What helps diarrhea now that the BRAT diet is outdated, and when to call

Key takeaways

• In two 2018 trials with 1,857 young children seen in U.S. and Canadian emergency rooms for stomach bugs, two probiotic products did no better than a placebo¹².
• In 2003, CDC called the BRAT diet of bananas, rice, applesauce and toast unnecessarily restrictive and said children should return to their usual foods once rehydrated⁷.
• Loperamide is safe at label doses, but people misusing it have taken 70 to 1,600 milligrams a day, and high doses can trigger deadly heart rhythms⁸⁹.
• Bismuth subsalicylate contains a salicylate, the same drug family as aspirin, so its label warns children and teens who have or are recovering from flu or chickenpox not to use it¹⁰.
• See a doctor if an adult’s diarrhea lasts more than two days or a child’s lasts more than a day, and right away for bloody or black stools or signs of dehydration⁴.

In November 2018, the New England Journal of Medicine published two trials side by side¹. Both tested probiotics in young children brought to emergency rooms with a stomach bug¹².

The U.S. trial gave 971 children, ages 3 months to 4 years, either Lactobacillus rhamnosus GG or a placebo for five days¹². The Canadian trial gave 886 children a product with two other strains².

Neither probiotic helped. Diarrhea lasted about 50 hours in both U.S. groups and 52 to 56 hours in both Canadian groups². “In this instance, probiotics added no measurable benefit,” said David Schnadower, who led the U.S. trial¹.

Those results don’t settle every probiotic question, but they fit a larger truth. Most diarrhea ends on its own within days, and the best care is plain: fluids, ordinary food and, for some adults, a drugstore remedy used by the rules.

The clock tells you what kind of diarrhea you have

Diarrhea means loose, watery stools three or more times a day, or more often than is normal for you, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)³. Its timeline matters³:

• Acute diarrhea usually lasts less than a week and clears up on its own.
• Persistent diarrhea lasts more than two weeks but less than four.
• Chronic diarrhea lasts at least four weeks, steadily or on and off.

Research suggests that people in the U.S. get acute diarrhea about once a year, and that up to 5% of Americans have chronic diarrhea³.

Common causes of acute diarrhea include viruses such as norovirus and rotavirus, and food poisoning by germs such as Salmonella, Campylobacter and E. coli⁴. Medicines are a quieter cause. NIDDK lists antibiotics, antacids that contain magnesium, some cancer drugs and sugar alcohols such as sorbitol, which show up in some liquid medicines and sugar-free gum and candy³⁴⁶.

Some people face bigger risks from a bout of diarrhea: those who are pregnant, over 65, taking antibiotics or living with a weakened immune system³. Dehydration is the complication to watch for³. Our article on water and digestion covers oral rehydration solutions, and our travel article covers travelers’ diarrhea.

Fluids first, then ordinary food

BRAT, short for bananas, rice, applesauce and toast, has long been common advice after a stomach bug⁷. In a 2003 report, the Centers for Disease Control and Prevention (CDC) called that diet “unnecessarily restrictive” and said it could leave children short on nutrition⁷.

CDC’s advice for children was to rehydrate first, then go straight back to a normal diet for their age⁷. Children fed early recovered sooner and were better nourished, and the agency called it inappropriate to hold back food for more than a day⁷. Its suggested menu: starchy foods, meat, yogurt, fruit and vegetables⁷.

What to skip? CDC singled out foods heavy in simple sugars, such as soft drinks, juice and gelatin desserts, because the sugar can pull water into the gut and worsen diarrhea⁷.

NIDDK’s 2024 advice for adults runs along the same lines. Eat your normal diet once your appetite returns⁶. Until you feel better, avoid⁶:

• alcohol and caffeinated coffee, tea and sodas;
• sugary drinks, some fruit juices, candy and packaged desserts;
• sugar-free gum and candy with sugar alcohols;
• greasy foods such as fried food, pizza and fast food;
• milk and other dairy foods with lactose, since trouble digesting lactose can last a month or more after you recover.

Children should keep eating their usual foods, and infants should keep getting breast milk or formula⁶.

The agencies differ on fat. CDC’s report for children didn’t advise cutting it, since fat helps sick kids get enough calories, while NIDDK’s adult list includes greasy foods⁶⁷. Eat what you tolerate.

Bananas, rice and toast aren’t bad foods. The lesson is that your body heals better when it gets real nourishment, which suits readers who trust appetite and whole food.

Probiotics for kids’ stomach bugs: two big trials, no benefit

In the U.S. trial, at 10 pediatric emergency departments, 11.8% of children on the probiotic had moderate to severe illness over the next two weeks, compared with 12.6% on placebo². There was no difference in daycare days missed or in spread to family members, and no subgroup did better¹².

