Diarrhoea tends to affect children quite a bit, especially those under five years of age who have begun eating adult food at the dinner table. In Malaysia, this study[1] published in 2018 says that the prevalence of diarrhoea among children under five was 4.4%.

The cause of diarrhoea in children is multifaceted. Factors include food handling and preparation and how and when the food is consumed. Perhaps the utensils or chopping board and knife were not thoroughly cleaned before being reused to prepare other food items; perhaps it was due to the child himself not washing his hands after going to the toilet or after playing outside and then using those same fingers to put food in the mouth; or perhaps it is the result of eating food that has not been fully cooked or insufficiently reheated or has been left out for too long and gone bad.

What Causes Diarrhoea?

A lot of times, diarrhoea in children is caused by food poisoning. In 2021, there were approximately 6000 food poisoning cases[2] reported in Malaysia and certainly, according to several studies, schoolchildren[3] seem to be the most affected. Food poisoning[4] is caused by foodborne bacteria, parasites and viruses such as Salmonella, E.Coli, Campylobacter, Shigella, Listeria, Norovirus[5] and many more found in raw or undercooked meat and poultry and poultry products, unpasturised milk and dairy products, seafood and raw shellfish, fruits and vegetables, and untreated water. Additionally, it can be caused by unhygienic food preparation, or food that has been contaminated by flies or even rats.

That is why parents have to be extra careful when buying stall or coffeeshop food for their families or eating out at restaurants with questionable cleanliness.

Food poisoning can also occur due to ingesting chemicals such as pesticides[6] , weed killers and toxins, metals such as lead, copper and mercury and poisonous plants and marine products.

Imbalance in Gut Microbiome

Apart from food poisoning, diarrhoea[7] can also be caused by food allergy, medication such as antibiotics, food additives and chemical ingestion. Or, it could be due to a disturbance to the intestinal bacterial flora causing harmful bacteria to outnumber beneficial bacteria. As a result, the gut becomes imbalanced[8] and inflamed. This imbalance could be caused by stress, lack of sleep, antibiotic use, taking too much sugar (especially in drinks loaded with fructose), an unhealthy lifestyle and poor food choices.

Evidence shows[9] that imbalance of the gut microbiota (the system of microorganisms in the gastrointestinal tract) increases susceptibility to various diseases and causes diarrhoea, Irritable Bowel Syndrome (IBS)which occurs in people of all ages including children[10] , allergies, cardiovascular disease and obesity.

That is why probiotics, available in powder or capsule form or as cultured milk drinks that have been fermented with good bacteria strains such as Lactobacillus rhamnosus GG, Saccharomyces boulardii[11] , Bifidobacterium lactis, or Lactobacillus casei have become very popular in the market. Probiotics[12] , taken in whichever form, have been found to be effective against digestive disorders such as diarrhoea and constipation because they add good bacteria to the digestive tract and help balance out an imbalanced gut microbiota and regulate the digestive system. In doing so, they also help in building immunity, promote better emotional and behavioural health[13] and reduce risk of infections.

This is also the reason why a lot of formula milk and growing-up milk add probiotics and prebiotics (food to grow good bacteria in the gut) to their formulation. It is to ensure that their formulas promote a balance of bacteria in the baby or child’s intestines and offset the growth of “unfriendly” organisms that could cause infections and inflammation. Ultimately, it is to provide the growing child balanced sustenance and nutrition and opportunities that promotes optimum growth and development.

Symptoms of Diarrhoea

Getting diarrhoea is a painful experience for anyone let alone a child. He will complain of painful stomach cramps and spasms and the urgent need to run to the toilet several times a day. He may be bloated and gassy, have fever, nausea and/or vomiting, watery runny stools, sometimes bloody stools, fever, headache, fatigue, loss of appetite and loss of body fluids (dehydration).

There are basically two types[14] of diarrhoea:

1: Short Term (acute) which lasts a few days: This may be caused by food or water that has been contaminated by bacteria such as in the case of food poisoning. Or it may be caused by a virus like the rotavirus.

Rotavirus is the number one cause of severe diarrhoea in babies and young children worldwide, irrespective of socio-economic class. It is a very common and contagious disease affecting 95% of children by the age of five years. In Malaysia, it has been found that 72% of rotavirus-associated diarrhoea[15] occurs in children under two years of age. Rotavirus is most often spread through the fecal-oral route, such as when a child does not wash his hands properly or often enough or being in close contact with a person who as diarrhoea. Playschools or childcare centres are a hotbed for rotavirus infection as the virus can live on surfaces such as doorknobs, toys, colour pencils or other hard objects for a long time.

2: Long Term (chronic) which lasts for weeks: It may be caused by health problems like IBS, intestinal diseases, Paediatric Ulcerative Colitis[16] , Paediatric Crohn’s disease[17] , Paediatric Celiac disease[18] and Gardia[19] (caused by parasites).

Why Should Diarrhoea in Children Be Taken Seriously?

In severe cases, diarrhoea could result in dehydration and electrolyte disturbances. The human body requires the right balance of water and salts to survive. Too much of a loss of water and salts could lead to disastrous consequences. The World Health Organisation (WHO) says that diarrhoeal disease is the leading cause of child mortality and morbidity in the world[20] .

If a child has chronic diarrhoea, occurring over 14 days or more, and recurring over the long term, it could result in malnutrition, growth stunting and impaired cognitive development.

What Can Parents do when their Child has Diarrhoea?

1: Prevent Dehydration

The Number One concern when a child has diarrhoea is to prevent dehydration. With diarrhoea, and especially when there’s vomiting as well, the child could easily lose essential fluids, salts and electrolytes. Therefore, making sure he is sufficiently hydrated during this time would be the most important thing to do.

