Friday, February 28, 2014

Poop Diaries. Giardias Lambia in adopted children.

Warning: The following DOES show graphic poop photos and details. Finish your lunch first. This is a must read for all of you with children from overseas.

Disclosure - I am not a Doctor. I am research driven adoptive parent with more experience on this matter than I care to have.

This parasite infection has been quite a journey for us. Over a year long in fact. While I don't really like the idea of publicizing my daughter's medical (or poop!) details, I believe it's an important message.

Fact is, I have seen many photos of your children's swollen bellies on blogs and Facebook, and I happen to know there are many of you who have not gotten your children tested because you see no symptoms. Well let me enlighten you and gross you the heck out.

Honestly, I believe it to be very rare for any adopted child from Africa (and other third world countries) to be free and clear of parasites/worms. Many orphanages 'deworm' every 6 months, but let me tell you, this only kills some infections, and many others are simply building up resistance to these commonly used meds. A general dewormer (typically Albendazole) is not very effective against Giardia and other protozoans. In fact, Albendazole is known to be as little as 35% effective. I do not understand why it is so commonly believed and trusted to kill everything. Some parasites can, will, and do kill children, and yet they are completely unsuspected because the children are dewormed every six months.

I know, I know... your child is fine, no diarrhea, no stomach cramps. Heck, being the diligent parent you are, you even had him tested! (Big pat on the back for being proactive, seriously, but it's not over. Read on...)

Giardiasis does not always present itself with symptoms, and HAVING A NEGATIVE FECAL TEST DOES NOT MEAN YOUR CHILD DOES NOT HAVE PARASITES. You must test clear for a minimum of 3 tests!

Now for the mumbo jumbo technicalities...

Giardia Lambia is also known as Beaver Fever here in North America and is the most common parasite infection among adopted children. Because of this, I believe it is quickly becoming resilient to mainstream medicines.

Giardia, as with many parasites, coat the lining of the small intestines, blocking nutrient absorption, possibly causing lactose intolerance and irritable bowel syndrome. This is a worse case situation for a child living in an orphanage setting. Often, these children lack great nutrition as is, so it is important that they can absorb as much nutrients as possible. Secondly, many babies are put on cows milk early due to the cost of formula. I cannot tell you how many illnesses and rashes we have seen due to lactose intolerance in Kenya.

What are the symptoms?

According to Wikipedia, symptoms include the following:  loss of appetite, diarrhea, hematuria (blood in urine), loose or watery stool, stomach cramps, upset stomach, projectile vomiting (uncommon), bloating, excessive gas, and burping (often sulfurous). 

However, many times children will not show any symptoms, or the symptoms may be so insignificant, it goes unnoticed.

When we first got Zahra, she was a big healthy girl.

She certainly didn't display any signs of malnutrition. However - the very first thing I did was take her to the lab for Fecal testing.


1. She was big and healthy, but also sported this bloated belly. Z will always be curvy, it's in her genetic make up, but I had suspicions that this belly was a little bigger than it should have been.

2. Her stools were pale in color, thin and 'greasy' or soft. Now I believe this to be a key symptom to watch for, even if you child displays no other symptoms. I also believe that this is likely the most over looked symptom of this infection.

First time parents do not always know what color the child's stool should be, texture or consistency. Especially if the child is still on milk bottles and/or wearing diapers!

The answer is simple, the child should have stools like a healthy adult. Once a day is normal for a 3 year old, well formed and medium brown in color.

If your child is still in diapers, but on solid food, the stools should be the same. Actually, stools should be formed well enough that they can roll off the diaper into the toilet. Diaper explosions may accurately describe an infant with Giardiasis. Again, the key is to make note of the color.

I cannot stress this point enough and don't think I can get the point across without a visual. I apologize in advance, but you need to see this to know what I am talking about.

This is what we have lovingly coined in my house 'Parasite Poo' vs normal poo.

The key differences are: Parasite poo is softer, 'greasier', and pale in colour. It usually is not as well formed as it is in this picture, but more thin. (Sorry, didn't have a selection of photos to choose from.) It also usually stinks more, but hey - poo is poo and it all stinks, so you can't really rely on that.

It is not diarrhea, It is not grey, and it could easily pass by a unsuspecting parent as 'normal'.

Zahra went from passing a bit of stool every time she went pee (at the height of her infection), to having this stool once - twice a day.

