Acute Diarrhea in Children

Thomas G. DeWitt
Pediatr. Rev. 1989;11;6-12
DOI: 10.1542/pir.11-1-6

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 Acute Diarrhea in Children
Thomas G. DeWitt, MD*

to fluid and electrolyte transport; the

The questions below should help second relates to the four principal
focus the reading of this article. pathophysiologic processes that can EDUCATIONAL OBJECTIVES
1. What are typical laboratory find- contribute individually or collectively 7. The pediatrician should have
ings in patients with lactase malab- to diarrhea. These processes tend to knowledge to make an appropriate
sorption? produce different types of diarrhea evaluation of a dehydrated infant
2. What clinical and simple labora- with varying fluid and electrolyte with gastroenteritis, assessing
tory findings are useful in the differ- losses that have significant implica- electrolyte status and identifying
ential diagnosis between viral and tions for management.
bacterial enteritis? the clinical situation in which oral
The developing gastrointestinal sys- rehydration is the desired method
3. What are the roles of oral hydra-
tion solutions and solid foods in the
tem has an age-related variation in of management rather than paren-
management of diarrhea with acute the metabolism of fluid and electro- teral fluid therapy, with specific at-
diarrheal illnesses? lytes. In the young infant, the intes- tention to resources available to
4. Why do soft drinks and fruit juices tinal mucosa tends to be permeable correct dehydration in a cost-
not make good oral hydration solu- to water. As the child matures, the effective manner (Topics, 89/90).
tions? permeability of the mucosa dimin- 31. The pediatrician should have
5. What are the characteristics of ishes. Therefore, in a young infant an appropriate awareness of the
Cryptosporidlum ententis? the impact of the increased luminal clinical features of Campylobacter
osmolality due to diarrheal processes ententis (Recent Advances, 88/
can result in a greater net fluid and 89).
electrolyte loss than in an older child 91. The pediatrician should have
Derived from the Greek dia or adult with a similar process. In an appropriate recognition of the
“through”and rhien “to flow”, the term addition, because 80% of fluid ab- value of the breath hydrogen test
diarrhea refers to stools that are ab- sorption occurs in the small bowel, a in the diagnosis of carbohydrate
normally frequent and liquid. The pathologic process that predominant- intolerance (Recent Advances, 88/
modifier “abnormal” is critical in pe- ly affects the small bowel will predis- 89).
diatrics because stools can normally pose the young infant to more rapid 99. The pediatrician should have
be frequent and liquid in the young dehydration. an appropriate understanding of
pediatric patient. Acute diarrheal ill- There are four basic pathophys- the factors involved in the decision
nesses account for more than 3 mil- iologic processes that produce diar- to start solid foods after an epi-
lion ambulatory pediatric visits, 10 rheal stools in children: secretory, cy- sode of acute diarrhea in an infant
million sick days, and 1 00 000 hos- totoxic, osmotic, and dysenteric. (Recent Advances, 88/89).
pital admissions per year in the United Diarrhea may be a combination of one
States. This review will focus primar- or more of these processes.
ily on acute pediatric diarrhea and its
sequelae because chronic diarrhea which in turn binds to the cell surface
Secretory Process
warrants its own review. In this article of the small intestine mucosal cell. A
(1) the pathophysiologic processes Acute secretory diarrhea is due to fragment of the enterotoxin then en-
that cause acute diarrhea will be ex- an enterotoxin produced by an infec- ters the cell and stimulates the adenyl
amined, (2) guidelines for evaluating tious, metabolic, or exogenous toxic cyclase system. The increased aden-
a child with acute diarrhea will be agent. The enterotoxin stimulates se- osine triphosphate that is produced
suggested, and (3) current manage- cretion of fluid and electrolytes from stimulates the active transport mech-
ment issues and approaches will be the mucosal crypt cells, the principal anism in the cell membrane and in-
explored. secretory cells of the small bowel. creases the active secretion of fluid
This process is mediated through and electrolytes out of the crypt cell
prostaglandins and effects cyclic into the intestinal lumen. There is a
Pathophysiology
adenosine monophosphate, guano- block in the reabsorption of fluid and
In acute diarrhea in children, one sine monophosphate, and Ca2 ion electrolytes in villus cells also caused
must consider two concepts related flows. The enterotoxin also may by the enterotoxin. The mechanism
to its pathophysiology: the first is the block absorption of fluid and electro- of this block is not as well under-
developmental aspects of the young lytes in the villus cells, which are the stood. This block of reabsorption
gastrointestinal system with regard principal absorptive cells. does not tend to effect the movement
Bacterial enterotoxins have been of glucose into the cell at a concen-
the most extensively studied of these tration of 2% to 3%. The movement
* Associate Professor of Pediatrics, Director, agents. The effect of bacterial enter- of glucose into the cell brings with it
Division of General and community Pediatrics, otoxin on gastrointestinal mucosal fluid and electrolytes. Therefore, it is
University of Massachusetts Medical center, cells is illustrated in Fig 1. The infec- this concentration of glucose that is
Worcester. tious agent produces an enterotoxin, used in rehydration solutions.