However, this does not mean loading him with too much water ─ that’s dangerous as well as it could lead to an imbalance of sodium in your child’s system and cause a serious condition called hyponatremia[21] . Also, do not hydrate with plain water alone. Your child will need to replenish the sodium, chloride, potassium and bicarbonate lost through liquid stools, vomit, sweat, urine and breathing.

2: Signs of Dehydration

For infants and very young children, even moderate diarrhoea can result in significant fluid loss and dehydration could follow in less than 24 hours if no treatment is given. Monitor the situation closely as severe dehydration can cause further infection, seizures, kidney problems and even death if treatment is not administered fast enough.

The clinical signs of dehydration include[22] :

• Dizziness and lightheadedness
• Lethargy, drowsiness
• Sunken eyes
• Dry mouth, tongue and lips
• Dry diaper or dark yellow urine or very little or no urine
• Restlessness, irritability
• Crying with no tears

Bring the child to the doctor immediately if the following signs are present:

• High fever or fever that lasts longer than 24 to 48 hours
• Blood or mucus in stool
• Severe pain in the abdomen
• Abdomen that looks swollen
• Vomiting that lasts more than 12 to 24 hours
• Vomit that looks green or tinged with blood
• Will not eat or drink
• Fast shallow breathing
• Bleeding or rash on the skin

As a rule of thumb, the younger the child, the more critical the condition when he has diarrhoea.

3: Feed a Mild Diet

Children with mild diarrhoea do not need to hold off eating although it would certainly help his stomach to settle if he eats smaller meals consisting of mild, non-spicy, and not overly-seasoned soft food[23] such as soupy noodles, pasta or white rice or porridge cooked with chicken or fish and a light mix of vegetables. He should not be given any food that has previously disagreed with him or any processed, fast or greasy food until his diarrhoea is resolved.

4: Zinc, Probiotics and Prebiotics

WHO associates zinc deficiency[24] with the risk of children contracting digestive tract infections. Zinc[25] is an essential mineral needed to maintain the body’s defence system as well as repair cells[26] in the intestinal tract. It therefore plays an important role in helping the child recover from intestinal diseases such as diarrhoea and even cholera.

Taking probiotics in recommended doses has also been proven beneficial to children with diarrhoea. Studies have shown that it can reduce the duration of the illness[27] , increase treatment effectiveness and shorten the length of hospital stay if hospitalisation is required.

As mentioned earlier, prebiotics which are indigestible fibers, also have their role to play in helping out with diarrhoea. As the body cannot digest these plant fibers, they travel to the lower digestive tract to be a food source for the healthy bacteria (probiotics). Prebiotics (fibers) work hand in hand with probiotics (good gut bacteria) for the health of the digestive and immune system. Not all dietary fibers qualify as prebiotics but the three established ones include inulin, fructo-oligosaccharides (FOS), and galacto-oligosaccharides (GOS)[28].

Often, a mix of prebiotics such as GOS and other dietary fibers are added to formula milk because evidence proves that they alter gastrointestinal microbiota to resemble breastmilk – the Gold Standard. Children supplemented on these formulations have a lower stool pH, a better stool consistency and frequency and a higher concentration of Bifidobacteria in their intestines[29] compared to children on non-supplemented formula.

Apart from its Bifidogenic effect, research also says GOS[30] reduces pathogenic bacteria and reduces colon infections.

In the case of prebiotics being able to treat diarrhea, recent research shows that these dietary fibers can hold excess liquid present in the intestinal opening inside the bowels and can increase stool consistency thereby helping in the treatment of diarrhoea. Furthermore, it can also prevent and avoid recurrence of diarrhoea[31].

One more benefit of prebiotics includes obesity prevention[32], a very useful benefit for overweight children. Over eating is prevented because dietary fiber enhances satiety and reduces food intake during future meals.

5: How can Parents reduce the risk of Diarrhoea in their Children?

• Get Your Child Vaccinated with the Rotavirus Vaccine

Most diarrhoea in children is caused by viruses, notably the rotavirus. Vaccines against the rotavirus are available in Malaysia although it is currently not included[33] in the National Immunisation Programme[34] that the government provides for free. However, it is a highly recommended vaccine[35] that parents should consider giving to their children. It is available at all private paediatric clinics and hospitals where a fee will be charged.

• Enforce Hygiene

Teach your children to wash their hands with soap and water after going to the toilet and before they touch food.

• Limit their intake of Sugary Drinks

A lot of times, diarrhoea is caused by consuming too much sugar, especially in sweetened drinks and beverages.

Prevention is Better than Cure

Growing up formula milk such as Morinaga Chil-kid, formulated for children aged one to seven, is fortified with over 45 essential nutrients such as Omega 3&6 Long-chain polyunsaturated fatty acids including DHA, nucleotides, as well as 27 vitamins and minerals to help children meet their developmental needs including building a strong digestive tract and immune system as they move into a world of socialising and eating a wide range of adult food.

Within its list of nutrients, Morinaga Chil-kid also has the addition of GOS which is the short form for Galacto-oligosaccharides − a frequently-used formula milk prebiotic, and Zinc.

The milk is a Japanese formulation made from cow’s milk in the Netherlands and has all its nutrients formulated in a ratio that is specifically designed for Asian children’s needs and physique.

The entire product is produced and packed in a state-of-the-art plant in the Netherlands and goes through a quality assurance process with samples sent to Morinaga Japan for a second inspection before the product is released into the market. Hence the nutrition, hygiene and quality of the milk formula is assured before it comes to you and your child.