3. My child was born and raised in a developing nation that struggles with clean water and sanitation.

Giardia is passed in Feces (poop). Typically found in untreated water, and therefore contracted when ingested. HOWEVER, It does not matter that your child came from the best orphanage, with world class hygiene, and clean drinking water. The problem is that many of the children (and staff) who come into the home are not from places that have clean drinking water sanitation, or good hygiene practices. If they have Giardiasis, it is very easily passed on in orphanages.

Giardiasis is contracted by swallowing Giardia picked up from surfaces such as bathroom handles, change tables, toys, handshakes, swimming pools etc. I simply do not know how any orphanage can be free of this risk. Most orphanages bathe multiple children in the same bath water. Many orphanage staff workers will change several poopy diapers before washing their hands.

All it takes is for a microscopic trace of poo on the caretaker's hand, she grabs the hand of the next child to change their diaper, and the child later sticks his fingers in his mouth. Also, we all know children are germ spreading, filthy creatures. They will stick their hands down their pants and then finger all the toys... they don't care. How many orphanages have the children wash their hands with soap before they eat? Many do not have the resources to do so before every meal or snack.

You get my point. Almost impossible to prevent, and almost a guarantee that your child has it.

4. Zahra would periodically complain of tummy pain, particularly after eating. I didn't necessarily link it to an infection, in fact I was starting to wonder if she had sensitivities to dairy, but it was still a possible symptom of parasite infection.

Zahra tested positive on her first sample in Kenya. We immediately invested in a lot of hand sanitizer and became religious hand washers. (Although truth was, we were before as we knew the risks were high.)

Prevention is key. We were lucky that none of us contracted this parasite from her. No bath sharing, and lots of hand washing... (also a quick introduction to potty training) is what kept us healthy.

The Doctor in Kenya prescribed us a seven day course of Flagyl, also known as Metronidazole.  This was absolutely a horrible experience for us as Z did not like sweet things and the medicine was compounded to taste like bubble gum.

I had to hold her down, plug her nose, fight her kicking and screaming to administer it! (The electrician actually came up to our 5th floor apartment one day to ask why she cries so loud. Then one day he witnessed it himself... and went away tsking and shaking his head.)

It was awful! If I knew then what I know now... I would not have treated her at this time. It was too early in our bonding period.

After treatment, she was better for 1 week until the symptoms returned. Months later, we repeated the treatment with the same results. I had a Canadian pharmacist confirm the doses, and the medicine was obtained from a Western Doctor in a upscale hospital, at a very reputable pharmacy. There was nothing wrong with the dosage, or the medicine - well, aside from the fact that it is not effective! (Doctors in your hometown will automatically assume that your child was not 'properly' treated due to the perception of lack of quality med care. In some cases this could be correct, but in the case of Kenya, it is not.)

Upon returning to Canada, we immediately had her tested again. She tested positive again as we suspected. Our Doctor wanted to subscribe her with Flagyl again. I refused. This medicine is not pleasant stuff... administering it, and on our little one's bodies. I refused to have her go through that again for nothing.

Our Doctor consulted with a pediatrician at the Children's Hospital in Vancouver for an alternative medicine. He simply recommended Flagyl. Once again, I refused.

Where the heck are the adoption specialist Doctors? I have yet to hear of a case of Giardias in an adopted child successfully being treated by Flagyl!

So I hit FB and the message boards to get an answer from the experts - Adoptive Parents.

What I discovered was many of them had similar stories! In fact, friends of ours had a little one (Baby 'B') who was treated twice in country (after 2 negative test results!!) and was referred to a specialist here in Canada who had him treated two more times with Flagyl before they would even consider other alternatives! 1 - 2 - 3 - FOUR times this 2 yr old was treated with Flagyl in one year, with no effect! (And did you catch it - he tested negative twice before being tested positive. This is a sneaky bug folks.)

What IS the effective treatment?


This is what the parents were telling me, and my research confirmed it. Article after article listed Tinidazole as the most effective treatment. Why they continue to prescribe Flagyl is beyond me. Some articles even cited the effectiveness being 90% vs 35%! in Flagyl

Unfortunately, it took me 2 months to get my hands on this as the pharmacy later told my Doctor it was not available in Canada. I will not bore you with the details, but after contacting a compounding pharmacy 12 hours from me, I discovered this was not the truth. This drug is absolutely available in Canada. However, it is not available at your regular pharmacy. You must obtain it from a Compounding Pharmacy. In our case it took a couple weeks for them to get it in and compound it.

