Ohio GI [Diarrhea

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INTRODUCTION Diarrhea refers to the passage of loose or watery stools, and occurs at some point in the life of nearly every child. Diarrhea is not a disease, but is a symptom of a number of illnesses. Although diarrhea is common and rarely life-threatening, it is important to understand when to seek help. Diarrhea can lead to dehydration, which alters the child's natural balance of water and electrolytes (sodium, potassium, chloride) and can be serious if not treated promptly.

This topic will review the major issues related to diarrhea in children. A brief summary is provided below ( see "Summary" below ). Diarrhea in adults is discussed separately. ( See "Patient information: Acute diarrhea in adults" ). A topic that discusses nausea and vomiting in children is also available. ( See "Patient information: Nausea and vomiting in infants and children" ).

DEFINITION The consistency and frequency of bowel movements varies with a child's age and diet, and the definition of diarrhea varies accordingly.

Frequency It is normal for young infants to have eight to ten stools per day, though this varies individually. Older infants, toddlers, and children normally have one to two bowel movements per day. Diarrhea can usually be defined as an increase in stool frequency to twice the usual number in infants or three or more loose or watery stools per day in older children.

Consistency The consistency and color of a child's stool normally changes with age, which highlights the importance of knowing what is normal for your child. Young infants' stools may be yellow, green, or brown, and may appear to contain seeds or small curds. All children's stools can vary as a result of their diet. The development of stools that are runny, watery, or contain mucus is a significant change that should be monitored. The presence of blood in stool is never normal and always requires medical attention.

Duration A prolonged history of diarrhea (one to four weeks or longer) is evaluated and treated differently than an acute case of diarrhea (lasting less than one week). The discussion below will focus on acute, rather than chronic, diarrhea.

CAUSES The most common cause of acute diarrhea is a viral infection. Other causes include bacterial infections, side effects of antibiotics, and infections not related to the gastrointestinal (GI) system. In addition, there are many less common causes of diarrhea ( show table 1 ).

Viral, bacterial, and parasitic infections are all contagious, and parents should use caution to prevent their child from spreading the infection. Children are considered contagious for as long as they have diarrhea. Microorganisms from diarrhea are spread from hand to mouth; hand washing is very important to prevent infecting family and other contacts. ( See "Hygiene measures" below ).

Viral infection Viral infection is the leading cause of diarrhea in children, and is seen most commonly in the winter months. Symptoms of viral infection can include watery diarrhea, vomiting, fever (temperature greater than 100.4ÿF or 38ÿC), headache, abdominal cramps, lack of appetite, and muscle aches. Viral infection usually begins 12 hours to four days after exposure, and resolves within three to seven days. No specific treatment is available for viral causes of diarrhea. Children with diarrhea from viral infections are best treated with supportive measures (oral rehydration solution, limited diet, rest). ( See "Home care measures" below ).

Bacterial infection Bacterial infection is sometimes hard to distinguish from viral infection. Persistent, high fever (greater than 40ÿC or 104ÿF) and diarrhea that is bloody or mucusy are somewhat more common with bacterial infection. Most children with bacterial infection do not require antibiotics and will improve with time and supportive measures.

Parasitic infection Generally, infection with a parasite is uncommon, but may be seen in children who have recently ingested contaminated water or who have traveled or lived in developing countries. Diarrhea from parasitic infections may last greater than two weeks.

Antibiotic-associated diarrhea A number of antibiotics can cause diarrhea in both children and adults. The diarrhea is usually mild, and typically does not cause dehydration or weight loss. In most cases, antibiotics should not be stopped, and the child's diet does not need to be changed. The diarrhea usually resolves one to two days after antibiotics are finished. A healthcare provider should be contacted if a child on antibiotics has diarrhea that is severe ( see "Frequency" above ), contains blood, or does not resolve after the antibiotic is stopped.

EVALUATION The evaluation of diarrhea in children requires a careful review of medical history, a physical examination, and on occasion, diagnostic testing. Testing is often not required, and would be selected based on the history and examination.

Medical history A medical history often suggests the underlying cause of diarrhea. The clinician will ask about how and when the diarrhea began, the appearance of the diarrhea (if blood or mucus is present), if vomiting has occurred, and if the child has recently been near other adults or children with diarrhea. It is important for parents to mention if their child has had a fever (temperature greater than 101ÿF or 38ÿC) or abdominal pain. Table 5 describes how to take a child's temperature ( show table 5 ).

The type and amount of recent oral intake (breast milk or commercial infant formula, food, other liquids), weight loss, time of last urination, and change in behavior should be noted. Other important points to discuss include food intolerances or allergies, recent travel to developing countries, water source (ie, well water versus city water), exposure to potentially contaminated food, recent medications, past and current medical conditions, and prior surgeries.

