SIGNS AND SYMPTOMS 
- Frequent, loose stools
- Signs of dehydration:
- Signs of dehydration reflect degree of loss of total body water and vary with the degree of dehydration: Mild < 5%, moderate 5–10%, severe > 15%
- Severe dehydration:
- Mental status change: Often depressed with significant dehydration associated with impaired muscle tone
- Mucous membrane: Dry
- Skin turgor: Decreased
- Anterior fontanel: Depressed
- Blood pressure: Decreased
- Pulse: Tachycardia
- Capillary refill: Prolonged (> 2 sec)
- Urine output: Decreased
- Eyes: Sunken and absent tears
- Thirst
History
- Onset and duration
- Mental status and muscle tone
- Fever and associated symptoms (e.g., abdominal pain, emesis)
- Stool frequency and character with blood and mucus
- Urine output
- Feeding
- Recent antibiotics
- Recent travel
- Possible ingestions
- Immunodeficiency
- Underlying intestinal anomalies (e.g., Hirschsprung disease)
Physical Exam
- Abnormal capillary refill > 2 sec
- Absent tears
- Dry mucus membranes
- 3 best exam signs for determining dehydration in children are an abnormal respiratory pattern, abnormal skin turgor, and prolonged capillary refill time:
- Clinical dehydration scales based on a combination of physical exam findings are better predictors than individual signs.
ESSENTIAL WORKUP
Majority of children with acute diarrhea do not require any lab tests. Consider workup if:
- Temperature > 103°F
- Systemic illness
- Bloody diarrhea
- Prolonged course > 2 wk
- Tenesmus
- Dehydration greater than mild, usually requiring parenteral therapy
- Diarrhea with blood or mucus suggests an enteroinvasive inflammatory or cytotoxin-mediated process (Salmonella, invasive E. coli).
DIAGNOSIS TESTS & INTERPRETATION
Lab
- CBC with differential, blood culture, urine culture, and UA—if any signs of systemic infection
- Basic metabolic panel including electrolytes, BUN, creatinine, bicarbonate, for any child treated with IV hydration for severe dehydration or with those patients with abnormal physical signs:
- Recent evidence suggests that serum bicarbonate is particularly helpful in detecting moderate dehydration.
- Stool pH < 5.5 or positive stool-reducing substances are positive in lactose intolerance.
- Stool occult blood
- Stool microscopy:
- > 5 fecal leucocytes per high-power field are suggestive of invasive bacterial infection:
- Shigella
- Salmonella
- Campylobacter
- Yersinia
- Invasive E. coli
- Stool culture:
- Unnecessary in most cases unless there is a high likelihood of identifying bacterial pathogens (positive guaiac and/or fecal leucocytes) for which the clinical course and period of contagion may be altered by antibiotic therapy
- Consider urine culture in febrile children ≤12 mo.
Imaging
Imaging is usually not indicated. Abdominal x-ray or ultrasound may be useful if the clinical suspicion is high for other diagnoses such as intersussception, ileus, appendicitis.
Diagnostic Procedures/Surgery
Usually not indicated unless high clinical suspicion for other diagnoses based on history and physical exam
DIFFERENTIAL DIAGNOSIS
- Postinfectious:
- Follows acute or bacterial or viral gastroenteritis; often associated with malabsorption, especially lactose
- C. difficile following use of antibiotics.
- Milk allergy
- Malrotation with midgut volvulus
- Inflammatory bowel disease
- Intussusception
- Malabsorption syndromes
- Extra intestinal infections
- Medications altering intestinal flora such as antibiotics (e.g., amoxicillin—clavulanate)
[Outline]
INITIAL STABILIZATION/THERAPY
- For severely dehydrated children in shock or near shock, IV or intraosseous access with 20 mL/kg 0.9% NS and 1 g/kg dextrose if hypoglycemic
- Alternatively, fluids can be subcutaneously administered using recombinant hyaluronidase human injection using strict protocols
- Pulse oximetry
- Endotracheal intubation may be required for children in shock.
ED TREATMENT/PROCEDURES
- For mild to moderate dehydration, correct dehydration using oral rehydration therapy (ORT), 50 mL/kg and 100 mL/kg, respectively, over a 4-hr period:
- Replace ongoing losses with 10 mL/kg of ORT for each stool.
