Acute Diarrhea in Children

Background

• Acute diarrhea in children is the passage of unusually soft or liquid stools ≥ 3 times in 24 hours which is usually self-limited and resolves within 2 weeks.
• Depending on the exposure of the patient, the risk factors for acute diarrhea-causing pathogens vary.
• The majority of cases of diarrheal illness have a viral cause and are self-limiting, but the differential diagnosis includes other possible concerning etiologies.
• Most uncomplicated cases of acute diarrhea in children have a good prognosis.
• Hand hygiene, certain vaccinations, following appropriate food safety practices, and probiotics may help to prevent transmission of pathogens associated with infectious diarrhea.

Evaluation

• Uncomplicated cases of presumed viral gastroenteritis can be initially evaluated and managed over the phone with appropriate questioning (Weak recommendation).
• Medical visits are indicated for:
  • age < 2 months
  • > 8 diarrheal stools/day with elevated stool volume
  • persistent vomiting
  • signs of severe dehydration by family report including changing mental status
  • blood in stool
  • persistent fever (> 38 degrees C [> 100.4 degrees F] in infants < 3 months old or ≥ 39 degrees C [≥ 102.2 degrees F] in children aged 3-36 months)
  • worsening symptoms, no improvement within 48 hours, or no urine output in last 12 hours
  • severe underlying disease such as diabetes or renal failure
• Obtain a detailed history, including exposures, and perform a thorough physical examination, including a dehydration assessment (Strong recommendation).
• Consider stool studies in children with fever, bloody or mucoid stools, severe abdominal cramping or tenderness, signs of sepsis, underlying chronic condition or immunodeficiency, prolonged symptoms (≥ 14 days), or clearly identified risk factors for a bacterial etiology (Weak recommendation).
• Consider multiplex polymerase chain reaction of stools for rapid organism identification.
• Blood testing is generally not recommended in most cases of acute diarrhea in children but electrolytes may be necessary in ill appearing, dehydrated children.
• Consider a blood culture in infants < 3 months old and in children of any age with signs of sepsis or systemic infection, suspected enteric fever, immunocompromised, high-risk conditions, and fever with travel to or contact with traveler from enteric fever-endemic areas (Weak recommendation).
• Consider endoscopy or proctoscopy in children and adolescents with certain complicating conditions (Weak recommendation).

Management

• Oral rehydration solution (ORS) is the initial treatment in most children with acute diarrhea.
  • A home-based treatment to provide ongoing hydration and replace fluid after each episode of diarrhea or vomiting is recommended for children with absent or minimal clinical signs of dehydration.
  • A health facility-based treatment with 50-100 mL/kg over 4 hours with additional fluid to replace ongoing losses is recommended for children with mild-to-moderate dehydration.
• Consider nasogastric rehydration administration of ORS in child with normal mental status who is unable to drink or who vomits persistently with oral ORS (Weak recommendation).
• Begin IV rehydration therapy with Ringer lactate or normal saline in children with severe dehydration or no response to oral rehydration. The rate of infusion is determined by age and the presence of hypernatremia, clinical deterioration, or shock. Assess status frequently.
  • European Society for Pediatric Gastroenterology, Hepatology, and Nutrition/European Society for Pediatric Infectious Diseases recommendations
    • For children with dehydration and shock:
      • give rapid IV infusion of 20 mL/kg isotonic crystalloid solution (0.9% saline or lactated Ringer solution)
      • if blood pressure has not improved after initial infusion, repeat every 10-15 minutes up to 3 total boluses
    • For children with severe dehydration without shock give 20 mL/kg/hour of 0.9% saline solution for 2-4 hours.
    • For children with hypernatremia:
      • use an isotonic solution for rehydration and maintenance
      • consider replacing fluid deficit slowly, usually over 48 hours (Weak recommendation)
    • Once rehydration is complete, give maintenance fluids based on ongoing losses plus recommended daily fluid requirements.
      • Consider using dextrose-containing solution with ≥ 0.45% saline (Weak recommendation).
      • Consider adding 20 mEq/L of potassium chloride if child is urinating and electrolyte values are known (Weak recommendation).
• See also Dehydration Correction Calculator (from Cornell University Critical Care Pediatrics) and Maintenance Fluid Calculator (from Pharmacology Weekly) for guiding IV fluids.
• Feeding, including nursing and formula feeds, can be continued and does not appear to result in persistent or increased diarrhea.
• Antimicrobial medications are not recommended for the vast majority of children who are otherwise healthy (Strong recommendation).
  • Bacterial gastroenteritis is usually self-limiting, and antimicrobials may not shorten course; antimicrobials are ineffective against viruses, the predominant cause of acute diarrhea.
  • If infection is due to Shiga toxin-producing Escherichia coli (STEC) O157, treatment with antimicrobials may increase risk of hemolytic-uremic syndrome (HUS).
• Consider antimicrobial medications in (Weak recommendation):
  • infants and children with bloody diarrhea and age < 3 months, suspected Shigella, or clinical features of sepsis due to suspected enteric fever
  • young infants with watery diarrhea who appear ill
  • immunocompromised children (with either bloody or watery diarrhea)
• Consider probiotics to shorten the duration of acute infectious diarrhea. Probiotics with efficacy data include Lactobacillus casei strain GG, Enterococcus lactic acid bacteria (LAB) SF68, Saccharomyces boulardii, and Escherichia coli strain Nissle 1917 (Weak recommendation).
• In children < 5 years old, especially in developing countries, consider zinc supplementation 10-20 mg/day for 10-14 days (Weak recommendation).
• Consider lactose avoidance in hospitalized children aged < 5 years with the goal of possibly reducing duration of diarrhea (Weak recommendation).