolerance is an individual's ethnic
background. Approximately 15% of adult Caucasians, and 85% of adult African
Americans in the United States are lactose intolerant. The rate of lactose intolerance is
also very high in individuals of Asian descent, Hispanic descent, Native Americans and
Jewish individuals.

What are the symptoms of lactose intolerance?

The symptoms of lactose intolerance can start during childhood or adolescence and tend
to get worse with age. The severity of symptoms is usually proportional to the amount of
the milk sugar ingested with more symptoms following a meal with higher milk sugar
content. The symptoms of lactose intolerance are abdominal distension and pain, excess

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burping, loud bowel sounds, excess gas and diarrhea following ingestion of lactose. An
individual who is lactose intolerant may have very watery and explosive bowel
movements. Individuals who are lactose intolerant may feel a sense of urgency with
bowel movements. This means that they feel that they have to get to the bathroom
immediately or they will have an accident. If someone who is lactose intolerant does not
eat lactose they will not have the symptoms noted above.

Although eating lactose containing products will result in discomfort for someone who is
lactose intolerant, they will not be harmed by eating lactose. There are no long term
concerns for someone who is lactose intolerant of developing more serious intestinal
disease because of this. The only exception to this would be for babies who are born with
primary lactase deficiency or children with secondary lactase deficiency as discussed
above. These children may have poor growth as a result of chronic diarrhea and
malnutrition if they are not switched to a lactose free diet or supplemented with the
lactase enzyme (commercially available).

What causes the symptoms of lactose intolerance?

Because lactose is not digested properly in the small intestine in individuals who are
lactose intolerant, it passes whole into the large intestine or colon. Upon reaching the
colon it is broken down by the normal colon bacteria. This breakdown results in the
production of carbon dioxide and hydrogen gases and short chain fatty acids. The carbon
dioxide and short chain fatty acids produced in the colon result in the symptoms of
lactose intolerance. The hydrogen is absorbed and ultimately excreted in the breath as
described below.

How is lactose intolerance diagnosed?

Lactose intolerance is diagnosed by a simple test called a breath hydrogen test. After a
period of fasting from midnight the night before the test, an individual drinks a specified
amount of the milk sugar as a syrup. In adults this corresponds to the amount of milk
sugar in a quart of milk. They then breathe into a test bag every fifteen minutes for
approximately two hours. The breath that they exhale into the bag is analyzed to
determine its hydrogen content. During the course of the test individuals who are lactose
intolerant will have an increase in the amount of hydrogen that they exhale. If the values
for hydrogen increase above a certain value the diagnosis of lactose intolerance is made.
Patients who are lactose intolerant may also develop their typical symptoms during the
test.

What can be done to treat or manage lactose intolerance?

The best treatment of the symptoms of lactose intolerance is a combination of dietary

modification and taking a supplement to aid in digestion of lactose. Individuals who are
lactose intolerant should meet with a dietician to review the sources of lactose in their
diet. Some reduction in the daily lactose consumption is usually required. When an

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individual is going to be eating a food that contains lactose they should take a
commercially available non prescription lactase supplement at the time of lactose
ingestion. This type of supplement can be taken throughout the day whenever lactose is
ingested. Some individuals will be less lactose intolerant and therefore will be able to
tolerate comparatively larger amounts of lactose. Alternatives to milk for lactose
intolerant individuals include products such as soy milk. If an individual is restricting
their milk/ dairy intake it is important to ensure adequate supplementation of calcium in
the diet. This is especially important for pediatric patients and women.

Recommended daily calcium intakes

1-3 years of age 500 mg

4-8 years of age 800 mg
9-24 years of age 1300 mg
Age 25 and above 800-1000 mg
Pregnant and nursing women 1200 mg

Is it possible to become temporarily lactose intolerant?

There are several conditions in older children, adolescents and adults that can cause
temporary lactose intolerance. The lactose intolerance usually resolves with treatment.
These diseases include acute diarrhea due to an infection, celiac sprue which is an
intolerance to wheat products, Crohn’s disease of the small intestine discussed below, and
other causes of malnutrition.

INFLAMMATORY BOWEL DISEASE

What is inflammatory bowel disease?