The Canadian trial, at six emergency departments, tested L. rhamnosus R0011 with L. helveticus R0052². Moderate to severe illness struck 26.1% of children on the probiotic and 24.7% on placebo².

Who paid matters. The U.S. trial had National Institutes of Health (NIH) funding, and a company called iHealth supplied the probiotic and placebo¹. The Canadian trial’s lead author reported nonfinancial support from several companies, including Lallemand Health Solutions². Industry ties here didn’t yield a favorable result.

The Canadian authors cautioned that their result can’t be stretched to cover other probiotic products on the market². NIDDK says many doctors and professional groups don’t think the evidence supports probiotics to treat or prevent diarrhea, and it advises asking a doctor first⁵. Our upcoming article on probiotics covers other uses, such as diarrhea after antibiotics.

Loperamide works at the label dose and turns dangerous above it

Loperamide, sold as Imodium, latches onto opioid receptors in the gut wall⁸. That slows the muscle waves that push stool along, gives the gut more time to absorb fluid and tightens the anal sphincter, easing urgency⁸. The FDA approved it for acute diarrhea in people 2 and older, and NIDDK says most cases of acute diarrhea can be treated with it or with bismuth subsalicylate⁵⁸.

The over-the-counter maximum for adults is 8 milligrams a day, and the prescription maximum is 16⁹. If diarrhea lasts more than two days while you’re taking it, stop and call a health professional⁹.

Doctors advise against drugstore anti-diarrhea medicines for infants, children and anyone with a fever or bloody stools, NIDDK says⁵. The prescription label rules it out for children under 2 because of breathing and heart risks⁸. It also rules out use with bloody diarrhea and high fever, or with gut infections from invasive bacteria or C. difficile⁸. CDC’s 2003 report on children cited 18 cases of severe belly swelling linked to loperamide in Pakistan, including 6 deaths⁷.

At high doses, loperamide becomes a heart risk. The FDA warned about serious heart problems in June 2016. In January 2018 it began working with makers to sell loperamide in blister packs or other single-dose packaging, with fewer doses per package⁹.

The label describes people taking 70 to 1,600 milligrams a day, 4 to 100 times the recommended amount, some to control diarrhea and some to head off opioid withdrawal⁸⁹. Those doses have caused dangerous heart rhythms, cardiac arrest and death⁸.

Some drugs raise loperamide levels in your blood, the label warns, including the antifungal itraconazole, the cholesterol drug gemfibrozil, the heart drug quinidine and the HIV drug ritonavir⁸. Older adults may be more sensitive to its effects on heart rhythm⁸.

Call 911 if someone who took loperamide faints, has a racing or irregular heartbeat or won’t respond, and tell responders about the loperamide⁹. Poison control is 1-800-222-1222⁸.

Bismuth subsalicylate is an aspirin relative

Bismuth subsalicylate, a staple of drugstore shelves, contains a salicylate¹⁰. Aspirin is a salicylate too, and the label’s warnings reflect that¹⁰.

On one current label, an adult dose is 525 milligrams, with no more than eight doses in 24 hours and no more than two days of use¹⁰. The label also says:

• Children and teenagers who have or are recovering from chickenpox or flu-like symptoms shouldn’t use it, because of the risk of Reye’s syndrome¹⁰.
• Don’t take it if you’re allergic to salicylates, including aspirin, or already take another salicylate product¹⁰.
• Ask first if you take medicine for blood thinning, diabetes, gout or arthritis¹⁰.
• Skip it if you have an ulcer, a bleeding problem or black or bloody stool¹⁰.
• Stop if your ears ring or you lose hearing¹⁰.
• For children under 12, ask a doctor¹⁰.

For children, CDC found that bismuth has limited benefit for stomach bugs, along with theoretical concerns about absorbing salicylate⁷. Our travel article covers bismuth for preventing travelers’ diarrhea.

Psyllium can firm up loose stools

Fiber is usually pitched for constipation, but psyllium can help the opposite problem. It forms a gel that holds on to water, as our article on soluble and insoluble fiber explains.

A Minneapolis trial tested that idea in adults with leaking of loose or liquid stools¹¹. Forty-two people, with an average age of 61, were randomly given psyllium, gum arabic (another fiber) or a placebo for 31 days, and neither they nor their clinicians knew which¹¹. Both fiber groups had less than half the share of leaked stools seen with placebo¹¹. The placebo group had the most loose or liquid stools, and the psyllium group’s stools held water best¹¹.

That’s one small trial in a specific group, so it rates as promising but early. Psyllium isn’t a stomach-bug treatment; it fits loose stools that keep coming back, after a clinician has looked for a cause. Take it with a full glass of fluid.

