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Diarrhea, Pediatric, Emergency Medicine

Basics

Description

- Noninfectious: - Postinfectious - Food allergies and intolerance: - Cows milk protein - Soy protein - Methyl xanthines - 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

- 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's disease, ulcerative colitis - Malabsorption syndromes (cystic fibrosis, celiac disease) - Irritable bowel syndrome

- 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

- Neomycin for E. coli-enteroadherent - Furazolidone or metronidazole for G. lamblia

- 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

  • One of the most common pediatric complaints; 2nd 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 diarrheaChildren <5 yr in US typically have 2 episodes annually.Responsible for ~10% of all pediatric ED visits and hospital admissions
  • Acute change in the "normal"ť bowel pattern that leads to increased number or volume of stools and lasts <7 days; World Health Organization (WHO) defines case as 3 or more loose or watery stools per day.Chronic if the diarrhea persists for >2 wk

Etiology

  • Acute enteritis:Infectious:Viruses: 70-80% of cases:Rotavirus most commonEnteric adenovirusNorovirus (foodborne outbreaks)Bacteria: 10-20%:Escherichia coli, Yersinia, Clostridium difficileSalmonella, Shigella, CampylobacterVibrioAeromonasParasites 5%:Cryptosporidiosis (waterborne)Giardia lambliaNoninfectious:PostinfectiousFood allergies and intolerance:Cows milk proteinSoy proteinMethyl xanthinesLactose intoleranceChemotherapy/radiation inducedDrug induced:Antibiotics, laxatives, antacidsIngestion of heavy metals-copper, zincIngestion of plants-hyacinth, daffodils, amanita speciesVitamin deficiency: Niacin, folateVitamin toxicity: Vitamin CAssociated with other infectionsOtitis media, UTI, pneumonia, meningitis, appendicitis.
  • Chronic diarrhea:Dietary factors: Excessive consumption of sorbitol or fructose from fruit juicesEnteric infections in immunocompromisedMalnutritionEndocrine: Thyrotoxicosis, pheochromocytomaInflammatory bowel diseases: Crohn's disease, ulcerative colitisMalabsorption syndromes (cystic fibrosis, celiac disease)Irritable bowel syndrome

Diagnosis

Signs and Symptoms

  • Frequent, loose stools
  • Signs of dehydration:WateryBloodyMucoidSometimes abdominal pain, fever, anorexiaTenesmus
  • 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 toneMucous membrane: DrySkin turgor: DecreasedAnterior fontanel: DepressedBlood pressure: DecreasedPulse: TachycardiaCapillary refill: Prolonged (>2 sec)Urine output: DecreasedEyes: Sunken and absent tearsThirst

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:ShigellaSalmonellaCampylobacterYersiniaInvasive 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)

Treatment

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 conditionsErythromycin for Campylobacter jejuniTMP-SMX for:Salmonella-complicated (infant <6 mo old, disseminated, bacteremia, immunocompromised host, enteric fever)ShigellaYersiniaE. coli-enteroinvasiveMetronidazole or vancomycin for:C. difficile (severe and/or prolonged enteritis)Neomycin for E. coli-enteroadherentFurazolidone or metronidazole for G. lamblia
  • Antidiarrheal agents not recommended
  • Probiotics: Lactobacillus GGProbiotics 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 meatsYogurtFruitsVegetablesFull-strength milk and formula unless there is a strong suspicion of lactose intoleranceAvoid 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

Follow-Up

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 patients 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

Followup Recommendations

Follow-up care depends on the length and severity of diarrhea, age of the child, and caregivers ability to comply with instructions:

  • Uncomplicated diarrhea does not typically need follow-up.
  • Neonates require strict follow-up care in a few days.

Pearls and Pitfalls

  • History and PE assists in differentiating uncomplicated diarrhea from other, often more serious conditions in children.
  • Vast majority of children with acute diarrhea do not need extensive lab tests, which are unlikely to affect the management.
  • Treatment with antidiarrheals and antibiotics has very limited role in childhood diarrhea.
  • Diagnoses like appendicitis, intussusception, UTI, and sepsis may need to be considered.

Additional Reading

  • 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

Codes

ICD9

  • 008.8 Intestinal infection due to other organism, not elsewhere classified
  • 008.61 Enteritis due to rotavirus
  • 787.91 Diarrhea
  • 008.63 Enteritis due to norwalk virus
  • 008.00 Intestinal infection due to E. coli, unspecified
  • 008.44 Intestinal infection due to yersinia enterocolitica

ICD10

  • A08.0 Rotaviral enteritis
  • A08.4 Viral intestinal infection, unspecified
  • R19.7 Diarrhea, unspecified
  • A08.11 Acute gastroenteropathy due to Norwalk agent
  • A04.4 Other intestinal Escherichia coli infections
  • A04.6 Enteritis due to Yersinia enterocolitica

SNOMED

  • 62315008 Diarrhea (finding)
  • 111843007 Viral gastroenteritis (disorder)
  • 186150001 Enteritis due to rotavirus (disorder)
  • 445152004 Inflammation of intestine due to Norovirus (disorder)
  • 111839008 Intestinal infection due to E. coli (disorder)
  • 80960004 Infection by Yersinia enterocolitica