Inflammatory bowel disease refers to a chronic (long term/ lifelong) inflammation or

irritation of the stomach, small intestine and/or colon (large bowel). Inflammatory bowel
disease should not be confused with irritable bowel syndrome which is discussed
elsewhere in the web book. There are two types or categories of inflammatory bowel
disease, Ulcerative Colitis and Crohn's disease. Patients can have either type but not both.
Occasionally one type of inflammatory bowel disease is diagnosed and with further
testing or time the disease may be re-diagnosed as the other type.

What is the difference between Ulcerative colitis and Crohn's disease?

Ulcerative colitis and Crohn's disease differ primarily in the portions of the bowel that
they each involve and also the layers of the bowel wall that are involved. Ulcerative
colitis involves only the large bowel. It can involve a part of the large bowel only or the
entire large bowel but it does not have “skip” areas. Skip areas are areas of the intestine

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that are normal with abnormal areas on either side of them. Ulcerative colitis only
involves the innermost layer of the bowel (the lining of the bowel) known as the mucosa.
It does not involve deeper layers of the bowel. Crohn’s disease on the other hand can
involve any area of the gastrointestinal tract from the mouth to the rectum (the last
portion of the colon) and the anus. Crohn’s disease involves not only the lining of the
bowel, but can and usually does involve the deeper layers of the bowel. Even though
Crohn’s disease can involve any portion of the gastrointestinal tract it typically does not
involve every portion of the gastrointestinal tract. The most common sites of involvement
are the end of the small intestine known as the terminal ileum, involved in up to 80% of
patients, involvement in the colon in approximately 50% of patients, with approximately
5% of patients having disease in their stomach or first part of the small intestine known as
the duodenum.

How common is ulcerative colitis and Crohn’s disease in pediatric patients?

Both ulcerative colitis and Crohn’s disease are relatively uncommon problems in both
children and adults. The incidence or number of new cases occurring each year appears to
be increasing more for Crohn’s disease than for ulcerative colitis. In a group of
approximately 100,000 children age 15 years or younger, it is estimated that
approximately 2 or 3 of them will develop Crohn’s disease each year. However in a
group of 100,000 children age 15-19, the rate of developing Crohn’s disease increases to
16 new cases per year. The chance of developing ulcerative colitis in childhood and
adolescence is less than the chance of developing Crohn’s disease, with an incidence of 2
to 10 new cases per 100,000 population per year. The teenage years are one of the most
likely times for inflammatory bowel disease to be diagnosed. The other most common
time is between 30-40 years of age.

Both ulcerative colitis and Crohn’s disease are more common in certain families. In large
studies it has been shown that if someone has either ulcerative colitis or Crohn’s and all
of their close family members (parents, grandparents, brothers, sisters and children) are
followed for a period of thirty years there is a one in three chance of another family
member developing either ulcerative colitis or Crohn’s disease. If the original family
member has ulcerative colitis the relative is likely to develop ulcerative colitis and if they
have Crohns disease the relative is likely to develop Crohns. Neither ulcerative colitis nor
Crohn’s disease are contagious, which means that you cannot catch it from your family
member. The reason for family members being more likely to develop these diseases is
probably due to inheriting a gene that makes an individual more susceptible to develop
this type of inflammation of the bowel. In addition to being more common in certain
families, both ulcerative colitis and Crohn’s disease are more common in certain ethnic
groups, especially Jewish individuals of eastern European descent.

What are the symptoms of Ulcerative Colitis in children and teenagers?

The most common symptoms of ulcerative colitis in children and teenagers are diarrhea,
blood in the bowel movements and pain in the abdomen. Patients with this condition may

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have pain prior to a bowel movement that improves after a bowel movement, and
frequent bowel movements up to 10 times per day or more. Patients may also feel that
they need to have a bowel movement immediately or they are going to have an accident.
Having bowel movements at night is not uncommon in patients with ulcerative colitis,
especially when the colon is more inflamed. Other symptoms in children can include
anemia (a low blood count), weight loss and poor growth, although the later two are more
common with longstanding disease and more likely to occur with Crohn’s disease.

What are the symptoms of Crohn’s disease in children and teenagers?

