How do we approach the young infant presenting with loose stools?
As in any case, a thorough and detailed history is important, related to stool pattern, any pointers to the baby being unwell, exposure to infection and feed pattern as well as the weight gain pattern. If the family is bottle feeding (using expressed milk or formula milk) for any reason, it is important to confirm if the sterilization (of the breast pump as well as the feeding bottle), is being done properly. If expressed milk is used, we need to verify if the milk is stored as per guidelines. Do remind the family that thawed milk should not be frozen again, and once thawed, the milk has to be consumed within 24 hours if kept refrigerated.
If there is any family member who is unwell (viral infections, diarrhoeal episodes, food poisoning, dysentery, etc.,), we should educate them on proper handwashing and food hygiene practices to avoid spreading to the baby. In these cases, there is a possibility of the baby being infected and the decision-making will depend on how well the baby is, and the nature of the loose stools. In these cases, there may be some justification for screening the baby for infections, and testing the stool (for pathogens associated with dysentery). However, antibiotics are only needed if there are systemic signs of sepsis.
Urinary tract infections can present with loose watery stools, irritability as well as failure to thrive, with or without fever. So, if you are concerned about the well-being of the baby, consider a midstream sample (or catheter sample) for urine routine and culture-please avoid a bag urine sample for urine culture as that will likely be contaminated and will confuse the decision-making process.
If the baby is thriving, is clinically well and the loose frequent stools are associated with frothy stools in a colicky baby (suggesting lactose intolerance), there is no need to perform stool culture or stool-reducing sugar. Assume this is related to the physiologic (exaggerated) lactose intolerance as detailed above.
In these cases, it is important to reassure the parents that stool frequency of even 10-12 times a day is common in breastfed babies, and both a green color and a little mucus in the stool are acceptable provided the baby is well. Teach the family to monitor the baby for concerns like reduced activity, poor feeding, and lethargy so they can come for an immediate review of concerns. Teach them the proper care of the nappy area so we can avoid nappy rash (will share the blog related to the same). It is important to educate the parents from the beginning to avoid overfeeding. It is important to get the cues right and not to push the baby to complete the feed volume.
Overfeeding can happen even with breastfeeding. In the first 7-10 days, we expect the baby to feed almost every 2 hours-this is because the milk production is increasing, the baby has a small stomach and the volume is gradually increasing. Unless we try to space, babies keep persisting with the pattern they are used to, and since the milk output has increased, they get excessive milk at a high frequency (and the features detailed above). The babies also have an active gastrocolic-reflex, and remind the parents that the more often they feed, the more often they pass stools. In case the baby is on partial or full formula feeds, we could consider a lower lactose-containing infant formula (like the comfort formulations), but there should be no disruption of breastfeeding. And we should never consider introducing formula milk in exclusive breastfeeding babies in any case (reduce the lactose load by the measures described above, there is no need to reduce it in the milk in breastfed babies as the benefits of exclusive breastfeeding are immense).
In most of these babies, the stool pattern will stabilize and improve over a week to two weeks, and the above changes (in feed frequency, volume and spacing) will likely improve the colic related symptoms and nappy rash. There is no role for lactase enzyme (drops) here as the babies are not lacking lactase enzyme but are relatively deficient (a simple reduction in the load should be adequate).
Please note that broad-spectrum antibiotics given orally have a huge negative impact on their gut microbiota, and this could impact their long-term health. It could also make the parents more worried and could disrupt exclusive breastfeeding. As I mentioned at the outset, the parents messaging me mention their baby is started on Taxim or even Ofloxacin in this situations-most of these are in the Indian scenario. Ofloxacin is not recommended in neonates or young infants unless you have a serious infection with a resistant organism (usually in intensive care settings). Growing ESBL (extended-spectrum beta-lactamase) E Coli in the stool culture (which was not indicated in the first place) is not an indication to use this potent antibiotic.
#diarrhea #pediatrician #antibiotic
5 май 2024
