Help my 14yo brainstorm the cause of her diarrhea?

[SKL]

***PLEASE DON'T QUOTE.***

My 14yo daughter has been having diarrhea after certain meals for some months now, or maybe about a year.  She says it happens roughly 2x per week.  We are trying to pinpoint what may be causing it.  I promised to ask you guys for ideas.  (I already told her to keep a diary of what foods she's eaten whenever this happens.)

The problem often occurs just after eating a restaurant meal, but so far, we don't have a clear pattern as to which meals cause it.  There is always something with similar ingredients that doesn't bother her.

Most recently, she had this problem at Cracker Barrel after eating the chicken & dumplings + fries + apple pie a la mode, and at an Indian restaurant after eating naan, lamb curry, and mango juice.  She also says she often gets it from Chipotle, where she gets chicken, white rice, and sour cream in a burrito.

She is genetically likely to be intolerant to milk, but she drinks tons of yogurt smoothies without issues.  And there isn't a significant milk content in all of the things that cause problems for her.

This is my kid who doesn't like food generally.  She does have some foods she likes, such as some versions of hot wings.  She doesn't complain after eating these.  She abhors most veggies but will eat many fruits (in moderation).

One person theorizes that her pattern of not eating regularly spaced meals is the issue.  She tends to skip breakfast and just eats when she's hungry.  After 13 years of strategizing to get her to eat at all, I allow her to choose when, what, and how much to eat, because that's how she eats best.  Other adults take issue with this.  Differences of opinion over how she should eat have caused a great deal of disharmony in the house.  But, if someone has an unbiased source about how eating breakfast or eating every X hours will cure the diarrhea problem, I am willing to present that information.

*** PLEASE DON'T QUOTE---

Edited January 17, 2021 by SKL

[scholastica]

Possibly fructose intolerance. Fructose is added to a lot of things as a cheap sweetener. Juice is naturally high in fructose. A GI doc can test this. There’s a limited diet for the day before and then they have the patient drink fructose. They monitor the patient’s breath for hydrogen, I think, every 15 minutes for two hours or until it gets to the threshold of fructose intolerance. If the patient has fructose intolerance it will be unpleasant for the patient because the gi symptoms will kick in. 
 

At home, you can eliminate all sources of fructose from the diet for several days and then drink juice or something with high fructose corn syrup in it to see if it produces the effect. Fructose is hidden in lots of things, so you have to check labels pretty carefully. It’s also in the pre-prepared foods and sauces and dressings at restaurants. After diagnosis, keeping fructose out of the diet is key.

 Some people can still eat fruit with it. The key is to eat fruit that is fresh and whole, not canned. Keeping the fiber with the fructose can mitigate it. Eating low sugar and low simple carb helps, too.

[Mrs Tiggywinkle]

A lot of people with dairy intolerance can tolerate yogurt because of the live bacteria in it.

The ice cream in the apple pie ala mode and the sour cream from Chipolte’s would be enough. 
All of those meals contain gluten as well, and gluten intolerance often causes diarrhea.

[catz]

I agree it could be a sugar/corn syrup/fructose thing.  It could still be dairy.  Could be gluten

I would also like to throw out there, it could be irritable bowel and not necessarily connected to a single ingredient.  If she is food journaling, you might also have her journal what else is going on during her days (exercise, stress, social, etc).  

I might try a reset for 2-3 weeks with minimal safe ingredients preferably GF, DF, very low sugar, no processed foods.  I might add a allergy free  multivitamin if I weren't doing that and possibly probiotics.  I manage IBS very well with a balance of things and don't actually avoid any one thing (other than highly processed foods, I avoid corn syrup/try to be low sugar).  I do occasionally have to reset.  Like if I do a lot of sugar over the holidays, I step back to a simple diet, up my probiotics for a couple weeks.   

[Sherry in OH]

Restaurant meals are high in fat.  Fat can trigger diarrhea.  So can stress, so perhaps you could kindly suggest that non-helpful family members butt out.

[Jean in Newcastle]

Has the doctor ever checked her glucose levels?  Eating big meals - especially restaurant ones that tend to be higher in sugar and fat - can cause someone who has blood sugar issues to "purge" the food from their system.  In this case it is better to eat smaller more consistent meals to keep blood sugar levels steady. 