The symptoms of Crohn’s disease may be subtler than those of ulcerative colitis or may
be dramatic. Abdominal pain, diarrhea and weight loss are the most common symptoms
occurring in 65-75% of patients. Poor growth is also common and a very important sign
of pediatric Crohn’s disease. A child who is usually amongst the tallest in their class who
becomes amongst the smallest, especially around the time of puberty may have Crohn’s
disease. The average time between the first symptoms of Crohn’s disease and the
diagnosis of Crohn’s disease may be up to a year in some studies, due to the subtle first
symptoms of Crohns disease. Fatigue or being tired due to anemia is common as is blood
in the bowel movements, although less common than in ulcerative colitis. Up to 25% of
patients will have disease around their bottom or anus; this may go unrecognized in a
teenager who is uncomfortable discussing bowel issues with their parents or doctors. This
includes extra folds of skin, which may become inflamed and can be painful, drainage of
pus from small openings in the skin known as fistulas and fissures or cracks in the skin
around the anus that may be painful.

How is the diagnosis made of ulcerative colitis or Crohn’s disease?

After a careful history and physical examination your doctor can order blood work to
screen for ulcerative colitis or Crohn’s disease. Blood work that would be abnormal in
these conditions can include a blood count demonstrating anemia, especially if the iron
level is low, an increased white blood cell count which may indicate inflammation or
infection, an increased platelet count (the part of the blood that is responsible for helping
blood clot), decreased blood levels of proteins such as albumin and an elevated
sedimentation rate, a nonspecific marker of inflammation. There are new additional blood
tests available that detect certain antibodies found more commonly in patients with
inflammatory bowel disease. However testing positive or negative for these antibodies
does not establish or rule out the diagnosis of inflammatory bowel disease and therefore
expert interpretation of these blood tests is required.

An x-ray called an upper GI with small bowel follow through can be obtained to look for
irregularity in the small intestine. This is particularly helpful in pediatric patients, as the
terminal ileum, which is the end of the small intestine, is the site most commonly
abnormal in children with Crohn’s disease.

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Endoscopy with biopsy (taking samples of tissue) also known as performing a scope test
is the definitive way to diagnose inflammatory bowel disease and also to determine how
much of the colon is involved. Endoscopy can also be performed of the stomach and first
part of the small intestine in patients suspected of having Crohn’s disease. Medications
are given during the procedure to sedate the patient and increase the comfort of the
procedure.

What does my gastroenterologist mean when he talks about “extra intestinal

manifestations” of Crohn’s disease or ulcerative colitis?

Although the stomach, small intestine and colon are the areas of the body that are most
commonly involved with inflammatory bowel disease, patients can develop symptoms
outside of the GI tract that are due to their inflammatory bowel disease. How severe the
symptoms are may in some cases be related to how severe the bowel disease is or may be
independent of the bowel symptoms. These symptoms are generally not due to
medications administered for the bowel disease. The table below indicates some of the
most common extraintestinal manifestations of inflammatory bowel disease.

Symptom Crohn’s disease Ulcerative colitis

Joint swelling or pain/arthritis yes yes
Skin rashes yes yes
Mouth sores yes no
Inflammation of the eye yes yes, but less common
Clotting problems yes yes
Kidney stones yes no
Abnormal liver function tests yes yes
Inflammation of the pancreas yes uncommon except with meds
Bone disease yes yes, but less common
Anemia yes yes

What are the treatment options for Ulcerative colitis and Crohn’s disease?

There are a variety of medications available to treat both ulcerative colitis and Crohn’s
disease. Important pediatric considerations for medical therapy include long term side
effects of the medications especially with regards to growth, bone disease such as
osteoporosis (decreased calcium in the bone), development of cataracts in the eyes from
medications such as steroids and a small risk of developing certain types of cancer with
some medications or as a result of having chronic inflammatory bowel disease over a
long period of time.

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Medications used for pediatric patients with inflammatory bowel disease include the
following:

Types How it is given

Aminosalicylate or 5-ASA products by mouth, as a suppository or an enema
Steroids by mouth, in the vein, or as an enema
Immunosuppressants (Imuran, 6-MP) by mouth
Immunosuppressants (Methotrexate) by mouth or by injection
Immunosuppressants (Cyclosporine) by mouth or in the vein
Antibiotics by mouth, in the vein
Immune-modulators (Infliximab) in the vein

There are a variety of nutritional options also available for patients with Crohn’s disease
and it has been shown that disease activity appears to decrease if patients are able to
significantly increase their caloric intake through the use of standard or specialized diets.
Supplementation with folic acid, calcium and Vitamin D in patients with decreased bone
calcium is also helpful in patients with inflammatory bowel disease.