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 GASTROENTEROLOGY

high enough concentration to be Os-

motically active, there is a net flux of
water into the lumen resulting in
loose, diarrheal stools. In many cases
of osmotic diarrheal processes, the
large bowel flora is inundated with
increased carbohydrate substrate
which is metabolized and produces
gas, abdominal pain, and a de-
creased stool pH.

Dysenteric Process
In dysentery there is inflammation
of the mucosa and submucosa of the
terminal ileum and the large bowel.
The inflammation, most commonly

Bacterial
diarrheas,
caused
particularly by
Campylobacter, Salmonella,
and Shigella, primarily affect
the large bowel, producing
frequent, often bloody, stools
that usually contain
leukocytes.

due to invasion by a bacterial agent,

causes edema, mucosal bleeding,
and leukocytic infiltration. Leuko-
cytes and blood are exuded into the
lumen of the intestine. Fluid absorp-
tion, which is the principal activity of
the large bowel, is decreased which
leads to liquid stools. The irritation of
the inflammation causes increased
Fig 1. Effect of bacteria! enterotoxin on muccsa! cells of the small intestine.
colon motility and frequent stooling,
often with tenesmus.
The types of diarrhea and the caus-
Cytotoxic Process and a marked decrease in the ab-
ative agents thought to be most com-
sorptive function of the small bowel
The cytotoxic process is character- monly associated with these proc-
mucosa.
ized by the destruction of the mu- esses are listed in Table 1 Several .

cosal cells of the villi of the small agents appear in two or more col-
intestine, most commonly by an infec- umns indicating that they may precip-
Osmotic Process
tious viral agent. After cell lysis, the itate several processes. Although the
villi shorten, and the mucosal surface Osmotic diarrhea is most com- longest list is in the secretory diarrhea
takes on an appearance similar to monly seen in malabsorption syn- column, the most common agents in
that seen in celiac disease. The func- dromes, although the process func- developed countries are the patho-
tional effect of this process is to de- tionally occurs with both secretory gens in the cytotoxic and dysenteric
crease the surface area of the small and cytotoxic diarrheas because of categories and include Rotavirus,
bowel, thereby decreasing the capa- the inability of the intestine in both Campylobacter, Salmonella, and
bility of the small intestine to absorb processes to absorb nutrients and Shigella.
fluidand electrolytes. In addition, electrolytes normally. The most com- There is an alteration in the gas-
most of the cells that remain are crypt mon malabsorption syndrome is lac- trointestinal motility associated with
cells, the principal secretory cells of tose intolerance due to the relative these processes. In secretory and cy-
the intestinal mucosa. In effect, there sensitivity of the lactase enzyme on totoxic diarrhea, there is most often
is the same functional process as that the mucosal cell brush border to any a functional ileus, with a decrease in
seen in secretory diarrhea with a pro- pathologic gastrointestinal process. If the intestinal tone that slows peri-
portional increase in the secretory the malabsorbed substance has a staltic movement through the intes-