Physical examination Physical examination provides helpful information about the severity of the diarrhea, particularly whether dehydration is present. Children who have a dry mouth, are not urinating frequently (less than one wet diaper or void per 6 hours), or who have a rapid heart rate (which varies, depending upon age) are likely dehydrated and in need of either oral or intravenous fluid replacement.

The clinician will perform a thorough examination because there are some infections unrelated to the bowels (such as an ear infection) that can cause diarrhea.

TESTS Many tests are available to diagnose the cause of diarrhea and to determine the severity of dehydration, although most children will not require testing. For those who do, a few carefully chosen tests are usually sufficient. Testing may include blood, urine, and/or stool specimens. Stool tests are generally useful only for children who have fever and bloody diarrhea. The clinician's office or the laboratory will provide instructions and the equipment needed to collect the specimen. Most children with diarrhea will generally not require x-rays or other imaging tests.

HOME CARE MEASURES The following are some simple recommendations to help care for children with diarrhea at home.

Dietary recommendations There has been much confusion and folklore about optimal foods for children with diarrhea. Fortunately, a number of studies have been completed that provide recommendations that are proven to be effective.

Children who are not dehydrated should continue to eat a regular diet, and infants who are breastfeeding should continue to do so unless the parent(s) is told otherwise by their clinician. Dehydrated children require rehydration (replacement of lost fluid). After being rehydrated, many children will be able to resume a normal diet. ( See "Oral rehydration therapy" below ).

Specific suggestions for children who are tolerating a regular diet include the following:

Most children with diarrhea tolerate full-strength cow's milk products. It is not necessary to dilute or avoid milk products (except in children with known allergies to cow's milk).

Recommended foods include a combination of complex carbohydrates (rice, wheat, potatoes, bread), lean meats, yogurt, fruits, and vegetables. High fat foods are more difficult to digest, and should be avoided.

It is not necessary to restrict a child's diet to clear liquids or the BRAT diet (bananas, rice, applesauce, toast). Neither contains enough nutrients, and giving only clear liquids for several days can actually prolong diarrhea (called "starvation stools").

Apple, pear, and cherry juice, and other beverages with high sugar content should be avoided. Sports drinks (eg, Gatorade) should also be avoided since they have too much sugar and have inappropriate electrolyte levels. When clear liquids are recommended, the best choices are the commercially prepared oral rehydration solutions for rehydration (eg, Pedialyte).

Monitoring for dehydration Mild dehydration is common in children with diarrhea. Signs and symptoms of mild dehydration include a slightly dry mouth, increased thirst, and decreased urine output (one wet diaper or voids in six hours). However, parents should monitor for signs of moderate to severe dehydration. Common findings with moderate or severe dehydration include decreased urination (less than one wet diaper or void in six hours), lack of tears when crying, dry mouth, and sunken eyes ( show table 2 ).

Oral rehydration therapy Oral rehydration therapy (ORT) was developed as a safer, less-expensive, and easier alternative to intravenous fluids. Oral rehydration solution (ORS) is a liquid solution that contains glucose (a sugar) and electrolytes (sodium, potassium, chloride) that are lost in children with vomiting and diarrhea. Various forms of rehydration solution are available. Parents should check with a healthcare provider to determine which solution is preferred. A child who is moderately or severely dehydrated needs to be evaluated by a healthcare provider. A parent may offer ORS, but children are often too ill and require professional evaluation and treatment.

ORT does not cure diarrhea, but it does help to treat the dehydration that often accompanies it. ORS can be purchased at most grocery stores and pharmacies in the United States without a prescription. A few widely available brands include Pedialyteÿ, Infalyteÿ, and ReVitalÿ, although generic brands are equally effective ( show table 3 ). Gelatin, tea, rice water, fruit juice and other beverages are not recommended for use as ORT in children with diarrhea. Parents should not try to prepare ORS recipes at home because the formulas must be exact.

ORS may be given at home to a child who is mildly dehydrated, refusing to eat a normal diet, or has vomiting and/or diarrhea. If needed ORS can be given in frequent, small amounts by spoon, bottle, or cup over three to four hours. A pediatrician may provide specific instructions for oral rehydration to their patients. One method is described below:

Parents should first measure out the total amount to be given with a standardized medicine syringe or measuring cup or spoon, rather than a regular cup or spoon.

A total volume of 5 teaspoons per pound, or 50 milliliters per kilogram, should be given ( show table 4 ). For a 20-pound child, this would equal 100 teaspoons; for a 9 kg child, this would equal 450 milliliters.