Can surgery cure ulcerative colitis or Crohn’s disease?

Surgery is curative for ulcerative colitis, but not for Crohn’s disease. Surgery is usually
performed for disease that does not get better despite medications, if severe medication
side effects develop or for other complications of the underlying inflammatory bowel
disease. Children undergoing removal of their colon for ulcerative colitis can have a
pouch fashioned of small intestine that serves as a reservoir for stool and takes the place
of the rectum. Children undergoing surgery for Crohn's disease generally do so for
development of a specific complication of their disease or their medication. Because
Crohn’s disease always comes back following surgery patients are usually continued on
maintenance medications following surgery to cut down how quickly or how severely the
disease comes back. Also the amount of bowel removed is limited in patients with
Crohns disease in order to prevent additional problems with absorption of nutrients after
surgery. Patients still require regular follow up with their pediatric gastroenterologist or
their gastroenterologist after surgery for either ulcerative colitis or Crohn’s disease.

DIARRHEA

Diarrhea is a very common problem in children younger than age five. In developing or
non-industrialized countries, multiple episodes of diarrhea can lead to serious problems
such as malnutrition (poor nutrition). In the United States and Canada, young children
have an average of two episodes of diarrhea per year.

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What is acute diarrhea?

Acute diarrhea often called acute gastroenteritis by physicians is when stools are softer
and more frequent then normal, (usually more than three bowel movements each day for
less than 3 weeks total). Diarrhea may be due to infections with bacteria, viruses or
parasites. Diarrhea is more common in children attending day care and is usually due to a
virus. While cases of diarrhea due to infection are usually mild and go away on their own,
it is important to avoid becoming dehydrated from loss of body fluid in diarrheal stools.

What is dehydration and how can I tell if my child is starting to develop this?

Dehydration is when someone is unable to take in sufficient fluid orally to meet their
daily requirements and compensate for losses in their stools. Physicians can determine if
someone is dehydrated and how severely they are dehydrated by examining them. Parents
can watch for signs of dehydration by checking how often their child is passing urine,
determining if they are able to cry with tears, or have dry lips. Figuring out how much a
child is urinating may be difficult if an infant is in diapers, and the urine is mixed with
loose bowel movements. Children often become fussy with decreased energy level.

What testing should my child have if they are having diarrhea?

Diarrhea due to acute infection (acute gastroenteritis) usually does not require tests. In
some cases doctors will order blood tests to determine if a child is dehydrated. Collection
of stool samples (stool cultures) can be done to identify the specific cause of the diarrhea
in some children, especially if they have blood in stools. Stool cultures can take from 2 to
5 days before a result is available. Stool studies can also be done to look for parasites
including giardia.

What can I do to treat my child’s diarrhea and dehydration?

Children with mild dehydration can be treated outside of the hospital with special oral
rehydration solutions (ORS) that can be purchased at the pharmacy or grocery store. Oral
rehydration solutions are the best way to rehydrate a child who is able to drink and is not
vomiting. Although other drinks such as juices, colas and sports drinks are frequently
used, they are not a good substitute for ORS, and can actually worsen the diarrhea.
Patients with more severe diarrhea, vomiting and dehydration may require intravenous
fluids (fluids given through a vein in the arm) in the hospital.

In a child who is otherwise healthy, it is very important to start feeding them their regular
diet as soon as possible. Breast fed infants should be nursed normally during episodes of
acute gastroenteritis. Formula fed infants can continue their regular diet and older
children should be re-introduced to their regular diet as soon as possible. Older children
may avoid dairy initially and try a bland diet consisting of bananas, apple sauce, rice, and
toast. Careful hand washing should be practiced by all family members especially after
diaper changes. Rarely, antibiotics are prescribed for children with specific bacterial or

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parasitic illnesses, although in most cases antibiotics do not change how long the diarrhea
lasts or its severity. While oral rehydration solutions can prevent dehydration, they do not
decrease the number of stools or how long the diarrhea lasts. Medicines which slow down
bowel movements are not recommended in children with acute diarrhea.

