What to Expect the Toddler Years (214 page)

Medication. Occasionally, the doctor may recommend a brief course of medication; do not give laxatives, stool softeners, mineral oil, herbal teas, or any other medicines for constipation without the doctor’s recommendation.

Prevention.
Most of the lifestyle changes necessary for treating constipation will also help keep it at bay. Fiber, fluids, and exercise should be part of every child’s health routine, but they are especially important for those with a history (or family history) of constipation.

Complications.
Unchecked constipation can lead to:
Disruption of the toilet-learning process.
A child who expects difficulty, even pain, with a bowel movement may hold it in, then may later have an accident when this self-control fails.
Fissures.
Anyone, young or old, who regularly strains on the toilet can develop painful cracks around the rectum. Since fissures bleed, there is often blood in or around the stools.
A lifetime of constipation.
Unhealthy toileting habits can lead eventually to such chronic constipation-related problems as hemorrhoids.

When to call the doctor.
When your toddler has not had a bowel movement
for 4 or 5 days; when constipation is accompanied by abdominal pain or vomiting; when bowel movements are dry and hard and/or painful; when constipation is chronic and the home measures described above have been ineffective; when there is blood in or around the stool. The doctor will probably want to rule out the slim chance of an underlying organic problem, as well as determine the best approach to treating the constipation.

Symptoms.
Spasmodic croup:
Sudden onset in the middle of the night, of gasping for breath, hoarseness, bark-like cough; usually no fever. There may be repeated episodes the same night or the next two or three nights.
Laryngotracheitis:
Cold symptoms that gradually develop into hoarseness and bark-like cough; noisy, labored breathing; retractions (the skin between the ribs can be seen to be sucked in with each breath) as airway swells and secretions increase and thicken. There may or may not be a fever.
Laryngotracheobronchitis:
Symptoms are similar to laryngotracheitis, but onset is more variable and fever can be as high as 104°F (40°C). Child usually looks sick.

Season.
Most often, fall and early winter.

Cause.
Narrowing of the airways below the vocal cords due to inflammation of the larynx and trachea, usually triggered in
spasmodic croup
by a combination of allergy and viral infection (though the mechanism isn’t clear); in
laryngotracheitis
by a viral infection (most often with a parainfluenza virus); and in
laryn-gotracheobronchitis
probably by a viral infection with a bacterial secondary infection.

Method of transmission.
Depends on the cause. Parainfluenza viruses are believed to be transmitted by direct contact and by contaminated secretions.

Duration.
Several days to a week. Spasmodic croup may recur.

Treatment.
Steam inhalation (see page 839). Or cool night air (take the child out into the fresh air for 15 minutes). Humidifying your toddler’s sleeping space may help, too (see page 838). Also crucial: comfort and support to minimize crying, which could worsen the problem. In severe cases, medical treatment to open the airways, occasionally, and hospitalization (usually brief) is necessary.

Dietary changes.
Extra fluids, especially warm ones, such as soup and warm orangeade (made with frozen orange juice concentrate and hot water).

When to call the doctor.
Immediately, if this is your toddler’s first attack of croup. If it’s a repeat, follow instructions the doctor has given you previously. Also call if the steam doesn’t stop the barky cough or if your child lacks color, seems lethargic or sleepy, refuses to eat or drink, has difficulty catching his or her breath (especially during the day), or you can see retractions. If you can’t reach the doctor, take your child to the nearest emergency room. Repeated attacks of croup along with voice changes, abnormal cry, or stridor (a harsh, vibrating, crowing sound on breathing in) may require further inquiry; rarely, they are due to warts (caused by the human papilloma virus) on the larynx.

Prevention.
None known, but humidification for a cold may help.

Symptoms.
Two or three (your child’s doctor’s guidelines may differ) or more liquidy stools in a 24-hour period; color and/or odor may vary from usual. Sometimes, an increase in frequency and volume of stool, mucus in the stool, vomiting, and/or redness and irritation around the rectum. Weight loss, when diarrhea continues for several days to a week. Many doctors consider diarrhea that continues for 2 to 3 weeks to be chronic; when it persists for 6 weeks or more, it’s termed “intractable.” An occasional looser-than-normal stool is not a cause for concern; it is often just a reaction to a dietary indiscretion—too much fruit, for example.

Season.
Any, but may be more common in warm weather, when more fruit is consumed and food spoils more quickly. Rotavirus-caused gastrointestinal infections, however, are more common in winter, in temperate climates.