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Acute Diarrhea

of this section will be primarily on this tus; and frequency of urination can
TABLE 1. Etiologic Agents in etiology of acute diarrhea. Seasonal help one assess general state of hy-
Diarrheal Processes variation is an important considera- dration. A history of markedly re-
tion because bacterial diarrheas tend duced oral intake, particularly with
Secretory
to have their highest incidence in large stool losses and decreased fre-
Escherichia coli*
Vibrio cholerae warm seasons and the viral agent quency of urination, should alert the
Clostridium diffidile predominates in cold seasons with clinician to the potential of significant
Clostridium perfringens Rotavirus causing as much as 50% dehydration. An altered mental state
Aeromonas hydrophila of the wintertime diarrhea in young isparticularly worrisome, especially if
Staphylococcus aureus children and infants. A simple algo- persistent, and requires immediate
Vibrio parahaemolyticus rithmic approachto acute pediatric evaluation. The history of dry lips is a
Bacillus cereus diarrhea proposed by Radetsky and variable sign of dehydration and may
Shigeila independent of season is shown in be representative of high fever as well
Salmonella Fig 2. The initial steps are clearly as the state of hydration.
Yersinia enterocoiltica
focused on information from the his- The patient or parent should be
Giardia lambila
Neuroblastoma tory and physical examination. The asked about fever, antibiotic therapy,
Cytotoxic special considerationsin this algo- exposure to day care or other chil-
Rotavirus* rithm include malabsorption, immune dren and adults with a diarrheal his-
Norwalk agent compromise, recent antibiotic use or tory, ingestion of certain foods such
Cryptosporidium travel, neonatal patient, day care, and as raw milk and poorly prepared or
Escherichia coil common outbreak. stored poultry and salads, and ex-
Osmotic The history, whether obtained from posure to other sources of potential
Lactose* the phone conversation or during the enterotoxin such as untreated water
Sorbitol
initial part of the office visit, needs to sources. A familial history of diarrheal
Dysenteric
be focused on assessing a child’s illnesses, especially associated with
Campylobacter fetus*
Clostridium diffidile state of hydration and the possible inflammatory bowel disease of food
Salmonella causative agents. Information regard- intolerance, should be obtained. Be-
Shigella ing amount of oral intake; frequency cause immuncompromised patients
Yersinia enterocolltica and volume of stool; general appear- require special consideration, infor-
Entamoeba histolytica ance of the child, especially with re- mation about this possibility should
* Most common etiologic agent in gard to hydration of lips; mental sta- be included.
category.

tines. This in turn causes (1) luminal

dilation, leading to visceral abdominal
pain and vomiting, (2) delayed gastric
emptying, which may contribute to
vomiting, and (3) rapid intestinal tran-
sit time with marked peristaltic
rushes. In the dysenteric process,
there is irritation of the colon by the
inflammatory process, leading to fre-
quent discharge and tenesmus. Pros-
taglandins play a significant role in
mediating functional ileus, although
their role in the dysenteric process is
not clear.
Campy Smear
EVALUATION + f
Treat if-Food Handler
History or Incontinent

In diarrheal illness, the history and

physical examination serves as an
initial screen to narrow the diagnostic
possibilities. The choice of laboratory
tests depends on the results of the
history and physical examination. Be-
cause most acute diarrhea in children Fig 2. Algorithm for diagnostic evaluation of acute diarrhea. Adapted from Radetsky M. Labo-
is due to infectious agents, the focus ratory evaluation of acute diarrhea. Pediatr Infect Dis. 1986;5:230-238 (used with permission).