When diarrhea lingers: bile acids, C. diff and other causes

Diarrhea that lasts four weeks or more deserves a clinician’s attention. NIDDK’s list of causes includes trouble digesting lactose or fructose, food allergies, celiac disease, Crohn’s disease, ulcerative colitis, pancreas problems, diabetes nerve damage, irritable bowel syndrome, past gut or gallbladder surgery and C. difficile infection after antibiotics⁴.

One cause missing from that list is bile acid diarrhea. Your body normally recycles the bile acids it uses for digestion¹². When that recycling fails, or the body makes too much, the extra spills into the colon and makes it pour out salt and water¹²¹³. The most common form comes from overproduction, with no physical damage to the recycling system¹².

The United Kingdom’s National Institute for Health and Care Excellence (NICE) says the condition may be underdiagnosed¹². Doctors there can use a capsule test called SeHCAT, which measures how much of a tracer your body keeps¹². A survey of 21 British experts notes that the test isn’t licensed in the U.S., which has held back understanding of its value, and that diagnosis is often delayed by more than five years¹³.

Treatment is a bile acid binder such as cholestyramine, colestipol or colesevelam¹². Across eight studies NICE reviewed, a median of 68% of people with a positive test improved on one¹². If you have chronic watery diarrhea, ask your clinician whether bile acids could be involved.

C. difficile, often called C. diff, is the classic infection after long antibiotic use⁴. Its link to disturbed gut microbes is explained in our article on gut bacteria and disease, and our article on fecal transplants covers treatment for repeat infections. If diarrhea starts while you’re taking antibiotics, stay in touch with your clinician and don’t take loperamide on your own⁴⁸.

For chronic diarrhea, NIDDK suggests keeping a food journal of what you eat, your symptoms and their timing to share with your doctor⁶. For toddlers with chronic loose stools, often called toddler’s diarrhea, NIDDK says more fat and fiber may help¹⁴.

Your first 48 hours, and when to call

This home-care plan is our own, built from NIDDK, CDC and FDA guidance, for short bouts in people who are otherwise well. With a chronic illness or a fluid limit, follow your doctor’s plan.

1. Hours 0 to 24: drink first. Sip often, in small amounts if you’re vomiting. Our water and digestion article explains when to use an oral rehydration solution.
2. Eat when you’re hungry. Choose ordinary meals and skip alcohol, caffeine, sugary drinks, sugar-free sweets, greasy food and milk until you feel better⁶⁷.
3. Choose medicine carefully. Adults without fever or bloody stools may use loperamide or bismuth subsalicylate exactly as labeled⁵⁹¹⁰. Don’t give either to a child unless a doctor says to⁵⁷.
4. Hour 24: check on children. Call the doctor if a child’s diarrhea has lasted more than a day, and don’t hesitate to call sooner⁴.
5. Hour 48: check on adults. If diarrhea is still going, stop any drugstore medicine and call a clinician⁴⁹.

Who	Talk with a doctor right away if	Also know
Adults	Diarrhea lasts more than 2 days; high fever; six or more loose stools a day; black, tarry, bloody or pus-filled stools; severe belly or rectal pain; frequent vomiting; irritability or low energy; signs of dehydration4	Stop drugstore medicine if diarrhea lasts more than 2 days on it9
Children	Diarrhea lasts more than a day; high fever; frequent loose stools; no wet diaper for 3 hours or more; crying without tears; a sunken soft spot on the head; drowsiness4	No anti-diarrhea medicine unless a doctor says so57
Babies under 12 months, premature babies, children with other medical conditions	Any diarrhea; any fever in a baby; refusing food and drink for more than a few hours4	Diarrhea can severely dehydrate a baby within a day or two4
Adults over 65, pregnant people, people with weakened immunity or taking antibiotics	Any adult sign above; these groups should stay in touch with their doctor during diarrhea4	Ask before using a rehydration drink if you have diabetes or kidney disease5; don’t use loperamide for colitis after antibiotics, such as C. diff8
Anyone who took loperamide	Fainting, a racing or irregular heartbeat or not responding means call 9119	Tell responders about the loperamide9

Our upcoming article on gut warning signs covers more red flags.