We were told it tastes like chocolate as that masks the flavor of everything. Wrong. This stuff has to be the most vile tasting medicine in the world. I tasted the smallest amount on my finger, and it was equivalent to chewing an entire bottle of aspirin and then swishing. However, it is only a single dose.

Zahra being older, and more trusting of us, it wasn't as nearly the painful experience as her other treatments. The reward (big buttered piece of bread - yes, she still loves her bread!) was worth swallowing this for.

Within a few days, we started to notice changes in her stools and eventually her belly came down.

She lost 1.75" around her waist, which is a considerable amount for her 21" inch belly!

She also now eats a fraction (1/2) of what she used to eat in the orphanage a year and a half ago, but yet has literally grown through 2 clothing sizes within 3 months of being treated (50% to 78% on the growth percentile chart)!

*Update - Baby 'B', who first charted under the growth scale, was finally charting at 15% after one year (and a lot of effort on the parent's end). However, within 3 weeks of being successfully treated, he gained enough weight and height (3.5 cms!!) to be charting at the 35% mark!

In many of our visits and work with orphanages, we always wondered how on earth those babies could eat SO much, but yet remain so tiny! It all makes sense now... malabsorption. Food literally going to waste.

So there you have it, our poop diaries.

I hope this post will not only help you identify possible infection, but save you time and grief as well. Please, have your child tested 3 times upon returning to country. Giardiasis is typically not fatal, but many other parasite infection are and can also go undetected.

If your child is 3+ and has been diagnosed with Giardiasis, don't be afraid to ask for Tinidazole right from the start.

Baby 'B' was 2 yrs old and therefore was prescribed Nitazoxanide (Alinia).

I know poop isn't a glamorous topic, but it's important that we share this information. I couldn't find any blog posts on this topic when we were going through this, which is why it was important to me to write about it.

This is an important issue, one that all adopting parents should know about! Please share this with your adopting friends.

See the CDC page for information on how to minimize the risk of contracting and spreading Giardia infection.


Christine said...

Awesome Post thanks so much

The Adventures Ashley said...

Wow much information! Thanks for sharing--not a glamorous topic, but super important!

Elizabeth said...

Thank you so much for sharing this valuable info. I wonder what Seattle Children's adoption would recommend. I was referred to them instead of BCCH at one point in my journey. Posts like this are so helpful and don't worry at all about the visuals as I am sure we have all seen worse. As an IBS sufferer it didn't phase me at all! Good to hear from you.

Denise said...

Thanks for writing this all out! I will share it with our Haitian adoption group. I will just add one thing - our daughter was tested 3 times and her results came up negative, but I knew she still had it (this isn't unheard of. I have another friend who's child was tested many times and always came up negative but the doctors now know she had it all along. Your poop pictures, while disgusting are so necessary as that is the only way to really tell!). The lab technicians here don't always know what to look for and/or it can hide really well! We also did the Tindamax (purchased it online at our doctor's recommendation). The one dose didn't kill it. I just gave her another 3 day dose to hopefully just kill it once and for all! I'm still waiting to see if that worked. I will tell you that it looked like she pooped out a "nest" of parasites one day. I'm hoping that is the end of it.

Suzanne said...

question: if your child doesn't have Giardia, would u still recommend the Tinizode (not sure i spelled that right)

Jolene said...

Thanks ladies!
Elizabeth, good question... I'm also curious!
Denise I hope your free of it now, let me know how it turns out!
Suzanne, I do not suggest you get treatment unless your child A. Test positive for Giardia or B. is showing symptoms of Giardisis, even if that just means failure to gain weight and you have ruled everything else out. Of course you should discuss this with your Doctor though. ;)

Anonymous said...

How long did it take before you starting seeing the change in your daughter's distended belly?

Jolene said...

We saw changes in her belly almost right away. Within a week of taking the med I would say. This photo was taken 2 weeks after the treatment.

Chrissy carlisle said...

My (biological) American born and raised three & a half year old was just diagnosed this morning! Reading up on it, I want to know everything I can about it before we start treatment! Thanks for the article