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 GASTROENTEROLOGY

Two factors that may be particu- child, paying particular attention to often helpful in obtaining a stool sam-
larly helpful in identifying the diarrheal state of hydration. Mucous mem- pIe for occult blood, culture, and ex-
etiology concern the history of vom- branes, more than the lips, should be amination for leukocytes, pH, and re-
iting and the character and frequency evaluated for moistness. The appear- ducing substances.
of the stool. The timing of the onset ance of the anterior fontanel and eyes
of vomiting can aid in differentiating a with regard to scaphoid presentation
small vs large bowel process. Small should be assessed. The skin hydra- LABORATORY EVALUATION
bowel processes, most commonly tion and turgor may give a sense of The most crucial initial laboratory
associated with viral agents, cause the degree of dehydration. The find- evaluation that the clinician should
delayed gastric emptying and luminal ing of doughy, tented skin is associ- consider is related to the assessment
distention which often induces vom- ated with hypernatremic dehydration. of degree of dehydration. Serum elec-
iting before the onset of diarrhea. Finally, the child’s mental status with trolytes, particularly sodium and bi-
Processes involving the small bowel regard to interaction with the exam- carbonate, should be assessed in any
tend to produce large volume, watery iner and parents can be used as a child considered significantly dehy-
stools that are relatively infrequent. measure of seriousness of illness and drated. Knowing the serum sodium
Conversely, large bowel involvement, dehydration. The importance of this concentration is crucial when deter-
usually due to a bacterial-induced in- global assessment is reflected in the mining the composition of the fluids
flammatory process, tends to pro- Yale Observation Scales for evaluat- and rate of rehydration to be used in
duce frequent, less watery stools. ing critically ill children. Two of the a child who is dehydrated. Knowing
The history of bloody stools is major components of these obser- the bicarbonaate level aids in deter-
highly suggestive of a bacterial path- vation scales are mental status and mining the degree of dehydration. As
ogen, particularly in the older infant state of hydration. tissue perfusion decreases with in-
and child. Although a child with All children with diarrhea should be creasing dehydration, the amount of
bloody diarrhea has at least a 50% carefully weighed unclothed for corn- lactic acid buildup in peripheral tissue
chance of having a bacterial patho- parison with previous weights and to increases and the bicarbonate con-
gen, only one in three children with provide a baseline for monitoring sub- centration decreases. Serum ob-
bacterial diarrhea will have bloody sequent weights during the course of tamed by venipuncture and bicarbon-
stools. In addition, in the infant less thedisease. Temperature, blood pres- ate concentration measured by mul-
than 6 months of age, the most com- sure, and pulse all may provide infor- tichannel laboratory analysis tends to
mon causes of blood in the stool are mation concerning the degree of ill- be less than serum bicarbonate cal-
cow milk intolerance or anal fissures. ness. An elevated temperature in- culated from an arterial or venous
Diarrhea without concurrent fever, creases insensible water loss and blood gas sample. If the bicarbonate
but with abdominal pain and greasy may lead to more rapid dehydration. concentration seems disproportion-
flatulent stools, is characteristic of a A decreased blood pressure, an ele- ately low in the context of the rest of
vated pulse, or decreased peripheral the child’s assessment, a venous
perfusion may indicate intravascular blood gas analysis may be helpful in
Lactose intolerance is a volume loss due to dehydration. The clarifying this disparity. A markedly
common side effect of many rest of the physical examination elevated BUN concentration with a
diarrheal processes and should be focused on signs of con- relatively normal creatinine value may
needs to be a consideration current viral illness such as upper indicate recent or rapid dehydration.
in the management and respiratory tract infections that may Serum creatinine concentrations tend
follow-up of any child with be associated with gastroenteritis, as to be low in infants and young chil-
acute diarrhea. well as abdominal findings. dren and a creatine value of 1 mg/dL
The abdominal examination should in this age group may represent a
begin with a general assessment of doubling of the normal value. A un-
malabsorptive process. A history of
whether the abdomen is distended or nalysis for specific gravity as well as
acute diarrhea, followed by continued
scaphoid. The distended abdomen the presence of leukocytes, ketones,
or intermittently occurring episodes
may be associated with an ileus as and crystalline material should be ob-
of loose stools, suggests malabsorp-
seen in enteritis or gaseous dilation tamed for any child considered to be
tion. This is most commonly due to
due to malabsorption. The scaphoid dehydrated. Because urinary tract in-
secondary lactose intolerance, often
abdomen may be associated with se- fections in children may be associ-
exacerbated by the ingestion of milk
vere dehydration. Auscultation may ated with diarrhea, a urine culture
or milk products. Excessive intake of
reveal the high pitched sounds of per- should be performed if there are leu-
high carbohydrate fluids, such as ap-
istaltic rushes found in the enteritic koyctes in the urine.
pie juice and nonabsorbable fillers
and secretory diarrheas. Signs of per- Examination of the stool may help
such as sorbitol, may also lead to itonitis, which may cause diarrhea determine the differential diagnosis
malabsorptive diarrhea.
due to inflammation and local enteric but is of little use in determining de-
irritation, should be carefully gree of dehydration. Although occult
PHYSICAL EXAMINATION
assessed. Dysenteric diarrheas tend blood in the stool may be present in
The physical examination should to be associated with a more quiet small infants with excoriated penianal
begin with a global assessment of the abdomen. A rectal examination is areas, the appearance of gross blood

