Last fall, two studies showed that probiotics may not work as well in kids who have “tummy bugs” as we had previously thought.

I am defining acute gastroenteritis here – that’s the term we docs use to describe a tummy bug – as that all-too-common few days of vomiting and loose stools/diarrhea your kids pick up at school.

In the studies (which were actually pretty good ones), two large groups of children (one study had 971, another had 886) were randomly selected to take five days of mostly Lactobacillus rhamnosus or Lactobacillus helveticus, two common probiotics we recommend for kiddos this age, if they walked into certain U.S. or Canadian ERs with symptoms of gastroenteritis. Another group was assigned a fake/placebo.

The studies seemed pretty fair. Their poops were tested and found to have similar germs (viruses vs bacteria vs no cause found). Similar numbers in each group had gotten antibiotics or vomiting medicines. Neither study was run by a corporation – they were publicly funded.

After 14 days, participants were given a survey to see how their symptoms were doing. I’ll spare you the details – the probiotic group didn’t feel any better than the placebo group in both studies.

What does this mean? Well. Probiotics may not be beneficial to our kids when it comes to tummy bugs. But, let’s remember our critical thinking skills when we read medical studies –

• They only tested two types of probiotics.
• They only tested a five-day course of it.
• These studies were done on one age group only: 3 months to 4 years.

Probiotics have, in other studies, been proven to be beneficial in helping other ailments! Like colic, irritable bowel syndrome, chronic constipation, and even preventing necrotizing enterocolitis in premature babies. So let’s not give up on them yet.

But I do think this is enough evidence to prove that probiotics likely wont help your kids tummy bug. If you have questions, talk to your pediatrician about other ways probiotics can help.

Commonly recommended ways to prevent constipation are to drink water, exercise, and eat fruits, vegetables and fiber-rich foods. Yet even when we use these techniques, our children still sometimes get constipated. Whether its contributing to stomach ache, delayed toilet training, bedwetting, or missed school, constipation is no laughing matter.

“But my child poops every day! My child can’t be constipated!”

Even if your child stools every day, he or she may be constipated. Think about your office desk; you may clear papers off regularly, but if you are not clearing as many papers as are building up, you will soon have a messy desk. Children may poop every day and still not be fully emptying their intestines. When constipation develops, the extra stool causes the intestines to stretch. Once this happens, the intestines may not be able to move as well, which leads to more constipation, and it becomes a vicious cycle. In infants constipation can be particularly hard to recognize because in this age group it is can be normal to have less than one stool per day.  Parents should look for a change in the frequency of stools along with firm stools when considering constipation. 

“What now?”

The good news is that constipation can often be treated with dietary changes. The key to making the treatment stick is continuing it long enough. If you stop too soon, the intestines have not had time to heal, and the constipation returns. As a physician who often sees this condition, I recommend treating constipation for as long as it has been a problem. For example, if constipation has been an ongoing problem for one month, treatment typically lasts at least one month. Treatment also depends on your child’s age.

• For infants over the age of two months, ask your pediatrician about giving small amounts of prune juice or pear juice.
• For a toddler, in addition to pear, apple, or prune juice, consider adding high fiber foods such as pears, peaches, and whole-grain cereals to his or her diet.
• School age children or teenagers can learn about which foods will help improve their symptoms and can then get involved in choosing foods that are fiber-rich and appealing to them.
• In cases that do not respond to dietary changes or are more severe, your pediatrician may recommend a medication to help treat the problem.

Contact your child’s doctor if you have any questions or concerns about your child and constipation.

Several treatment options are available but does one of the most common options for treating constipation pose a serious risk for your child?

You may have read one of the recent media articles highlighting a concern among some families that MiraLax may lead to neurologic or psychiatric side effects such as tremors, tics or obsessive-compulsive behaviors. Previous reports have shown that some samples of MiraLax had trace amounts of ethylene glycol and diethylene glycol (which are ingredients in anti-freeze and have been linked to neuro-psychiatric problems). The FDA has fielded these concerns over time and commissioned a large study which is currently ongoing looking at the safety of MiraLax in pediatric patients.

With those concerns, I thought now would be a good time to give you some of my thoughts on MiraLax.

Treatment for Constipation

Children who are constipated often only pass stool once or twice a week, have hard stools or have stools that are large and cause pain. If constipation is very severe, it can lead to stool leakage into the child’s underwear as loose stool passes by the hard, formed stool in the intestine.

Treatment for constipation is generally based on the idea of softening stool up so that it can easily pass through the intestines. I always recommend that parents start with a change in diet and fluid intake. Children who are constipated should drink extra fluids (32-64 ounces). This is the one instance where I will recommend introducing some juice (usually prune or pear). In addition, children should eat foods that are high in fiber (think fruits and vegetables).

However, these changes are sometimes not enough. So, what do you do next? After talking with your doctor, it’s likely they will recommend a medication. Which medication? Most commonly, Miralax. But, is MiraLax safe? Should you be giving it to your child?

How Miralax works

MiraLax works by attracting water into the intestines which helps to soften the harder stool which is leading to constipation. It is a synthetic material which is manufactured in a lab (the ethylene glycol and diethylene glycol are byproducts of manufacturing). I like to think of it as synthetic fiber. One of the things that is nice about MiraLax is that it’s tasteless so it can be added to a child’s drink. You can also increase or decrease the dosage based on the child’s needs.