Other suggestions up thread are possibilities as well. 

[AmandaVT]

Restaurant meals started to bother me around that age too. I think it's the high fat content. I had to start making very light choices at restaurants or take a pre-emptive pepto bismol. For me, I think it's the high fat and that I tend to eat more in a restaurant than I'd serve myself at home. If I do order something rich, I'll eat a very small serving of it now and I can usually tolerate it. 

[Junie]

I used to have digestive issues after eating in restaurants -- but not when I ate the leftovers at home.  We narrowed it down to the soda (Sprite) I was drinking at the restaurant.  (I found out years later that I'm allergic to limes.)

[Annie G]

Our youngest daughter went through a spell of that every time we ate at a restaurant.  We never figured it out. For her, it happened right away- often before she was even finished with her meal. Oddly enough it didn’t happen if we brought takeout home.  We wondered if there was some anxiety involved, but like I said, never figured it out. Hope you can find an answer- that’s tough for a teen. 

[ktgrok]

Honestly, have her go to a GI doctor. Have her labwork checked for basic easy things, like celiac. It's worth doing the actual medical tests. 

[Spryte]

Lots of sympathy from this corner of the world.

I agree with a lot of the above.  What jumped out for me was gluten, dairy, possible corn ingredients, but if I understand correctly those aren’t an issue other times.  Since I deal with allergies, it was a first thought, but upon reading more - it doesn’t seem likely.

What does she drink at the restaurants?  I have a friend who gets sick from iced tea at most restaurants - something about the way it’s prepared or stored.  It took her forever to figure that one out.  Junie’s post above about Sprite  reminded me.

I think Jean could be onto something with the glucose issue, though I’ve not heard of that before.  Worth investigating.

If you regularly eat out, can you take two weeks and eat only food/drinks from home?  Even if you have to pack them?  It would be interesting to see if it still happens when she only consumes food and drinks from home, and might give you useful data.

I wouldn’t rule out IBS as a possibility, either.  Ugh.  Hope it’s not that!

[Random]

38 minutes ago, Junie said:

I used to have digestive issues after eating in restaurants -- but not when I ate the leftovers at home.  We narrowed it down to the soda (Sprite) I was drinking at the restaurant.  (I found out years later that I'm allergic to limes.)

This is such a great example of the detective work that goes into figuring these things out.  Once, after much time and consternation we stumbled upon the knowledge that it was ds's shampoo that was causing reactions.

There is a lot of great advice here already.  Because you mentioned she's always been a reluctant eater and the diary isn't giving you any leads, it's probably time for a GI visit.  I'm sorry she's suffering.  I hope you can figure it out quickly and that you all get some relief.

[stephanier.1765]

For a long time I wondered if it was the ice in the drinks causing my digestive problem. I remember once reading an article about certain ice machines growing mold and the mold causing digestive issues. It's been too long for me to remember the details but once I took ice out of the equation I no longer had any problems.

[Laurie]

My first thought was also the high fat content of restaurant foods.   

My daughter has IBS (the diarrhea kind), and oily/fatty foods bother her.   And she also has certain times of the month when she's even more sensitive to foods...since this seems to have started with your daughter within the last year it could maybe be related to hormonal/PMS stuff, too?   

I'm sorry.  I hope she can find out what's bothering her.  

 

[lewelma]

Before you do any elimination diet, make sure you do a celiac test or any other tests. Once you start feeling better by removing the offending foods, you have really very little interest in putting the food back in your diet for 10 weeks so that they can test you to prove it is the problem. As me how I know. 

Look into the FODMAP died if you are considering fructose intolerance. 

[PeterPan]

She could try taking a digestive enzyme (containing bromelain, papayin, something basic) to see it helps. She could try taking a lactose digestive to see it helps. I'm not saying either will, just saying they're kinda low key things she could do. My dh has that and it's the fat.

No, changing the frequency of her eating will not change the digestion/gut problem. And you said she's drinking lots of yogurt smoothies, so maybe she's eating more often than you realize? That would be a normal thing to eat for breakfast. 