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Acute Diarrhea

in the stool is diagnostically impor- outbreak in a day-care setting. An tion test by which the integrity of the
tant. A distinctively abnormal stool initial identification of Cryptospori- small bowel mucosa is assessed.
odor or lack thereof, as is often the dium can be done by examining an One hour after an oral dose of xylose
case in small bowel involvement, may iodine-stained wet mount of centni- is administered, a single determina-
help differentiate the etiology, but fuged stool for oocysts, which appear tion of serum xylose is made. In proc-
that diagnostic test is best left to as unstained oval structures. If pre- esses such as small bowel bacterial
knowledgeable noses. The presence sent, a definitive assessment with a overgrowth, celiac disease, and re-
or absence of reducing substance modified acid-fast stain should be gional entenitis, the damaged mucosa
and the stool pH have not consist- performed. In the immunocompro- is unable to absorb xylose normally
ently been shown to clarify the differ- mised child, special consideration and the 1-hour serum level is low. If
ential diagnosis of acute infectious must be given to culturing for an array the D-xylOse test result is positive,
diarrhea. However, the presence of of organisms that may become additional evaluation, including bi-
reducing substances and a low pH pathogenic in such a host. opsy and diagnostic imaging studies,
are indicative of malabsorption. The In recent years, several rapid tests should be considered. However,
presence of mucus is commonly as- have been developed to identify infec- most tests for the evaluation of small
sociated with bacterial diarrheas. tious agents, eg, the latex fixation intestinal integrity and function
The presence of stool leukocytes test and enzyme-linked immune as- should be reserved for the work-up
is helpful in identifying bacterial diar- says for Rotavirus. Of potential help of chronic or recurring diarrhea.
rhea, especially those causing a dy- to the clinician in the near future may
senteric process. Patients with leu- be similar diagnostic tests being de-
MANAGEMENT
kocytes in their diarrheal stools have veloped for bacterial pathogens in-
approximately a 70% chance of hay- cluding Salmonella, Shigella and The use of oral hydration solutions
ing a bacterial infection. Moreover, as Campylobacter. Campylobacter, the represents the greatest advance in
many as 90% of patients with bacte- most common cause of bacterial diar- the treatment of diarrhea in the past
rial dysentery have leukocytes in their rhea in young children as well as 15 years. Prior to the introduction and
stools. Thus, presence of stool leu- adults, may be rapidly identified by demonstrated efficacy of the World
kocytes has both a high-positive pre- presence of the characteristic Gram- Health Organization oral rehydration
dictive value and a high sensitivity for negative vibnio, “gull wing,” orga- solution, intravenous hydration was
bacterial diarrhea. The method for as- nisms in a gram-stained stool sample. the only accepted treatment for sig-
