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Evaluation of diarrhea in

children
Clinical features
The age of the child, associated findings, appearance of the stool,
and history of exposures may provide clues to distinguish viral
from other pathogens.
Age Bacterial and parasitic agents generally cause
gastroenteritis in children at an older age (eg, 2 to 4 years),
whereas viral pathogens tend to cause serious gastroenteritis
in those younger than 2 years.
Presence of blood or mucus The presence of gross blood or
mucus in the stool suggests bacterial or parasitic infection;
these almost never occur with viral gastroenteritis. Blood detected
in the stool only by guaiac test is not a useful discriminator.
Exposures Bacterial or parasitic acute gastroenteritis may be
associated with foreign travel, exposure to poultry or other farm
animals, or consumption of processed meat.
Febrile with non-bloody diarrhea
The presence of fever in an immunocompetent
child with diarrhea is the hallmark of infection.
Most febrile children with nonbloody
diarrhea have viral enteritis.
Afebrile with non-bloody diarrhea
Many afebrile children with nonbloody diarrhea
will also have viral enteritis.
For those taking antibiotics, such as
amoxicillin, the diarrhea may be related to the
medication.
Overfeeding may cause diarrhea during the
first 6 to 12 months of life.
The tip-off to this diagnosis is the history of
excessive fluid intake in an overweight child
Febrile with bloody diarrhea
Febrile children with bloody and/or mucousy
diarrhea typically have infectious bacterial
enteritis.
Possible exceptions include the following:
Pseudomembranous colitis is an important consideration in
children with bloody diarrhea who have also received antibiotic
therapy, especially if systemic toxicity, abdominal distension,
and gross blood in the stools are present.
Amebiasis merits consideration in children or immigrants from
endemic areas (eg, India, Africa, Mexico, Central and South
America) and, less commonly, among travelers to these
regions.
An occasional child with inflammatory bowel disease may
present with an initial episode of acute, bloody diarrhea. In
most of these cases, the physician can elicit a preceding
history of weight loss or recurrent abdominal pain.
Afebrile with bloody diarrhea
Afebrile children with bloody diarrhea represent the most
worrisome category because most patients with intussusception,
HUS, and pseudomembranous colitis have this symptom
constellation:
Intussusception should be considered carefully in any child
less than one year of age with grossly bloody diarrhea that
does not appear to have an infectious cause. A history of
severe, colicky abdominal pain in a lethargic child warrants
an abdominal ultrasound or contrast enema.
Bloody diarrhea with pallor, purpura, elevated serum blood
urea nitrogen or creatinine, and hematuria point to HUS.
Prior antibiotic therapy raises the possibility of
pseudomembranous colitis.
Hospital admission is warranted in children with any
one of the following findings:
Diagnosis of or strong clinical suspicion for a life-
threatening cause of diarrhea, such as HUS or other
systemic illnesses
Severe dehydration or significant electrolyte
abnormalities upon presentation
Lack of improvement with rehydration
Continued copious diarrhea that is likely to lead to
recurrent dehydration if intravenous replacement of
ongoing losses does not occur
Inability to drink
Vitamins and minerals
Zinc
Several studies have demonstrated that zinc
supplementation reduces the severity and
duration of diarrhea and reduces the incidence
of subsequent episodes of diarrhea for several
months.
Based on these studies, the WHO
recommends zinc for children under 5 years of
age with diarrhea (10 mg/day for under 6
months and 20 mg/day for 10 days for 6
months to 5 years).
Vitamin A
Children with diarrhea in developing countries
are at high risk of vitamin A deficiency and
should receive high dose supplementation
with vitamin A.
Patients with signs of xerophthalmia, severe
malnutrition, or a history of measles should
receive a three dose series of repeated
treatments for vitamin A deficiency
Children with acute diarrhea should NOT
receive antimotility agents or antiemetics.
Antimotility agents (loperamide , diphenoxylate-
atropine, and tincture of opium ) prolong some
bacterial infections and may cause fatal
paralytic ileus in children.
Antiemetics (chlorpromazine, prochlorperazine,
promethazine , and metoclopramide ) have
sedating effects that can interfere with
rehydration and may cause extrapyramidal
reactions and respiratory depression
Empiric antibiotic therapy for acute bloody
diarrhea should be targeted against Shigella
species.
Antimicrobial treatment of Shigella
gastroenteritis reduces the duration of fever
and diarrhea, decreases the duration of
bacterial shedding, and may reduce the risk of
life threatening complications of infection such
as bacteremia
Amebic dysentery due to the intestinal parasite
E. histolytica may be clinically indistinguishable
from shigellosis and does not respond to anti-
Shigella therapy.
Direct stool microscopy can be used for
presumptive diagnosis as discussed above.
Metronidazole (35 to 50 mg/kg per day in three
divided doses for 7 to 10 days in children to a
maximum of 750 mg PO three times daily) is a
standard treatment regimen with a cure rate of
approximately 90 percent
Hemolytic uremic syndrome
Shigella dysenteriae serotype 1 produce Shiga
toxin, which is associated with hemolytic uremic
syndrome.
In patients with Shigellosis treated with
appropriate antibiotics, there is no increase in
toxin production or risk of HUS. This is in
contrast to Shiga-toxin producing E. coli, for
which retrospective and prospective
observational studies have reported an
increased risk of HUS with the administration of
antibiotics during the bloody diarrhea phase.

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