Yeah it doesn't sound like telling her what she should eat is getting anywhere. I'll just throw out a crazy suggestion, but is there a sensory or myofunctional (mouth function) explanation for part of her eating issues? She's leaning toward things that are soft. My ds does this, and we just got him eval'ed. For him eating is so fatiguing he puts it off. Turns out he has a posterior tongue tie. I think in the absence of explanation for *why* she is making those choices, you have to assume that rolling *with* how she feels is working with the data she has. When you have better data, then she could make different choices. But it really doesn't work to call something behavioral (not being willing, being bad) if there's an actual problem.

If you wanted to have the conversation (which would really just be like throwing it out there, no clue) about the mouth function and her eating, that would be with an SLP who does myofunctional evals. 

I wouldn't let it go on too long. I don't know how they investigate IBS and celiac, but given that it has proceeded to where it has I would probably plow multiple paths at once, seeing the doctor AND talking about the mouth/sensory stuff and consulting with a nutritionist.

Edited January 17, 2021 by PeterPan

[almondbutterandjelly]

Have her try skipping the sour cream at Chipotle and seeing if that helps.  That's an easy thing to try that might give a clue.

[ktgrok]

Meant to add, I know it is frustrating to go to doctor appointments if they can't figure stuff out, but some things are easy tests. Celiac, looking for certain markers in the blood that indicate IBS, looking for certain things in the stool (she poops in a container and drops it at the lab) that will indicate digestive enzyme issues, crohns, etc. Black and white objective tests. 

[katilac]

 

1 hour ago, PeterPan said:

 No, changing the frequency of her eating will not change the digestion/gut problem.  

It absolutely can if she has an underlying condition such as IBS. 

[kristin0713]

This used to be a consistent problem for my son and taking Lactaid with any meal with dairy has helped him avoid the problem almost 100%.  Dairy is in SO many things.  Greasy/heavy food is also a very common culprit of stomach issues. 

[LJPPKGFGSC]

I have a similar issue.  Most of the time that we eat out, I have uncomfortable digestion, even while still in the restaurant.  But if we have take-out, even the same exact foods - no issues.  I believe that mine is caused by the dish detergent that is used at the restaurant.  My understanding (from a caterer who worked in commercial kitchens) is that there is an additive in the final rinse that is supposed to be left to dry on the dishes.  The rinse has some microbial properties, but it clearly does not agree with me.  Hope that helps!

[wintermom]

MSG from the food, maybe? Lots of restaurants use it to enhance our perception of flavour, but it's a common allergen.

[alisoncooks]

Does she find it's more common certain times of her cycle? I often have similar stomach issues triggered by fatty/heavier meals, but even more so midcycle and in the week before my period. 

Edited January 18, 2021 by alisoncooks

[Lady Marmalade]

I have a dairy/lactose intolerance very similar to your DD.  I have no problems with yogurt and small amounts of hard cheese.  Lots of dishes have hidden dairy that may or may not be revealed in a menu description.  For example, many curries are finished with heavy cream, but you'd not know it unless you are familiar with curry.  The fat content of the dairy can make it go through me much faster.  If I eat Cold Stone Creamery ice cream, I'll be looking for a bathroom before I'm even finished with my scoop of ice cream.  

Dairy elimination would be crazy easy to test out.  Have her try to be super strict about it for two weeks and see if it makes a difference.

 

[mathnerd]

All the meal examples that you listed have heavy cream or full fat dairy products in them. Some people can not metabolize heavy dairy fat or greasy foods and get diarrhea. The Cracker Barrel meal might have cream in the apple pie, the Indian meal might have heavy cream in the curry base (very commonly used) and full fat yoghurt in the mango lassi if that is what you meant by juice, Chipotle meal has sour cream. Try to order something different from these places, preferably without the dairy fats in it and see if she responds better. That is a really easy test to do before modifying anything else.

[Moonhawk]

I know that if I go a longer space of time without eating, or without eating much, the next time I eat I will get diarrhea. If I go 1.5 days without eating (or only a few celery sticks, etc), the next meal will get a bad reaction; and the heavier/bigger the next meal is, the worse it is for me. I have to slowly ease back into eating, and even then I can have either constipation or diarrhea for the next day. 