sessing stool leukocyte content is Although some malabsorption is nificantly dehydrated children. Pa-
noted in Table 2. commonly associated with most diar- tients were hospitalized, given noth-
Stool for culture should be ob- rheal processes, when it is the prin- ing by mouth, resuscitated with intra-
tained if the history and stool exami- cipal diagnosis being considered, venous fluid, and then gradually given
nation strongly suggest a bacterial there are a series of laboratory as- increased amounts of oral fluids. If
cause. A fresh sample of stool in a sessments that can be useful. The diarrhea recurred, as it almost inevit-
clean, if not sterile, container is pre- simplest and quickest are for stool ably did, the oral intake was reduced
ferred for accurate culture results. pH and reducing substances. A low and intravenous hydration was con-
However, a well-soaked rectal swab, pH and the presence of reducing sub- tinued. An understanding of the
two or three if possible, in transport stances suggest malabsorption. In pathophysiologic process mentioned
media is usually sufficient. Fresh stool the infrequent cases in which the diar- previously has dramatically changed
for ova and parasites should be ex- rhea is prolonged, more complex this approach. Use of oral rehydration
amined, especially when Giardia lam- tests can be subsequently per- solutions with appropriate concentra-
b/ia or Cryptosporidium is suspected, formed. One of the most commonly tions of glucose (approximately 2%)
as would be the case in the diarrheal used tests today is the noninvasive and varying concentrations of elec-
breath hydrogen lactose tolerance trolytes as appropriate for the stage
test. In lactose intolerance, there is of rehydration has significantly de-
an increase in breath hydrogen ap- creased the need for inpatient, intra-
TABLE 2. Stool Leukocyte proximately 2 hours after administra- venous hydration.
Assessment tion of a standard oral lactose dose The first stage of intravenous re-
1. Obtain small amount of stool, as the malabsorbed lactose is metab- hydration classically consists of a
preferably with mucus. olized to hydrogen gas by the flora of rapid infusion of an isotonic solution
2. Smear thinly on microscope the large intestine, transported to the to expand the intravascular volume
slide. lungs, and exhaled. A minimal in- usually given at a rate of 1 0 to 20
3. Add drop of methylene blue crease in breath hydrogen usually in- mL/kg of body weight throughout a
and apply coverslip. dicates that lactose intolerance is un- 1- to 2-hour period. Subsequent in-
4. Scan with low-power lens
likely, whereas an early increase in travenous hydration is a combination
(lOx) and then examine under
high power (40x). breath hydrogen may suggest other of replacement of the estimated fluid
5. Presence of a high-power field small bowel pathologic process such loss based on the degree of dehydra-
with >5 leukocytes is consid- as bacterial overgrowth. Further elu- tion added to the regular mainte-
ered positive result. cidation of small bowel disease can nance needs. This should occur
be pursued with a o-xylose absorp- throughout 16 hours, unless the child