What the evidence shows

Claim or remedy	What the research shows	Rating
Return to usual foods soon after rehydrating	CDC tied early feeding to shorter illness and better nutrition in children7	Strong evidence
Loperamide at label doses for adults without fever or blood	FDA-approved for acute diarrhea, and the agency calls it safe at approved doses; NIDDK lists it as an option589	Strong evidence
Bile acid binders for confirmed bile acid diarrhea	A median of 68% improved across eight studies12	Promising but early
Psyllium for leakage of loose stools	In one small blinded trial, leaked stools fell to less than half the placebo rate11	Promising but early
Other probiotics to treat diarrhea	Many doctors and professional groups don’t think the evidence supports them5	Not enough evidence
A BRAT-only diet or fasting	CDC calls BRAT unnecessarily restrictive and fasting over 24 hours inappropriate; NIDDK says most experts don’t advise fasting67	Evidence says no, or unsafe
L. rhamnosus GG or the two-strain product for kids’ stomach bugs	Two large placebo-controlled trials found no benefit12	Evidence says no, or unsafe
Loperamide above label doses, or in young children	Heart rhythm deaths in misuse; deaths in children in Pakistan78	Evidence says no, or unsafe
Bismuth for kids recovering from flu or chickenpox	The label warns of Reye’s syndrome10	Evidence says no, or unsafe

Questions readers ask

The bottom line

Most diarrhea is short-lived, and the plain steps work best: drink often, eat ordinary food when you’re hungry and give it a day or two. The BRAT diet and the probiotics tested in children’s stomach bugs aren’t needed.

For adults, loperamide and bismuth subsalicylate help when used exactly as labeled, with real cautions. Children, infants, older adults and anyone with blood, black stools, high fever or signs of dehydration need a clinician, as does diarrhea that lingers past a few weeks.

Keep exploring: acid reflux lifestyle changes.

Related reading

• Water helps your gut most with fiber and during a stomach bug
• Travel wellness starts with the basics, not a suitcase of supplements
• Sick guts hold different microbes, and proving the microbes did it is harder
• Stool became FDA-approved medicine for one infection, and other uses are still experiments
• Memory rewrites your symptoms, and a diary keeps the record straight

Sources

1. National Institutes of Health. “Probiotics Not Helpful for Young Children With Diarrhea” (NIH Research Matters), December 4, 2018.
2. “Two Probiotic Products Don’t Prevent Gastroenteritis in Children, Studies Show” (on Schnadower D, et al., and Freedman SB, et al., New England Journal of Medicine, 2018). MDedge, 2018. mdedge.com
3. National Institute of Diabetes and Digestive and Kidney Diseases. “Definition & Facts for Diarrhea.” NIH, last reviewed September 2024. niddk.nih.gov
4. National Institute of Diabetes and Digestive and Kidney Diseases. “Symptoms & Causes of Diarrhea.” NIH, last reviewed September 2024. niddk.nih.gov
5. National Institute of Diabetes and Digestive and Kidney Diseases. “Treatment of Diarrhea.” NIH, last reviewed September 2024. niddk.nih.gov
6. National Institute of Diabetes and Digestive and Kidney Diseases. “Eating, Diet, & Nutrition for Diarrhea.” NIH, last reviewed September 2024. niddk.nih.gov
7. King CK, Glass R, Bresee JS, Duggan C. “Managing Acute Gastroenteritis Among Children: Oral Rehydration, Maintenance, and Nutritional Therapy.” MMWR Recommendations and Reports, CDC, November 21, 2003;52(RR-16). cdc.gov
8. U.S. Food and Drug Administration. “IMODIUM (loperamide hydrochloride) Capsules” prescribing information, revised October 2016. accessdata.fda.gov
9. U.S. Food and Drug Administration. “FDA Drug Safety Communication: FDA Limits Packaging for Anti-Diarrhea Medicine Loperamide (Imodium) to Encourage Safe Use.” January 30, 2018. fda.gov
10. DailyMed, National Library of Medicine. “Bismuth Subsalicylate Suspension Regular Strength” (Drug Facts label), updated September 2025. dailymed.nlm.nih.gov
11. Bliss DZ, Jung HJ, Savik K, et al. “Supplementation With Dietary Fiber Improves Fecal Incontinence.” Nursing Research, 2001;50(4):203-213 (University of Minnesota record and Evidence-Based Nursing abstract). experts.umn.edu and ebn.bmj.com
12. National Institute for Health and Care Excellence. “SeHCAT (Tauroselcholic [75 Selenium] Acid) for Diagnosing Bile Acid Diarrhoea” (DG44), overview, June 2021, and evidence chapter. nice.org.uk and nice.org.uk
13. UK Bile Acid Related Diarrhoea Network. Survey of UK expert opinion on managing bile acid diarrhoea. Frontline Gastroenterology, 2020;11(5):358. fg.bmj.com
14. National Institute of Diabetes and Digestive and Kidney Diseases. “Eating, Diet, & Nutrition for Chronic Diarrhea in Children.” NIH, last reviewed February 2017. niddk.nih.gov