When diarrhea lasts longer than three weeks it is considered to be chronic. There are
many causes of chronic diarrhea. Usually chronic diarrhea is due to a disease that causes
inflammation of the bowel, but diarrhea may also be due to other causes such as
malabsorption of nutrients. Common causes of chronic diarrhea are shown below:

Diarrhea following infection (post infectious diarrhea)

Chronic nonspecific diarrhea
Celiac disease (wheat intolerance)
Inflammatory bowel disease (ulcerative colitis and Crohn’s disease)
Lactose intolerance
Irritable bowel syndrome
Diarrhea after antibiotic use (antibiotic associated colitis)
Food allergies

The diagnosis of these conditions usually requires confirmatory tests. Chronic non-
specific diarrhea is seen in toddlers and is usually dietary in origin, such as from drinking
too much juice. It resolves by simply limiting the amount of juice intake. Celiac disease
is mostly seen in Caucasian children and usually presents with chronic symptoms
including diarrhea, poor weight gain, decreased energy, and abdominal distension. A
child can be screened for this condition by a blood test. Inflammatory bowel disease is
discussed above. Irritable bowel syndrome is a common cause of diarrhea in teenagers,
although many patients will present with abdominal pain and diarrhea that alternates with
constipation. Irritable bowel syndrome and diarrhea are discussed elsewhere in this web-
book. Antibiotic associated diarrhea is seen after antibiotic use and is thought to be due to
an imbalance between the ‘good and bad’ bacteria in the intestine. One such bacterium is
called clostridium difficile, which can be tested for in stool samples. Establishing the
exact cause of chronic diarrhea may require several different tests, some of which are
listed below:

Common tests for chronic diarrhea

Blood tests
Stool tests
X-ray studies
Endoscopy with biopsy (EGD)
Colonoscopy with biopsy
Lactose breath hydrogen test

Colonoscopy is usually indicated when stool studies have not identified an infection and
diarrhea persists. It is most useful in distinguishing acute inflammation of the colon that

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gets better on its own, known as acute self limited colitis, from chronic inflammation of
the bowel known as chronic colitis. Colonoscopy does not usually help to find the cause
of diarrhea due to infection with the exception of diarrhea that follows antibiotic use.
Colonoscopy is invaluable in making the diagnosis of inflammatory bowel disease and
figuring out what portion of the colon is involved with the inflammation. Your physician
can assist you in choosing the best treatment after determining the cause of your child’s
diarrhea.

CONSTIPATION

What is constipation?

Constipation is defined as infrequent bowel movements, hard bowel movements, and

difficulty in passing bowel movements or painful bowel movements. It is a very common
problem but not always easy to treat. Children may not complain of this problem to their
parents. Parents may be reluctant to talk about this problem with their family members or
physicians. It is one of the most frequent reasons that children are sent to see a pediatric
gastroenterologist.

What is considered a normal bowel pattern?

Infants
The first bowel movement usually occurs within 36 hours after birth in term babies
(babies born within two weeks of their expected due date). Regular or normal bowel
movements can vary significantly among children, especially among infants. Breast fed
infants usually have more frequent bowel movements than formula fed babies.

Children
Most children have from 3 bowel movements per day to 3 per week.

What causes constipation?

Any change in a child's normal routine including a change in diet, a change in activity
level or a different bathroom can cause constipation. Although it can start without any
clear cause, there are certain times when a child is more likely to become constipated:

When solid foods are introduced as an infant

During toilet training
At the start of school
Birth of a sibling
Parents separating or divorcing
Move to a new place

Whenever bowel movements become hard, passing them becomes a painful and
unpleasant experience. The child then usually tries to avoid passing bowel movements by

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holding it. This may eventually lead to larger, harder stools that worsen the situation. The
children may cross their legs, stand on toes, or squeeze their buttocks together to try to
avoid passing a bowel movement. Many times parents misinterpret these behaviors as
straining to pass stools when in reality the children are trying not to have a bowel
movement. These behaviors are called retentive withholding.

Who is likely to develop chronic constipation?

It is slightly more common in boys than girls. About 25-50% of children with
constipation will have a family member with similar problems. Children whose
development is delayed and those born with problems affecting the anus or rectum are
more likely to suffer from chronic constipation, as do those with attention deficit
disorder.

What happens when my child is constipated?