That being said, I don't think a 12-16 hour fast would have that reaction, especially if it is common for her. Unless it's a fast + heavy restaurant meal/particular ingredient that is working in combo with one another. 

Good luck!

[Farrar]

Another thought - I wonder if the meal she thinks is the cause is the cause. Some people have a longer or shorter time from one hole to the next. Sometimes it's the food that you ate two meals ago.

[mlktwins]

I also believe it could be IBS.  Does she go regularly (no diarrhea)?  Is she constipated at other times?

[SKL]

***Please don't quote ***

So the whole history of this girl's eating and pooping has been complicated.  For most of her childhood, she was more likely to be constipated.  It would take her a half hour every time she went to the bathroom.  It still does sometimes.

When I took custody of her at age 1, she wouldn't eat at all, other than to drink one ounce of milk at a time.  Gradually, strategically, I was able to get her to eat a balanced diet of mostly organic foods, but over time, the variety of foods she'd eat decreased.

Around age 5, she started to be a sugar-holic.  I think this started because she was rewarded with candy all the time at school.  I felt it was affecting her behavior, so I tried to place controls on it, but she started hoarding and stealing.  At some point I decided it was better to let her have the sugar.

Both of my kids stopped drinking milk some time in elementary school, but they continued drinking yogurt.  She likes ice cream and eats it often.  Both kids like sour cream and eat it often.

Behavior problems got worse as puberty approached, and she also started talking about suicide, so I had blood work done to test for sugar issues among other things.  The blood work came back normal, other than vitamin D deficiency.

She has MTHFR mutation on both sides (as does her sister).  I buy whole food vitamins that include folate instead of folic acid, but I know there is still folic acid in various foods she eats.  She also takes vegan dha & omega 3 gummies and D gummies.

She has also been diagnosed with OCD and misophonia.  And yes, she has always had sensory issues.  How this affects her eating experience (and bathroom stuff) - I could go on and on.  But I don't know that any of it relates to the diarrhea issue.  She takes 500mg of inositol daily (when I remember to give it to her) - sugar free and vegan.

I should also note that she's been menstruating for 2.5 years, but she reports that her cycles are still not regular.

She's in good general health, slim, muscular, and athletic.

*** Please don't quote ***

Edited January 18, 2021 by SKL

[prairiewindmomma]

My thoughts:

1. Add a quality probiotic, like florastor for a couple of months. Repeat each time she has antibiotics.

2. Back way down on the dairy and add lactaid and wait and see.

3. Consider allergy testing and an evaluation for IBS-D if this continues

Heads up, if you didn’t know, that there is a correlation between decreased gut flora and behavioral health issues in part because the gut starts the happy hormone process. It’s not a magical resolution, in our experience, but it’s a noticeable shift.
https://www.google.com/amp/s/www.hopkinsmedicine.org/health/wellness-and-prevention/the-brain-gut-connection%3famp=true

[Ellie]

11 hours ago, Mrs Tiggywinkle said:

A lot of people with dairy intolerance can tolerate yogurt because of the live bacteria in it.

Yogurt doubles up my dairy-intolerant daughter almost instantly.

If I had a child who had any kind of dairy issue, I would avoid dairy in any form, always.

[klmama]

1 hour ago, Farrar said:

Another thought - I wonder if the meal she thinks is the cause is the cause. Some people have a longer or shorter time from one hole to the next. Sometimes it's the food that you ate two meals ago.

I agree.  And the timing of the reaction may vary depending on the food.  One food may cause diarrhea in 30 minutes, another in 2 hours, and yet another in 24 hours.  That's where keeping a detailed diary of food and symptoms comes in handy.  Be patient and persevere with it.  Over time, you can start to recognize any patterns.

Looking at the foods you mentioned, I would suspect high fructose corn syrup in the apple pie, ice cream, and mango juice.  Does she get soda at Chipotle?  It likely has high fructose corn syrup, as well.  

FWIW, not eating regularly can cause digestive problems for some people.  Not all, but some.  That happens here shortly after eating if I skip earlier meals that day.  It's not what I just ate, but rather the fact that I didn't eat earlier that causes the problem.  Again, a food diary can help you sort this out.  

