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4 month child having greenish watery stool. Not cured by medicine. What is wrong?

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Practicing since : 1982
Answered : 698 Questions
Hello Doctor. My 4 month son (DoB: 7th May 2012) has been having watery stools that has a greenish tinge for the last week. He hasn't been feeding well either. On taking him to his pediatrician we were advised to administer Pre Pro Kid (half pack every morning and evening) and ColicAid EZ for three days. Today his dosage was completed but the problem still persists.

We did a stool analysis. Following are the details -

1. Color - Greenish
2. Appearance - Loose
3. Mucus - Present
4. PH - Acidic
5. Occult Blood - Negative
6. Ova & Cyst - Absent
7. Pus Cells - 10-15/hpf
8. RBC - NIL
9. Others - NIL
10. Bacteria - Present
11. Reducing Substance - NIL

We are now advised to administer 3.5ml of Normet morning and evening.

We are worried and want to know if there's anything wrong. Please advise. He is currently 6.5 kg and is active. Just gets cranky at times.

He is exclusively breast fed
Posted Sun, 7 Oct 2012 in Child Health
Answered by Dr. Taher Kagalwala 23 minutes later

Thank you for posing your question on this site. I am Dr. Taher, a Pediatrician. I have read your query in detail and would like to offer you some important advice.

He has been growing well. Congratulations! I am very happy to learn that he is exclusively breastfed.

His stool report is suggestive of a bacterial infection. I am not aware of what reasons prompted the doctor to use Colicaid EZ, but please stop it. Even Normet is not indicated as it has Metronidazole with Ofloxacin ... and the former is not needed for a bacterial dysentery.

Kindly give him Ofloxacin syrup 50 mg/5 ml, 3.5 ml Twice a day for 6 days. Commonly available brands include OF, OQ, Oflox.

Also, encourage normal feeding, and give small, but repeated sips of WHO approved ORS salts solution (such as Electral dissolved in water ... follow the instructions on the sachet).

Give him Z & D drops 5 drops twice a day for 14 days (that is, even beyond the six day course of ofloxacin).

Continue Pre-Pro Kid as it is a probiotic, and will help restore gut normalcy later on.

That's all. Don't worry, he will be fine soon.

With best wishes for his speedy recovery,

Dr. Taher
Above answer was peer-reviewed by
Follow-up: 4 month child having greenish watery stool. Not cured by medicine. What is wrong? 12 days later
Thanks for the Advice. We were late in checking this answer regrettably. :(

we had given him Norflox for 5 days (from 8th Sep 2012 to 12th Sep 2012) as prescribed by his paediatrician, on the 6th day he appeared to be getting back to normal. However on 14th sep 2012, the situation recurred with more intensity, on taking him to another paediatrician, we were informed that 5 day anti-biotic course wasn't enough.

His latest stool analysis report revealed "Plenty of Pus Cells" and subsequently did a tool culture done which had "No Pathogens found. Normal Flora suppressed".

We have been asked to give Ofloxin Syrup (4ml-0-4ml) along with enterogermina (1-0-0) till yesterday (20th Sep 2012) by the second paediatrician.

His situation has not improved. In fact it has worsened by the looks of it. He is now passing motions (greenish froth at times, greenish with idli batter consistency and stickiness other times) almost twice after every feed (he is still being breastfed). On consulting again with the second doctor, we were advised to administer enterogermina twice a day, along with half a XXXXXXX of zedott (morning and evening) and zinconia (3ml) in the afternoons apart from the Oflox (4ml twice a day).

We were asked to feed him only "Zerolac" for two days and repeat the stool analysis. However the doctor did say that we could give him breastmilk in case he's refusing the formula.

My son refuses to have Zerolac and insists on being breastfed (which we are ending up doing in order to ensure that he's having something!). We are still trying to spoon in some Zerolac but most of it is spat out.