- Ideal ORT solution has a low osmolarity (210–250), glucose of about 2 g/dL, and sodium content of 50–60 mmol/L.
- For moderate to severe dehydration, correct dehydration using parenteral fluids combining maintenance and deficit requirements.
- If diarrhea is not associated with dehydration, use 10 mL/kg of ORT for each stool alone.
- Antibiotics only for defined acute enteritis: Routine use is not recommended; use only in either severe or invasive disease or patients who are immunocompromised or who have significant underlying GI conditions
- Erythromycin for Campylobacter jejuni
- TMP-SMX for:
- Salmonella—complicated (infant < 6 mo old, disseminated, bacteremia, immunocompromised host, enteric fever)
- Shigella
- Yersinia
- E. coli—enteroinvasive
- Metronidazole or vancomycin for:
- C. difficile (severe and/or prolonged enteritis)
- Neomycin for E. coli—enteroadherent
- Furazolidone or metronidazole for G. lamblia
- Antidiarrheal agents not recommended
- Probiotics: Lactobacillus GG
- Probiotics degrade and modify dietary antigens and balance the anti-inflammatory response to cytokines. They reduce the duration of diarrhea
- Post-ED diet:
- While rehydrating, feed children with diarrhea age-appropriate diets.
- Well-tolerated foods:
- Rich in complex carbohydrates (rice, potatoes, bread)
- Lean meats
- Yogurt
- Fruits
- Vegetables
- Full-strength milk and formula unless there is a strong suspicion of lactose intolerance
- Avoid fatty foods and foods high in simple sugars.
MEDICATION
- Ampicillin: 50–200 mg/kg/24h IV/PO q6h
- Erythromycin: 40 mg/kg/24h PO q6h; 10–20 mg/kg/24h IV q6h
- Metronidazole: 30 mg/kg/24h PO divided QID × 7 d
- Neomycin: 50–100 mg/kg/24h PO q6–8h
- TMP-SMX: 8–10 mg/kg/24h as TMP PO divided BID
- Vancomycin: 40–50 mg/kg/24h PO q6h
- Loperamide (not for use in children < 6 yr old or in those with heme-positive stools): Age 6–8 yr, 2 mg PO div. BID; age 8–12 yr, 2 mg PO div. TID
- Cefixime: 8 mg/kg/d PO per day for 7–10 days
- Ceftriaxone: 50 mg/kg/d IV/IM for 7–10 days
- Lactobacillus GG and Saccharomyces boulardii: 5 billion doses/d
- Zinc: 10–20 mg/d for 10–14 days (children < 5 yr)
First Line
- TMP-SMX for Salmonella and Shigella sp.
- Doxycycline for Vibrio cholerae
- Metronidazole for C. difficile
Second Line
- Ceftriaxone and Cefotaxime for Salmonella and Shigella sp.
- Erythromycin for V. cholerae.
- Vancomycin for resistant C. difficile
[Outline]
DISPOSITION
Admission Criteria
- Surgical abdomen
- Inability to tolerate oral fluids
- 10% dehydration or greater
- Suspected complicated Salmonella enteritis
- Toxic-appearing child
Discharge Criteria
- Improvement in the patient's condition
- Caregivers of child can follow through with appropriate ORT and diet.
- Caregivers able to identify signs and symptoms of dehydration
Issues for Referral
- Immunocompromised host
- Conditions associated with complications such as seizures
- Underlying bowel disorders
FOLLOW-UP RECOMMENDATIONS
Follow-up care depends on the length and severity of diarrhea, age of the child, and caregiver's ability to comply with instructions:
- Uncomplicated diarrhea does not typically need follow-up.
- Neonates require strict follow-up care in a few days.
[Outline]
- Canavan A, Arant BS Jr. Diagnosis and management of dehydration in children. Am Fam Physician. 2009;80(7):692–696.
- Levy JA, Bachur RG, Monuteaux MC, et al. Intravenous dextrose for children with gastroenteritis and dehydration: A double-blind randomized controlled trial. Ann Emerg Med. 2013;61:281–288.
- Spandorfer PR, Alessandrini EA, Joffe MD, et al. Oral versus intravenous rehydration of moderately dehydrated children: A randomized, controlled trial. Pediatrics. 2005;115:295–301.
- Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated? JAMA. 2004;291(22):2746–2754.
See Also (Topic, Algorithm, Electronic Media Element)
Vomiting, Pediatric