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 GASTROENTEROLOGY

has hypematremic dehydration, in or outpatient, and (2) orally or intra- feedings. For the child with less than
which case the rehydration duration venously, is dependent upon several 5% dehydration, oral rehydration
is increased to a 24- to 48-hour factors. the first is the state of dehy- should always be attempted.
period. dration. Children with greater than After vomiting has ceased there is
This same process can occur with little evidence that withholding food
oral rehydration solutions by use of - from a child with diarrhea is medically
an electrolyte solution with the so- helpful. If lactose-containing foods,
dium concentration between 70 and Oral hydration, usually with the exception of breast milk, are
90 mEq/L for the initial fluid resusci- administered to the patient avoided during the acute diarrheal ill-
tation and intravascular volume ex- as an outpatient, should be ness, then the early introduction of
pansion. The volume should be cal- the treatment of choice for all food may actually be a benefit to the
culated similarly to that of the intra- but the most severely ill child. Except for concerns about
venous hydration, 10 to 20 mL/kg of dehydrated patients or aspiration during vomiting and that
body weight. This initial stage then is patients whose caretakers the volume of diarrhea tended to be
followed by continual administration cannot administer the fluids. increased in those children who were
of oral hydration solutions with a so- fed early, it is unclear why the gen-
diurn concentration between 40 and erally accepted approach to children
50 mEq/L and volumes calculated to 10% dehydration or hypematremic with diarrheal illness has been to re-
satisfy deficit and maintenance re- (Na >150 mEq/dL) dehydration strict food intake. However, as
quirements. The electrolyte and car- should be admitted to the hospital. pointed out in an article 40 years ago
bohydrate concentrations of corn- Oral rehydration for these children by Chung, children who were fed
mercially available oral rehydration may be attempted in the hospital, throughout their diarrheal illness lost
solutions and common home reme- depending on the circumstances and less weight and recovered sooner
dies are listed in Table 3. It is impor- cardiovascular stability of the patient. than those children who were
tant to note the inappropriately high However, if there are any indications starved. Although there is a potential
carbohydrate and low sodium con- of significant peripheral vascular corn- for increased sensitization to dietary
centration of most of the home rem- promise or pending shock, intrave- protein in infants with diarrhea be-
edies. nous hydration is mandatory. For the cause of the damaged mucosa’s in-
Oral rehydration with small (15 to child who is isotonically 5% to 10% creased permeability to whole pro-
30 mL), frequent sips of fluid may be dehydrated, the choice of inpatient vs tein, the clinical impact of this process
initiated before all vomiting ceases. outpatient management is dependent has not been elucidated.
This approach has the theoretical ad- on the clinician’s comfort with the The antimicrobial treatment of the
vantage of reducing the degree of ability of the person caring for the child with diarrhea caused by an in-
gastric distention and subsequent child to administer the oral fluids. Chil- factious agent is given in Table 4. All
vomiting that would occur with larger, dren with this degree of dehydration of the bacterial agents, with the pos-
infrequent volumes, If vomiting does tend to do well with oral hydration sible exception of Clostridium diffi-
recur, a brief 30-minute to 1-hour de- and this should be attempted initially. dile, tend to produce an acute but
lay before the reinitiation of oral re- Contraindications to this are severe self-limited course and probably do
hydration is recommended. protracted vomiting or inability of the not require antibiotic treatment.
The determinations of whether the child’s health care provider to comply There are no antiviral medications
rehydration occurs (1) as an inpatient with the required regimen of oral currently available. Metronidazole is
effective against both Giardia and En-
tamoeba hystolytica infections. For
Campylobacter infections, erythro-
mycin is the drug of choice, which
clearly reduces the duration of fecal
excretion of the bacteria and the du-
ration of the symptoms when started
Commerdal-! early in the course of the illness. Sal-
WHO solul monella infection is usually not
Hydra-Lb - = treated except in small infants in
Rydrolute whom sepsis is suspected. Shigella,
PediaIyte! which was once susceptible to am-
Lytren picillin, now tends to be resistant to
Resol
that antibiotic. Documented entero-
Infalyte
Home remed colitis caused by C diffidile is treated
Jello (half
with vancomycin or metronidazole.
Gatorade Antidiarrheal agents in the pediatric
Soft drinkS population, particularly in younger pa-
Ap tients, should be used with caution.
Because the frequent stooling should

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Acute Diarrhea

Brown KH, MacLean WC. Nutritional manage-

ment of acute diarrhea: an appraisal of the
TABLE 4. Antimicrobial Treatment for Infectious Diarrhea alternative. Pediatrics. 1984;73:1 19-125
Organism Drug Chung AW, Viscorova B. The effect of early
oral feeding versus early oral starvation on
Aeromonas hydrophila Amoxicillin, trimethopnm-sulfamethoxazole the course of infantile diarrhea. J Pediatr.
Campylobacter Erythromycin 1948;33:1 4-22
Clostridium diffidile Vancomycin, Metronidazole DeWitt TG, Humphrey KF, Mccarthy P. clinical
Clostridium perfringens Penicillin, tetracycline predictors of acute bacterial diarrhea in
Escherichia coil Trimethoprim-sulfamethoxazole young children. Pediatrics. 1 985;76:551 -