The fluid can be given by teaspoonfuls (approximately equal to 5 milliliters each) every one to two minutes or as tolerated.

After the total amount has been given, a normal diet can be resumed.

A child who refuse to drink or vomits immediately after drinking ORT should be monitored closely for worsening dehydration. Children who are not dehydrated may drink ORT after every episode of vomiting to prevent dehydration. ( See "Monitoring for dehydration" above ).

Medications Medications such as antibiotics and antidiarrheal agents are generally not necessary and could be harmful for infants or children with diarrhea. Rarely, antibiotics may be used in cases of bacterial infection when a specific cause of the diarrhea has been found or is strongly suspected, particularly after recent travel. Inappropriate use of antibiotics will not improve diarrhea. Furthermore, antibiotics can cause side effects and lead to development of antibiotic resistance.

Antidiarrheal agents (including Imodiumÿ, Pepto-Bismolÿ, and Kaopectateÿ) are not recommended for infants or children since the benefits do not outweigh the risks. One risk of using an antidiarrheal agent is that it could mask worsening symptoms and delay treatment.

There are "healthy" bacteria (called probiotics) that may help reduce the duration of diarrhea (by about 12 to 30 hours). Some of these are available in drug stores without a prescription. While it is not unreasonable to use them, their overall benefit is small and they can be expensive.

Preventing spread Parents with children who have diarrhea should be cautious to avoid spreading infection to themselves, their family, and friends. Care with hand washing, diapering, and keeping sick children out of school or daycare are a few ways to limit the number of people exposed to the infection.

Hygiene measures Hand washing is an essential and very effective way to prevent the spread of infection. Hands should ideally be wet with water and plain or antimicrobial soap, and rubbed together for 15 to 30 seconds. Special attention should be paid to the fingernails, between the fingers, and the wrists. Hands should be rinsed thoroughly, and dried with a single use towel.

Alcohol-based hand rubs are a good alternative for disinfecting hands if a sink is not available. Hand rubs should be spread over the entire surface of hands, fingers, and wrists until dry, and may be used several times. Hand rubs are available as a liquid or wipe in small, portable sizes that are easy to carry in a pocket or handbag. When a sink is available, visibly soiled hands should be washed with soap and water.

Hands should be cleaned after changing a diaper or touching any soiled item. They should also be washed before and after preparing food and eating, after going to the bathroom, after handling garbage or dirty laundry, after touching animals or pets, and after blowing the nose or sneezing.

WHEN TO SEEK HELP The following is a list of signs and symptoms that are worrisome and require immediate medical attention:

Bloody diarrhea

If an infant refuses to eat or drink anything for more than a few hours

Moderate to severe dehydration

Abdominal pain that comes and goes or is severe

Fever greater than 102ÿF (39ÿC), or fever over 101ÿF (38.4ÿC) for more than three days

Behavior changes, including lethargy or decreased responsiveness

SUMMARY

Most episodes of acute diarrhea resolve on their own. However, immediate medical attention should be sought for children who have any of the following: bloody diarrhea; signs of moderate to severe dehydration; refusing to eat or drink anything; abdominal pain that comes and goes or is severe; fever greater than 102ÿF or 39ÿC, or fever over 101ÿF or 38ÿC for more than three days; behavior changes, including lethargy or decreased responsiveness. ( See "When to seek help" above ).

The most common cause of acute diarrhea is a viral infection. Other causes include bacterial infections, side effects of antibiotics, and bodywide infections not related to the gastrointestinal (GI) system. In addition, there are many less common causes of diarrhea ( show table 1 ). ( See "Causes" above ).

Children who are not dehydrated should continue to eat their regular diet. Children who are dehydrated should be rehydrated, after which they can resume their normal diet (with possibly some modifications). Children who are breastfeeding should continue to do so unless told otherwise by their clinician. ( See "Dietary recommendations" above ).

Oral rehydration therapy (ORT) should initially be given to children who are dehydrated. Common signs and symptoms of dehydration include decreased urination (less than one wet diaper or void in six hours), lack of tears when crying, dry mouth, sunken eyes, and weight loss. ORT can be purchased at most grocery stores and pharmacies in the United States without a prescription. ( See "Oral rehydration therapy" above ).

Medications such as antibiotics and antidiarrheal agents are generally not recommended for infants or children with diarrhea. ( See "Medications" above ).

Parents with children who have diarrhea should be cautious to avoid spreading infection to themselves, their family, friends, and others. Care with hand washing, diapering, and keeping sick children out of school or daycare are a few ways to limit the number of persons exposed to infectious microorganisms. ( See "Preventing spread" above ).