[Farrar]

The history of constipation can cause long term issues. It sounds like this is too complex an issue and way too complex a medical history for us to really say here. She really needs a gastrointestinal specialist.

[BeachGal]

She could also have chronically low levels of intestinal alkaline phosphatase (IAP) which can occur after even short-term, low-grade salmonella infections. The salmonella increase neurominidase activity in the small intestine which quickly “ages” the IAP causing rapid turnover. This doesn't correct itself on its own and the result is chronic inflammation that can lead to IBD.

You could try giving her a good quality curcumin supplement like Thorne Meriva and also a small amount of food-grade diatamaceous earth (must be food-grade).

If you eventually do go to a gastro, you might want to bring this research in and ask their opinion. Results came out in 2017, I think, so pretty new-ish.

https://www.eurekalert.org/pub_releases/2017-12/spmd-grr121817.php

Small bacterial infections that may go unnoticed and which the body easily clears without treatment, such as occurs during mild food poisoning, nevertheless can start a chain of events that leads to chronic inflammation and potentially life-threatening colitis. These new findings may also help identify the long-mysterious origins of inflammatory bowel disease (IBD).

...

"We have discovered an environmental and pathogenic origin of chronic intestinal inflammation in the course of modeling human food poisoning as it occurs repeatedly over the adult lifespan," explains Marth. "Remarkably, Salmonella have figured out a way to disrupt a previously unknown protective mechanism in the gut that normally prevents intestinal inflammation." 

The disease mechanism was linked to an acquired deficiency of intestinal alkaline phosphatase (IAP), an enzyme produced in the duodenum of the small intestine. Salmonella infection elevated neuraminidase activity in the small intestine, which in turn accelerated the molecular aging and turnover of IAP, resulting in IAP deficiency in the colon. IAP is important because its job is to remove phosphates from molecules such as the pro-inflammatory lipopolysaccharide (LPS) -- which is produced by various resident bacteria in the colon -- thereby transforming LPS from a toxic to nontoxic state. 

"These findings are of potential great concern to the human population," adds Marth. "Food contamination at these low bacterial levels is likely to be more common than we recognize, while symptoms could be nonexistent or mild and disappear in a day or two without treatment. Repeated over time, we find that such minor infections are sufficient to trigger disease months and perhaps years later, depending upon the number and timing of infections an individual has experienced over his or her lifetime."

The good news is that ways to boost IAP levels and inhibit neuraminidase activity exist. IAP augmentation can be as simple as adding the enzyme to drinking water. Neuraminidase inhibition can be achieved using a currently marketed antiviral neuraminidase inhibitor, a drug that is used to prevent influenza viral infections. 

Mahan says, "We found that both treatment approaches were similarly effective at preventing the onset of colitis. In fact, published studies by others have recently reported IAP deficiencies and high neuraminidase levels in IBD patients." 

Adds Marth, "There is an unexpected additive effect of previous infections in the likelihood of developing colitis. This environmental factor may be responsible for triggering disease among some segments of the human population."

[ktgrok]

FYI, constipation, food refusals, depression/anxiety/ocd are all possible symptoms of Celiac. And low vitamin levels are as well. 

She really needs to see a GI doc with that history. 

[popmom]

I haven’t read all the replies... My husband is sensitive to caffeine. Whenever we eat out at a restaurant (when we were young), he would get multiple refills of tea or cola. Every time it tore him up. 

My mother has trouble with carbonated beverages. Just a thought. 

[Amy in NH]

I have an intolerance to basil which causes almost immediate GI upset like you describe.  I figured out what was causing the problem through trial and error, and discovered that I cannot tolerate foods with either fresh or dried basil. 

[J-rap]

It sounds like you've worked so hard to help your sweet daughter!  It's possible that by now she just has a very sensitive stomach and little things can throw it off.  My mother was always like that.  I can get thrown off too, but as long as I follow my general "rules" I feel fine.  I could never tolerate breakfast either.  Forcing myself to eat a big breakfast first thing in the morning generally makes me gag!  I've always been that way.  I also used to get sick from just having to stand up and walk right after eating.  I remember all the high school football games I used to go to, where I'd grab a hot dog at the concessions and then walk around with my friends, and I ended up sick every time.  (Whereas if I sat down right after eating, I'd be fine.)  Or if I'm hungry and then wait too long before I finally eat, I also get sick.  Often eating at restaurants makes me feel sick or bloated.  (Whereas I could cook the same food at home and feel fine.)  I drink lots of coffee, but cheap hotel coffee or cheap restaurant coffee makes me feel sick.  If I overeat I feel sick.