He has not lost weight (he's currently 6.66kg), and is active, but cranky most of the time. He has his last feed around 7.45pm and then sleeps soon after. He doesn't pass any motion during his sleep. He gets up 3-4 times (11pm, 1am, 3am and 5am) in the night for more feeding. After the 5am feed, he passes his first motion for the day around 5.30am, thereafter followed with more with every feed (as described earlier).
Answered by Dr. Taher Kagalwala 1 hour later

Thanks for the revert. I would like you to repeat his stool test; the reason for recommending zerolac is not clear, so, you should tell the lab to run tests for the presence or otherwise of "lactose intolerance": this includes testing the stool for presence of lactose by a simple "Benedict's test" for "reducing substances" while he is on breast milk, and also checking the pH of the stool (this is acidic and below 6 if there is lactose intolerance). for the pH study, though, you need to go to a big lab which can test the EXACT pH. Most of the smaller set-ups have a basic litmus test that tells you if the stool is "acidic" or "basic", but not the exact pH. This is of no use. If, however, we find that the Benedict's test is positive (more than 2+) and the pH is 5.5 or less, then it is confirmed that there is a problem with digestion of lactose, the main carbohydrate in human (and animal) milk. In such a case (in fact, this is very rare), one HAS TO STOP breast milk and start Zerolac or a similar product.

Coming now to the other issue of pus cells: the fresh stool test must confirm if the "plenty" of pus cells are still present or not. Even if they are, there can be causes other than infection with bacteria: it can be due to amoebic infection (which we earlier said is not likely), fungal infection (this can occur secondarily in some children because the use of antibiotics sometimes makes the baby vulnerable to a "super-infection" with fungi. For this, a trial of an anti-fungal drug is the easiest way to reach a diagnosis.

Before you start worrying about all the above, may I first suggest that:

You stop all the antibiotics
Continue Enterogermina only
No Zedott
No Zinconia
Continue ORS
Continue breastfeeding

After 2 days, if there is no change, go for the above stool tests.

Let me know what is the progress.

Thank you once again.

- Dr. Taher
Above answer was peer-reviewed by
Follow-up: 4 month child having greenish watery stool. Not cured by medicine. What is wrong? 30 hours later
Dear Doctor,

We repeated the stool analysis today (going by your recommendation, as well as his local paediatrician's). We insisted on the exact pH value as suggested. The following are the results -

1. Color - Greenish
2. Appearance - Loose
3. Mucus - present
4. pH - Acidic (6.5)
5. Occult Blood - Negative
6. Ova & Cyst - Absent
7. Pus Cells - 6-8 /hpf
8. RBCs - 2-4 /hpf
9. Bacteria - Present
10. Reducing Substance - Absent

The doctor on seeing this report is now suggesting that we give Metrogyl Suspension (2.5ml morning & evening) for 5 days and stop all other medications earlier prescribed. He says that he suspects a rare parasite (like ameobia etc), which should possibly be treated by this new medication.
Also, he is insists that we stop breastfeeding for two days to allow the intestinal villi to be repaired so that the baby can digest breastmilk better after 2 days.
We would be meeting him again on Monday morning.

Please advise.

Note: We thank you for your contd. support and guidance, and hope you would be able to help shed light into this issue and resolve it at the earliest.
Answered by Dr. Taher Kagalwala 20 minutes later

Actually, the pH of 6.5 on breast milk *and* the absence of reducing substances almost surely rules out lactose intolerance. I am reluctant to agree with the doctor on stopping breast milk; however, if your wife can manage to remove her breast milk periodically by hand so that she does not get breast congestion and fall ill (an unnecessary complication, I think), it might be worth a try to stop feeding him and giving him Zerolac in its stead ... unless he simply keeps screaming for the breast ... in which case, you can give him breast feeding at least at night.

If he just does not take Zerolac and keeps spitting it out, you can try giving him Nestum Rice dissolved in boiled water to a medium thin consistency with a spoon. Babies as young as yours can digest Nestum Rice. It is free from milk, so that you can continue your milk-free trial *and* nourish your baby successfully with this regime.

Metronidazole seems an okay input, but I am not so sure why a completely breastfed baby should have amoebiasis. However, in view of the fact that there is a consensus to stop antibiotics from both, his pediatrician and myself, it might be a sound idea. I am somehow inclined to believe that the infection may be on its way out. We just need to be a little patient.

What was his weight when you visited the pediatrician? Was it 6.6 kg or more, or is there a weight loss? This has a bearing on the diagnosis and the outcome.

I am afraid that with this answer, your free follow-ups may have expired. If you need to continue to be in touch with me, you could either send me a fresh query directly to me, or get in touch with me by phone in Saudi Arabia ... the number is on my profile.

Thank you for your appreciation.

With best wishes,

Dr. Taher
Above answer was peer-reviewed by
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