Cause.
Many causes, including microorganisms (viruses, bacteria, parasites) picked up from contaminated food or another person (directly or indirectly); excessive amounts of “laxative” foods (such as fresh fruit, prunes and other dried fruit, or fruit juices, especially pear, apple, prune, and grape); consumption of foods (or chewing of gum) containing sorbitol or mannitol; an intolerance or allergy to a food (often milk) or medication; an infection elsewhere in the body (a cold, ear infection, and so on); a course of antibiotics; and, possibly, teething. Intractable diarrhea may be linked to an overactive thyroid gland, cystic fibrosis, celiac disease, enzyme deficiencies (particularly of enzymes that digest sugars, such as lactose or sucrose), and other disorders. Some times, diarrhea in toddlers is related to constipation (the feces become impacted and leakage of watery stool around them looks like diarrhea).

Method of transmission.
Diarrhea caused by microorganisms can be transmitted via the feces-to-hand-to-mouth route or by contaminated foods. Incubation periods vary according to the causative organism.

Duration.
Acute episodes usually last anywhere from a few hours to several days; some intractable cases can last indefinitely, unless the underlying cause is found and corrected. Chronic nonspecific diarrhea is usually outgrown by age three or four.

Treatment.
Varies with cause. The most common treatment for diarrhea with no underlying medical problem is dietary (see Dietary changes, page 604). Diarrhea due to an underlying medical problem is treated by dealing with the problem appropriately. Antibiotics may be prescribed for bacterial and parasitic infections, but medication is not routinely given for simple acute diarrhea. Kaolin-pectin products (such as Kaopectate, Donnagel PG) are not generally recommended, because although they improve stool consistency, they do nothing to reduce frequency, volume, or fluid loss. Products containing atropine sulfate (such as Lomotil) or loperamide hydrochloride (Imodium A-D, Pepto Diarrhea Control) are considered neither effective
nor
safe for children. While a bismuth subsalicylate product (such as Pepto-Bismol) can decrease the water content and number of stools, it should never be given to a child if there is even the suspicion of a viral illness (salicylate is aspirin; see page 597). Studies suggest that a human
Lactobacillus
strain combined with oral rehydration therapy (described in Dietary changes, page 604), as well as probiotics in general, promotes recovery from acute diarrhea; if confirmed, this may become a routine treatment.

Even with treatment and dietary changes, diarrhea doesn’t always stop immediately. To determine if treatment is working, look for gradual improvement (sometimes the first stool of the day will look better, but later ones may be looser again) and for signs of dehydration to disappear (see page 606).

To prevent spread of infectious organisms in the diarrhea to the vagina, be particularly meticulous in cleaning a little girl after a bowel movement; always wipe from front to back.

Dietary changes.

Increased fluid intake (at least 3 ounces an hour, while the child is awake). For mild diarrhea with no dehydration (see page 606), milk, juice, or juice and water mixtures may be sufficient. For severe diarrhea (watery bowel movements every 2 hours or more often) or mild diarrhea with vomiting or dehydration, particularly in children under age two, oral rehydration therapy (ORT), using a commercially available electrolyte solution, is recommended. Ask your child’s doctor to suggest a specific brand and stock a bottle in your medicine cabinet. Offer a few sips of the solution by spoon, cup, or bottle every 2 or 3 minutes, working up to five 8-ounce cups for a child weighing about 22 pounds, about
5
³
/
₄
cups for the 27-pounder, and a little more than 6 cups for the 32-pounder. If your child vomits the solution, continue giving it, but in very small sips, or make ice pops (with the solution and a small amount of a favorite juice) for your child to suck on. ORT should be continued for 24 to 48 hours. If your toddler rejects the ORT solution, try using a syringe to direct it to the back of the mouth where the taste will be less noticeable.
Do not
give sugar-sweetened drinks (such as colas or ginger ale), athletic drinks, glucose water, homemade sugar water or sugar-salt-water mixtures or undiluted juices. They may make the condition worse. White grape juice may be a better choice than apple juice when a toddler has diarrhea. Ask your pediatrician which type of drink he or she recommends.

For mild diarrhea. Normal diet, according to the child’s appetite. Diarrhea tends to improve more quickly when solids are continued. Cutting back on milk, or stopping it entirely for a day
or two, may also be helpful if the diarrhea worsens when your child has dairy products; some children become lactose-intolerant during a bout with diarrhea.