Wow, that sounds like I feel sick a lot, but I rarely do because I know what I need to do.  I skip breakfast except for coffee (generally made at home, but I can tolerate quality coffee from good coffeeshops just fine) and maybe a protein bar, have an early lunch that's simple (a homemade sandwich, smoothie, soup, yogurt and fruit, etc.), snacks throughout the afternoon (nuts, yogurt, cheese and crackers, bananas, a homemade cookie, etc.), and a good homemade dinner.  I know when I'm full, and then I stop.  I've learned that I feel better not having too many extra carbs, but I don't eliminate them.   I rarely eat junky desserts anymore, and I think that helps a lot too.  (Although peanut m&m's seem to be fine, as well as small amounts of ice cream and such.  :))

Anyway, just throwing that out there!  

Celiac is a possibility, although I thought the blood tests weren't so black and white.  At least my dd needed to have a biopsy to determine for sure whether she had it or not.  (Her blood test said she did, but her biopsy said she didn't.)

I hope you can figure it out!

 

[Katy]

Onions are one ingredient in all of those meals that cause diarrhea in my family. 

[PeterPan]

Trauma therapy. The trauma stores in the PSOAS, which runs in that whole region. I had issues with sluggish bowels for years in spite of the nutritionist, so she'd just blame me saying I wasn't compliant enough. Did the trauma therapy, and boom now I have magic amazing bowels. Seriously.

So that's thing one. Thing two, she should probably be eval'd for spectrum. It would be a global explanation for all those dots. Just saying.

[SKL]

5 hours ago, PeterPan said:

Trauma therapy. The trauma stores in the PSOAS, which runs in that whole region. I had issues with sluggish bowels for years in spite of the nutritionist, so she'd just blame me saying I wasn't compliant enough. Did the trauma therapy, and boom now I have magic amazing bowels. Seriously.

So that's thing one. Thing two, she should probably be eval'd for spectrum. It would be a global explanation for all those dots. Just saying.

Re spectrum, I did ask the psychiatrist who diagnosed her with OCD.  She doesn't think it's ASD because of something my kid does or doesn't do (I can't remember what right now).

[PeterPan]

3 hours ago, SKL said:

Re spectrum, I did ask the psychiatrist who diagnosed her with OCD.  She doesn't think it's ASD because of something my kid does or doesn't do (I can't remember what right now).

Odds are the pdoc is wrong. Just saying. This happens all. the. time. You're too social, blah blah. Hogwash. Read some articles about girl spectrum. And it doesn't have to be, but I'm just saying odds are it is. 

https://www.socialthinking.com/Articles?name=social-thinking-social-communication-profile  

Have you ever tried inulin on her? Comes as gummies if she will eat them, and it's kind of magical. It's a *prebiotic* so it can quietly reverse some funky issues. It's fiber, so it might tighten up, move some things through. She needs to drink water with it, but it sounds like she already is. If she's on medications, don't take it close to the medications since it's fiber and would affect their absorption. 

Have you ever read about Interoception? https://www.kelly-mahler.com/what-is-interoception/  Mindfulness, improving self awareness is big both in the mental health community and for autism. I'm not saying it directly solves any of your problems, but it might eventually help her get her own answers or help her give enough data to others that they can figure it out. Some of the issues with her eating, sensory, and self regulation are tying back to her interoception. 

https://www.kelly-mahler.com/resources/blog/5-keys-to-supporting-behavior-regulation/  Kelly is doing a free webinar TODAY. If you have time, it might be worth your time. It's saying live 1-3 pm EST but available recorded for 2 weeks. This would be a don't miss.

http://www.kimclairy.com/about/  An OT who speaks both about her autism and her eating disorders. You might find a youtube of her speaking or something. 

Don't get stuck on the label. You've got a mix of issues that is pretty common in the autism community, so maybe just knock on those doors too.