Constipation may be associated with stomachaches or pain in other parts of the abdomen.
Constipation can result in tears of the anus called anal fissures. These cause blood in the
bowel movements. Because stools may be painful to pass over an anal tear, children who
have these tears may develop withholding behavior as described above. Withholding can
result in chronic constipation, soiling of the underwear with stool and even difficulty
walking. Soiling is usually an indication of rectal impaction with stool. It often occurs
when the child is relaxed such as in a warm bathtub or sleeping and is not withholding.
Soft, ‘clay-like’ stool then leaks around the ball of impacted stool in the rectum. Children
who are withholding their bowel movements often have a decreased appetite and activity
level.

Is my child's constipation a sign that they have another disease?

In over 90% of children, constipation is not associated with other diseases. There are
however certain 'red flags' or worrisome characteristics that should alert the physician
that another underlying disease should be considered and tested for. Diseases that can
have constipation as one of their symptoms include:

Hirschsprung's disease - a condition where the nerves of the large intestine (colon) are
not properly formed at birth
Thyroid problems- usually underactive thyroid
Celiac disease- a severe wheat intolerance
Lead poisoning
Hormonal problems that cause abnormal blood calcium levels

Constipation can also be a side effect of a medicine that the child is taking for another
condition.

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When should my child see a specialist about their constipation?

If constipation does not go away or does not get better after the treatment that your
pediatrician prescribes, seeing a pediatric gastroenterologist can be helpful. These
specialists will obtain a detailed history and perform a physical examination to
distinguish constipation that is due to withholding behavior or from constipation due to
an underlying disease. While most children do not need any tests, your physician is the
best judge to decide which test if any is necessary and to provide the most information
about the cause of your child’s constipation.

What types of tests might my child have to determine what is causing their
constipation?

Your doctor may suggest one or more of the following special tests for constipation:

Plain x-ray of the abdomen (also known as a KUB)

This is a single or set of x-rays that can give your physician a rough idea if
there is a lot of stool present. It may also indicate if the colon is dilated.
This type of x-ray is also obtained prior to a barium enema which is
described below.

Anorectal manometry or motility test

This test determines if the nerves and muscles responsible for passing a
bowel movement are working together. It is performed by inserting a very
small balloon at the end of a catheter into the rectum and blowing up the
balloon. The response to inflating the balloon determines if the nerves and
muscles are working together properly. This test is used to diagnose
Hirschsprung’s disease. Normal relaxation of the anal muscles, known as
the anal sphincter, after inflation of the balloon means that a patient does
not have Hirschsprung's disease.

Barium enema

This is an x-ray test where barium or another type of contrast is inserted

via a catheter into the rectum and x-rays of the abdomen are taken. The
test may or may not require a special bowel preparation to clean out the
bowel before the test. This test is used to diagnose a blockage in the
intestine or an area that may be narrowed or abnormal. It is also used in
the diagnosis of Hirschsprung’s disease. This test is being used less
frequently to diagnose Hirschsprung’s disease than it has been in previous
years because of the availability of other simpler types of tests such as
anorectal manometry that is described above.

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Rectal biopsy

This is a test where a small (pinch) biopsy is performed from the lining of
the rectum to determine if normal nerve cells are present in its walls. The
sample of tissue that is obtained is examined under the microscope. This
test is being used less frequently than it has been in previous years because
of the availability of anorectal manometry testing.

Transit study or marker study

This test is performed to determine if the reason for constipation is due to

slow movement throughout the colon or just in the last part of the colon
known as the rectum. Plastic markers, which can be seen on x-ray, are
swallowed and then several x-rays are performed over the next 4-7 days to
determine how long it takes them to pass through the GI tract. Patients
with normal motility pass the majority (>80%) of the markers within 5
days. If the markers are not passed but are found to remain throughout the
colon, this suggests slowing of the entire colon. If the markers do not pass
and are clustered in the rectum, this may indicate a problem in the rectum
only.

Colonoscopy

This is a scope test. This test is usually not indicated for the evaluation of
routine constipation in children. This test may be helpful if children have
blood in their bowel movements not due to a fissure or straining or for
placing a colonic manometry catheter (see below).

Colonic manometry

This is a specialized test done in children who have continued problems

with intractable constipation despite adequate medical therapy. It involves
placing a catheter at the time of colonoscopy to determine whether there
are normal contractions in all parts of the colon. The test requires a period
of prolonged monitoring of the contractions of the colon after placement
of the catheter. This test is used to establish the diagnosis of colonic
pseudo-obstruction in children, a very rare condition.

