What's the Big Deal about Stools?

In primary care practice I am frequently asked about a child’s stooling pattern. Often the child’s pattern is similar to one of the parents -- but the parents have not discussed this particular biological event, so they don't know what normal is for them.

The good news is it is rarely a cause for great concern. Dr. Martin Ulshen, a pediatric gastroenterologist at Duke, describes why below.

-- Dennis Clements MD, PhD, MPH

Martin H. Ulshen, MDMost of us prefer not to give any more thought to stools than absolutely necessary (except, perhaps, for someone in my line of work!).

Despite this, parents commonly monitor the stool patterns of their infants or toddlers as one means of assessing the overall health of their child.

Feeding Affects Stool Patterns

In infancy, the type of feeding can greatly influenced the frequency and consistency of stools.

Infants who are exclusively nursed tend to begin life with frequent loose stools. Some nursing infants will continue this pattern, but, after two or more weeks of life, some will develop a pattern of infrequent stools. They may go even two weeks between stools, but the key is that the infant appears comfortable, and when a stool is passed, it is soft and normal looking. Generally when solids are introduced into the diet of these children, stool frequency increases.

The stools of bottle-fed infants may be affected by diet as well. Soy formulas tend to cause firmer stools and, at times, constipation. Special predigested formulas, used for food allergy, tend to produce a looser stool. Rice cereal may cause constipation, whereas, oatmeal produces a softer stool. Fruit juices, especially apple or prune, are well known for causing a looser stool in infants and, therefore, are beneficial for constipation.

Some infants in the first months of life will seem to strain and strain with difficulty passing a stool. Yet, when they do, it is soft and normal in appearance. Typically, this is a transient problem, which resolves after the first few months of life. It is thought to be the result of immaturity with poor coordination of rectum and anus. If the problem is more severe or does not resolve, you should consult your primary care physician.

Diarrhea

During the second six months of life and especially after one year of age, some otherwise healthy children will develop intermittent loose stools. These episodes seem to occur without rhyme or reason. The stools tend to be passed early in the day and not during the night. This pattern of stooling has been called “toddler’s diarrhea.” It is not dangerous to the child’s health and resolves spontaneously, typically within the first three years of life.

Often, these children ingest liquids and snacks frequently throughout the day and may drink excessive amounts of juices. Generally, cutting down on the frequency of feedings (i.e., cutting out the snacks and liquids between meals) will improve the stool pattern. If the child is not growing and thriving, it is important to consult your primary care provider to rule out other possible causes of diarrhea.

Children may from time to time have transient diarrhea secondary to an infectious gastroenteritis. Often the cause is obvious because other members of the family or schoolmates will be ill as well. This will resolve spontaneously in days to weeks. Transient constipation happens occasionally as well.

Constipation

After the first two or three years of life, chronic constipation is a much more frequent problem than chronic diarrhea. Often it is associated with involuntary fecal soiling. Constipation tends to be self-perpetuating. Fecal retention leads to painful, large stools and young children, therefore, will stool hold. In addition, stretching of the rectum due to stool retention decreases the ability of the rectum to function normally. As a result, it is more difficult to get the stool out. Chronic distention of the rectum leads to decreased sensation and these children do not feel like they need to pass stool. At the same time, the loss of rectal sensation allows for soiling.

All of these problems with chronic constipation are nearly always reversible once the colon is adequately cleaned out. However, it is important to have the child stay on treatment to keep the rectum well evacuated or the problem will recur. Typically, a year or more of treatment with stool softener is required before the rectum is able to function adequately without medication. For specific details of treatment, one should consult their primary care physician.

Intermittent diarrhea in an otherwise well child might represent irritable bowel syndrome, a condition that is very common in adults. Chronic diarrhea in an older child can be the sign of a more serious underlying disorder. Diarrhea that begins late in the first 10 years of life or teens can be secondary to adult-onset lactose intolerance. This condition is especially prevalent in African-Americans, Asians, and people of Mediterranean descent. The occurrence of symptoms with dairy products would be a clue.

Diarrhea with poor weight gain or weight loss, abdominal pain, extreme fatigue, or growth retardation can be caused by celiac disease. These symptoms as well as blood in the stool might suggest inflammatory bowel disease (ie, Crohn’s disease or ulcerative colitis) as well. If your child is having persistent or recurrent diarrhea, one should discuss this with their primary care physician.

Most issues discussed above are various degrees of normal and a visit to the primary care physician can help reassure parents. When the problem is persistent and with other medical symptoms then sometimes a referral to a pediatric gastroenterologist is warranted.

-- Martin H. Ulshen, MD, is chief of Duke's Department of Pediatrics division of Gastroenterology, Hepatology, and Nutrition.

-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.