The FDA has not approved the use of MiraLax in children, nor has it approved its use for long periods of time. However, many children can and do take MiraLax on a daily basis.

The Studies

There have been at least five open label studies focused on kids (where the participants knew what they were giving their children) which showed MiraLax to be safe and effective. These studies had about 300 patients combined. Other studies blindly comparing MiraLax with other laxatives such as lactulose and Milk of Magnesia have shown it to be either more effective or as effective and with less side effects. Children in those studies included patients taking MiraLax between 2 weeks and 12 months (most in the 2-6 month range).

The most common reported side effects in studies were: diarrhea, bloating and abdominal pain. All laboratory testing including electrolytes, liver and renal function remained normal. Of note, I could not find a single patient that was reported to have dropped out of a study based on neuro-psychiatric symptoms.

One of the most renowned pieces of evidence in medicine is a Cochrane review. The team at Cochrane reviews all the available studies and makes a recommendation about the safety and effectiveness about treatment recommendations. The Cochrane review of 18 trials (including 1643 patients) showed good effectiveness, safety. There was one child who had an allergy to polyethylene glycol but there were no other serious side effects documented.

About the author

Justin Smith is a pediatrician and the Medical Advisor for Digital Health for Cook Children's in Fort Worth, Texas. He has an active community on both Facebook and Twitter as @TheDocSmitty and writes weekly for Cook Children's checkupnewsroom.com. His interest in communications started when he realized that his parents were relying more on the internet for medical information. He believes that strategic use of social media and technology by pediatricians to connect with families can deepen their relationship and provide a new level of convenience for both of their busy lifestyles. Dr. Smith’s innovative pediatric clinic, a pediatric clinic “designed by you,” is set to open in Trophy Club in 2017.

Watch the video below for five key facts about diarrhea that every parent needs to know in only a minute. 

In today's video, Doc Smitty explains:

1. What are the common causes?
2. How long can it last?
3. When are the symptoms more than a stomach bug?
4. When do you call your pediatrician?
5. What are the biggest risks?

Learn the answers to these questions. It only takes a minute.

How do you know when it is something else or when it could be more dangerous?

A report last week from the CDC described a cluster of infections caused by shigella, a bacteria that can cause severe diarrhea.

Shigella is common, causing an estimated 500,000 cases of diarrhea in the United States annually. But this group of infections is unique because it has been found to be resistant to the most common type of antibiotic used in adults used for shigella. Most cases have been located on the East and West coast and many have been associated with travel outside the United States.

Fortunately, there were no cases of this more severe form of shigella reported in Texas so I feel that we are pretty low risk at this point. I did want to take a second to tell you about warning signs that might alert you that diarrhea might be more than a stomach bug.

Here are some symptoms that might alert you that should trigger a call to your doctor:

1. Severe vomiting with decreased urine frequency or other signs of dehydration.
2. Fever more than 102.
3. Blood or mucous in the stool.
4. Severe belly pain.
5. Diarrhea that last more than one week.
6. Let your doctor know if your child has traveled recently.

What are Salmonella and Shigella?

Two of the most common bacterial causes of infection are salmonella and shigella. They are both fairly frequent causes of severe diarrhea in children.

They can both be transmitted by contaminated food or water but can also be spread from person to person. Salmonella is more frequently caused by transmission from contaminated food, but also can be contracted from infected reptiles. Shigella is more frequently acquired from other children and is much more contagious than salmonella.

(Just to give you an idea, stool of a child infected with shigella contains 100,000,000 bacteria per gram of stool. Ingesting just 200 bacterial cells is enough to cause infection. Because of this, outbreaks of Shigella are common in child-care settings.)

The most common symptoms with both infections are diarrhea, abdominal pain and fever. With shigella, fever is often higher and children are more likely to have blood or mucous in their stools.

For either infection, your doctor can run stool studies to confirm the diagnosis. This may not be necessary if there are known cases that the child has been exposed to.

Both infections will typically go away on their own in seven days or less. Most healthy children do not require antibiotics. I do not routinely recommend anti-diarrheal medications in children because they can prolong symptoms with some infections.

If you suspect your child has one of these infections, consult with your doctor and keep them out of day care until we are sure they will not put other children are risk.

Fever, headaches, joint and muscle aches, weakness, fatigue, diarrhea, vomiting, stomach pain and lack of appetite.

Over the next few months, many children will have these symptoms and many parents will, and should, call their Cook Children’s pediatrician because of how their child’s feeling.

Unfortunately, many parents will assume the worst … Ebola. But the chances of that being a reality are extremely low. While knowing it’s not likely to be Ebola may be a relief, it’s important to remember that Ebola is not the only dangerous virus on the horizon for our children. The symptoms listed above are much more likely to be the flu.

Investigation of 25 outbreaks of Ebola over 38 years has shown that only direct contact with a person with Ebola would cause someone to become infected. Right now, there’s no approved vaccine to limit the epidemic in West Africa.

On the other hand, influenza can be deadly. The 2013-2014 flu season led to 108 pediatric deaths in this country. The flu is spread readily through the air by small droplets which can be infectious to someone near a person who is coughing and sneezing and is much more easily acquired and easily prevented through vaccination.

Please make sure to get your children the flu vaccine and parents should get them too! ASAP. Both injection and nasal mist vaccines are effective.