How is constipation treated in children?

The best way to treat constipation is a combination of education, behavioral modification,

dietary modification and non-habit forming medications. If there is an impaction of stool,
which means a very large amount of stool in the rectum, it needs to be evacuated first
either by an enema or by a medication given by mouth. Patients are then started on a
maintenance medication for a few months to soften the stools, and a program of bowel

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retraining is started. The child is advised to sit on the potty after every major meal for 5-
10 minutes and try to have a bowel movement. Positive reinforcement (reward) is
provided if the child has a stool in the potty. Behavioral modification may be needed in
some patients. Some children, especially boys, tend to get so involved in sports or
playing video games that they ignore the ‘urge’ to have a bowel movement. Postponing
the event makes things worse in the long run. The goal of treatment is to make having a
bowel movement pain free for the child by softening the stools. Consistency in treatment
is crucial for success.

Dietary and lifestyle changes may be helpful in improving a patient’s symptoms.

Increasing dietary fiber over 1 to 2 weeks is often helpful, by increasing bulk that then
stimulates colon contractions. This strategy may take a while to work and should not be
tried in children with severe constipation as it may make it worse. High fiber foods
include:

Bran
Fresh fruits: apricots, apples, pears, melons
Fresh vegetables: asparagus, beans, broccoli, carrots, beets, cauliflower,
other greens
Whole wheat products: cereals, breads, and pasta.

Fiber supplements are available if parents find their children will not eat more fiber in
their diet. There is little information to recommend one product over another. A patient
may have to try several before finding one that is acceptable and that they are willing to
take regularly. Fiber supplements are given two times a day and must be taken with a
sufficient amount of water. Some patients may notice increased passage of gas while on
fiber supplements. Increasing a patient’s physical activity is also helpful to promote
regular bowel movements.

What types of medications are used in children?

If constipation does not get better with dietary and behavior modifications, stool softeners
are indicated. The two most common stool softeners used in children are Miralax and
lactulose.

Miralax (polyethylene glycol) has become the most widely used medication for treating
constipation in children. It is a white powder that can be dissolved in juice or water and
does not get absorbed. It is tasteless, safe and non-habit forming. They have soft, more
frequent stools on this medication.

Lactulose is a laxative that is made of a sugar that is not absorbed by the intestine. It
works by pulling water into the bowel movements that helps to keep them soft. Because it
is not absorbed, lactulose is not associated with side effects except for increased gassiness
and diarrhea if the dose of the medicine is too high. Lactulose is not a stimulant and
therefore the bowel does not become dependent on it.

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Milk of Magnesia is a mild stimulant laxative that may be used at bedtime in children
with mild constipation. It is available over the counter without a prescription. The major
limiting factor in its use in children is its taste, even though it is now available in different
flavors.

Mineral oil, which is given mixed with juice or milk, acts as a lubricant to allow bowel
movements to pass easier. This type of medication is particularly useful in toddlers who
withhold their bowel movements. Older children may have leakage of the oil in their
underwear that may not be acceptable. This problem usually goes away with decreasing
the dose of mineral oil. Mineral oil should not be given to children with neurologic
problems who are at high risk for aspiration. Flavored forms of mineral oil are also
available.

Stimulant laxatives, such as senna or bisacodyl (dulcolax), that cause the colon to have
strong contractions, are not popular with pediatricians due to the concerns that they may
damage the intestinal nerves, if given over prolonged periods.

Is surgery ever performed for treatment of constipation?

Surgery is rarely needed for constipation. The exception to this is Hirschsprung’s disease,
which is treated with surgical removal of the portion of the bowel where there are no
normal nerves. Also, there are rare cases when children develop a dilated and floppy
colon that has no normal contractions, a condition called pseudo-obstruction. These
children also may benefit from removing the affected colon surgically. Recently special
surgical procedures, such as cecostomy (opening between the bowel and skin which
allows drainage of stool), have been devised to help children with spinal cord
abnormalities that have severe problems with constipation.

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6400 Goldsboro Rd., Suite 450, Bethesda, MD 20817
P: 301-263-9000 F: 301-263-9025 Internet: www.acg.gi.org