Persistent diarrhea in orphan child.

My child who is 20 months old has a problem with persistent diarrhea. H e had the post-adoption medial workup and nothing came back positive. I just do not understand why his bowels are so loose if there is nothing medically going on with him?

Unfortunately, chronic diarrhea is a very common problem found in many post-institutionalized children. Causes can vary from medical concerns, dietary intolerances to psychological situations. In pediatric medicine in general, children have usually one medical problem at a time. In the orphan child that had lived many years in an institution, several different medical conditions can occur concurrently.

The normal stooling pattern for all children in general for children are 1-2 times per day. When this frequency increases to multiple times per day, large amounts, foul smelling with little consistency, diarrhea would be a diagnosis of concern in an Internationally adopted child, regardless of the fact that the initial evaluation was determined
to be negative.

Some of the common things that may cause recurrent diarrhea in the internationally adopted child can be multifold. If a diagnosis is made appropriately, then the proper medical therapy can be implemented subsequently resolving the chronic diarrhea symptoms.

Overeating is the most common reason for recurrent diarrhea. Adopted children are known to be fixated with food post arrival. Sometimes they seem to be bottomless pits. One must remember that food for these children was scarce in the orphanage. When it was available, it did not taste good at all. Now these children have an endless amount of food available, and most of the time it taste good, they do not know if they will have this meal again, so they just eat. Catch up growth in these children is always very dramatic. Growth parameters tend to take a vertical pattern on the growth chart. Diarrhea secondary to overeating can only be made once all medical concerns are ruled out. Sometimes, probiotics such as a product called Florastar, this may help the children overcome their complaints caused by dietary changes.

Toddlers Diarrhea is another common cause of recurrent loose bowel movement in the general pediatric world. It is even more common in the adopted child because, like with food, they tend to drink large amounts of juice. Apple juice, a common drink given to the pediatric population is a notorious cause of Toddler’s diarrhea. The recommend therapy of choice is to limit the amount of juice.

The diarrhea caused from dietary intake is called osmotic diarrhea. Both of the above mentioned cause of diarrhea could only be made once other medical concerns are ruled out.

Medical concerns that need to be looked into are mentioned below:

Giardia Enteritis: A parasitic infection of the bowel common place in children that live in orphanages. Infected children in the developing parts of the world are generally not treated for this organism because of the high recurrence rate. Once a child is diagnosed with positive stool specimens for ova and parasitic infection, as well as a positive Giardia antigen, therapy is started with either metronidazole or the newer drug called Alinia. Metronidazole is a complicated and not so easily attainable medication. The medication must be specially compounded by the pharmacist, foul tasting and needs to be administered four times daily. A newer and better tasting medication is called Alina. The company states that a child needs to be treated once a day for a total of three days. Personal experience with this medical is that a longer course of therapy in required. I had spoken with the medical director of the company who stated that, especially children adopted form Russia, they seem to carry a resistant type of Giardia. They require longer therapy from the very beginning.

Milk protein allergy is another common cause for recurrent diarrhea. In children under 2 years of age, cow’s milk protein allergy is more common. Adopted children in the orphanages are given different types of milk products, such as Kefir, soymilk, and sometimes goat milk. It is only until they arrive to the U.S.A. and the new adoptive parents introduce whole milk to their diets that intolerance to milk protein is discovered.
Eliminating cow’s milk from their diet and supplementing it with soy or rice milk can easily manage children with this condition.

Lactose intolerance can occur temporarily in children following a course of antibiotic therapy, intestinal infection. This condition is found sometimes in children adopted from China. There is a deficiency in the enzyme called lactase that is used to in the process of digesting milk products. A lactose free diet and the use of lactate supplements when enjoying a milk product should be sufficient to control the symptoms of the child.

Sorbitol found in a medication called Isoniazide used to treat a positive PPD reaction is another common cause of explosive diarrhea in the internationally adopted child. I have had cases where we were treating the child’s positive tuberculosis screen and caused explosive, foul smelling diarrhea, with a negative stool workup. A simple remedy to this problem is to have the pharmacist compound the Isonizide using a sorbitol free preservative.

More serious conditions such as Celiac disease, Cystic Fibrosis, malabsorbtion syndrome usually present with chronic diarrhea in a child that does not thrive at all. The one thing that many internationally adopted children do is thriving well post adoption. When they do not, it should be a red flag for your physician.

Once a qualified pediatrician determines the cause for the child’s recurrent diarrhea, only then can appropriate therapy be implemented.

One should try to stay away from food products that may upset the child’s bowels:
1) Raw fruits and vegetables
2) Juice, soda and milk
3) Greasy and fried fast food products
4) Spicy foods
5) Sauces and sweets.

Things that can help to alleviate the upset stomach
1) Small frequent meals
2) Pasta, Rice and hot cereal without milk
3) The Brat diet is routinely used in the Pediatric Medicine community. It stands for products made from, Bananas, rice, applesauce and toast.
4) Plenty of fluids such as electrolyte solution (pedialyte) are good to help ward off acute dehydration cause by prolonged diarrhea with poor liquid intake. It is not the treatment for diarrhea however.

Again, the exact cause of the chronic diarrhea needs to be investigated before an appropriate course of therapy can begin. The above examples are just some simple common cause for recurrent diarrhea in the internationally adopted child. If one was to look into a pediatric medical textbook under the differential diagnosis of chronic diarrhea you will find a list that has 30 – 40 different medical conditions associated with diarrhea.

By George Rogu M.D. Medical Director and Founder of Adoptiondoctors.com and Adoptioneducationclasses.com