Author:
Rajender K.Gattu
RichardLichenstein
Description
- One of the most common pediatric complaints; second only to respiratory infections in overall disease frequency for ED visits
- Leading cause of illness and death in children worldwide
- Acute infectious enteritis (AIE):
- Vomiting and diarrhea
- Children <5 yr in the U.S. typically have 2 episodes annually
- Responsible for ∼10% of all pediatric ED visits and hospital admissions
- Acute change in the “normal” bowel pattern that leads to increased number or volume of stools and lasts <7 d; World Health Organization (WHO) defines case as 3 or more loose or watery stools per day
- Chronic if the diarrhea persists for >2 wk
- From a pathophysiologic point of view, there are two basic mechanisms involved: Osmotic and secretory. Secondary to these mechanisms, alterations in intestinal motility can also occur
Etiology
- Acute enteritis:
- Infectious:
- Viruses: 70-80% of cases:
- Rotavirus most common
- Enteric adenovirus
- Norovirus (foodborne outbreaks)
- Bacteria: 10-20%:
- Escherichia coli, Yersinia, Clostridium difficile
- Salmonella, Shigella, Campylobacter
- Vibrio
- Aeromonas
- Parasites 5%:
- Cryptosporidiosis (waterborne)
- Giardia lamblia
- Noninfectious:
- Postinfectious
- Food allergies and intolerance:
- Cow's milk protein
- Soy protein
- Methylxanthines
- Lactose intolerance
- Chemotherapy/radiation induced
- Drug induced:
- Antibiotics, laxatives, antacids
- Ingestion of heavy metals - copper, zinc
- Ingestion of plants - hyacinth, daffodils, amanita species
- Vitamin deficiency: Niacin, folate
- Vitamin toxicity: Vitamin C
- Associated with other infections:
- Otitis media, UTI, pneumonia, meningitis, appendicitis
- Chronic diarrhea:
- Dietary factors: Excessive consumption of sorbitol or fructose from fruit juices
- Enteric infections in immunocompromised
- Malnutrition
- Endocrine: Thyrotoxicosis, pheochromocytoma
- Inflammatory bowel diseases: Crohn disease, ulcerative colitis
- Malabsorption syndromes (cystic fibrosis, celiac disease)
- Irritable bowel syndrome
Signs and Symptoms
- Frequent, loose stools
- Characteristics of stools:
- Sometimes abdominal pain, fever, anorexia, tenesmus
- 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 s)
- Urine output: Decreased
- Eyes: Sunken and absent tears
- Thirst
History
- Onset and duration
- Mental status and appearance
- 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 s
- Absent tears
- Dry mucous membranes
- 3 best exam signs for determining dehydration in children are an abnormal respiratory pattern, abnormal skin turgor, and prolonged capillary refill time: Also evaluate mucosal membranes
- 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)
Diagnostic Tests & Interpretation
Lab
- CBC with differential, blood culture, urine culture, and UA - if any signs of systemic infection. Urine-specific gravity and ketones need assessment
- 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 US may be useful if the clinical suspicion is high for other diagnoses such as intussusception, ileus, and 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)
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 produced
- 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 may reduce the duration of diarrhea
- Post-ED diet:
- While rehydrating, feed age-appropriate diets for children with diarrhea
- 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/24 hr IV/PO q6h
- Erythromycin: 40 mg/kg/24 hr PO q6h; 10-20 mg/kg/24 hr IV q6h
- Metronidazole: 30 mg/kg/24 hr PO div q.i.d × 7 d
- Neomycin: 50-100 mg/kg/24 hr PO q6-8h
- TMP-SMX: 8-10 mg/kg/24 hr as TMP PO div b.i.d
- Vancomycin: 40-50 mg/kg/24 hr 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 b.i.d; age 8-12 yr, 2 mg PO div t.i.d
- Cefixime: 8 mg/kg/d PO per day for 7-10 d
- Ceftriaxone: 50 mg/kg/d IV/IM for 7-10 d
- Lactobacillus GG and Saccharomyces boulardii: 5 billion doses/d
- Zinc: 10-20 mg/d for 10-14 d (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
Disposition
Admission Criteria
- Surgical abdomen
- Inability to tolerate oral fluids
- 10% dehydration or greater
- Suspected complicated Salmonella enteritis
- Toxic-appearing child
- Children with significant underlying conditions
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
- 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
- Brand tKG, Castro AntunesMM, SilvaGA. Acute diarrhea: Evidence‐based management . J Pediatr (Rio J). 2015;91(6 Suppl 1):S36-S43.
- CanavanA, ArantBS Jr. Diagnosis and management of dehydration in children . Am Fam Physician. 2009;80(7):692-696.
- LevyJA, BachurRG, MonuteauxMC, et al. Intravenous dextrose for children with gastroenteritis and dehydration: A double-blind rand omized controlled trial . Ann Emerg Med. 2013;61:281-288.
- RiddleMS, DuPontHL, ConnorBA. ACG clinical guideline: Diagnosis, treatment, and prevention of acute diarrheal infections in adults . Am J Gastroenterol. 2016;111:602-622.
- Spand orferPR, Alessand riniEA, JoffeMD, et al. Oral versus intravenous rehydration of moderately dehydrated children: A rand omized, controlled trial . Pediatrics. 2005;115:295-301.
- SteinerMJ, DeWaltDA, ByerleyJS. Is this child dehydrated ? JAMA. 2004;291(22):2746-2754.
See Also (Topic, Algorithm, Electronic Media Element)
Vomiting, Pediatric