Diarrhea

Diarrhea may be defined as "frequent and watery bowel movements." In the childcare setting, diarrhea is often simply an inconvenience to staff who must diaper the children and assist with toileting. However, diarrhea also can be a more serious concern, depending upon its cause. Diarrhea can be infectious in that it easily can be transmitted from person to person. However, it also can be noninfectious in that it is a reaction of the child's body to something and therefore, is not spread to other people. Before you exclude a child from childcare, it may be helpful to determine the cause of the diarrhea.

Noninfectious Diarrhea

One of the more common causes of diarrhea is the use of antibiotics. The potential varies from child to child, but there are some antibiotics that far more frequently cause diarrhea than others. If a child taking an antibiotic is suffering from stomach cramps or diarrhea, you may want to encourage the parent to discuss it with the child's doctor. It may be possible to prescribe a different antibiotic for that child. Also, giving the child yogurt with active cultures may help prevent diarrhea. Sometimes diarrhea accompanies a respiratory or ear infection. For reasons not at all clear, the intestine may overreact and cause diarrhea, with increased water content in the stools.

Eating or drinking too much or too fast can cause diarrhea; usually this results in only a single episode of watery stools. This is far more common among overeating adults than children. Another common culprit is sorbital, a complex sugar found in some liquid medicines and in foods such as apple juice, pear juice, and some mixed fruit drinks. Thus, these foods can cause diarrhea in small children. Food allergies also can be a cause of diarrhea in children. Milk is one of the more common allergens of this type.

Infectious Diarrhea

Of far more importance to the childcare provider is infectious diarrhea, known as an "enteric disease." Blood or mucus in the stool is a sign of possible infectious disease. It is contagious and easily spread from person-to-person by the fecal-oral route. This means that small (microscopic) bits of stool are put in the mouth. Germs are present in all stools, and with the typical incomplete hand washing habits of young children, the germs may be transmitted to toys and environmental surfaces that other children touch or put in their mouths.

The most common infectious diarrheas are those caused by viruses. These are highly contagious. Rotavirus (discussed in Healthy Childcare, Vol. 3, Issue 6) is one such virus that can cause severe illness. Other viruses include adenovirus and astrovirus. Infectious diarrhea can also be caused by parasites, such as giardia or cryptosporidium, which are easily spread through contaminated water supplies and human contact. Treatment may involve a prescription medication to kill the parasite.

Diarrhea also can be caused by bacteria, including salmonella, shigella, E. coli, and campylobacter. One of the most common germs causing severe diarrhea is salmonella, which can be found in foods containing raw eggs or undercooked poultry or meat. Salmonella is frequently found in pet turtles and other reptiles. So pet turtles are not advisable in the childcare settings!

There are five different classes of E. coli bacteria that can cause diarrhea. One of the most dangerous is E. coli O157:H7, which produces a toxin that can lead to severe illness affecting many organs. It can be fatal. Most E. coli infections are spread through contaminated food or water. A major source of E. coli poisoning is ground beef, so all meats, especially hamburger, must be cooked well done to assure safety.

Prevention

Meticulous and frequent hand washing is by far the most important procedure to minimize fecal-oral transmission of agents that can cause diarrhea. Staff must wash their own and the child's hands after each diaper change or toileting as well as before meals or snacks. An additional washing after outdoor play or free play where there is a lot of child-to-child touching also is recommended. Regular disinfection of toys and surfaces, especially diapering and food preparation areas, also is essential. These procedures must be reinforced regularly through staff training and monitoring.

If a child develops diarrhea while in childcare, he should be promptly separated from the group until he can be picked up by the parent or guardian. He may return to childcare if the cause of diarrhea has been determined to be noninfectious (such as a reaction to food or medication) or when the infectious diarrheal illness is over. Furthermore, providers also must be conscientious about hand washing and possibly excluding themselves if they have diarrhea. This is especially true for food handlers.

By Don Palmer, MD
American Academy of Pediatrics Committee on Early Childhood, Adoption, and Dependent Care

Resources

ABC's of Safe and Healthy Child Care, the Centers for Disease Control and Prevention;
800- 553-NTIS; www.cdc.gov/ncidod/hip/ABC/abc.htm

National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care Programs, American Academy of Pediatrics; 800-433-9016; www.aap.org. The text of this publication can be found on the National Resource Center for Health and Safety in Child Care's web site, nrc.uchsc.edu.

Resources

www.kidshealth.org

www.drkoop.com

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