Entamoeba histolytica Metronidazole, diodohydroxyquin 556

Guerrant RI, Lohr JA, Williams EK. Acute infec-
Giardia lambila Metronidazole, furazolidone, quinacrine
tious diarrhea, I. Epidemiology, etiology and
hydrochloride pathogenesis. J Pediatr. 1 986;5:353-359
Salmonella Tetracydine, chloramphenicol Gishan FK. The transfer of electrolytes in the
Shigella Amoxicillin, trimethoprim-sulfamethoxazole gut and the use of oral rehydration solutions.
Vibrio cho/erae Tetracycline, tnmethoprim-sulfamethoxazole Pediatr Gastroenterol. 1988;35:35-51
Yersinia Tetracycline, chioramphenicol Radetsky M. Laboratory evaluation of acute
diarrhea. Pediatr Infect Dis. 1986;5:230-238
Santosham M, Daum AS, Dillman L, et al. Oral
rehydration therapy of infantile diarrhea-a
treatment for the majority of pediatric controlled study of well-nourished children
be considered a purging mechanism hospitalized in the United States and Pan-
ama. N EngI J Med. 1982;306:1 070-1 076
for ridding the intestines of the caus- diarrheal illnesses. Silverman A, Roy cc. Selected laboratory
ative pathogens, the use of any anti- tests. In: Pediatric CllnicalGastroenterology.
diarrheal agent is not indicated in SUMMARY St Louis, IL: CV Mosby; 1983;889-905
most acute diarrheal episodes. Be- Tolia VK, Dubois AS. Update on oral hydration:
Acute diarrhea is a common prob- its place in treatment of acute gastroenteri-
cause the increased motility of many lem in children. Understanding the dif- tis. Pediatr Ann. 1985;14:295-299
of the pathologic processes de- Williams EK, Lohr JA, Guerrant AL. Acute in-
ferent pathologic processes that
scnibed earlier are mediated by pros- cause diarrhea, and the agents that fectious diarrhea, II. diagnosis, treatment
taglandins, prostaglandin inhibitors are associated with those processes,
and prevention. Pediatr Infect Dis. 1986;
tend to be effective antidiarrheal 5:458-465
can aid the clinician in predicting the
agents. Bismuth subsalicylate has ef- etiology of the diarrhea in an individ-
fective antiprostaglandin activity and ual patient. Small bowel involvement,
also binds bile salts which may con- most commonly caused by Rotavi-
tribute to the diarrheal process. How-
rus, produces a high incidence of
ever, it can cause elevated serum vomiting, often before the onset of Self-Evaluation Quiz
salicylate levels which raises concern diarrhea, and large, watery, and rel- 1. Which of the following would be cx-
about Reye syndrome. Loperamide atively infrequent stools. Large bowel pected after administration of lactose to a
also has principally antiprostaglandin involvement, usually due to Campy- patient with lactose malabsorption?
activity and, because it does not con- /obacter, Salmonella, or Shigella pro- A. Normal stool pH.
tam salicylate, may be a reasonable duces frequent, often bloody stools B. No reducing substances in stool.
choice. Agents with narcotic sub- containing leukocytes. Treatment of C. Positive breath hydrogen test result.
stances as the active agent should diarrhea should be focused on con- D. Poor D-xylOSe absorption.
be avoided because they may pro- recting dehydration, principally with
E. Reducing substances in urine.
long the excretion and pathologic oral rehydration solutions containing 2. A 2-year-old girl has diarrhea and a tem-
process of some bacterial agents. appropriate concentrations of elec- perature of 38#{176}C.
Which of the following
Binding substances such as kaolin trolytes and carbohydrates. Early re- would suggest that she has viral, rather than
and pectin are only modestly effective feeding, avoiding foods containing a bacterial, enteritis?
but, unlike the narcotic-based antidi- lactose, should be considered for A. Stool leukocytes.
arrheal agents, have less of an impact most pediatric patients with acute
B. Mucus in stools.
on the course of the pathologic proc- C. Blood in stools.
diarrhea. Antimicrobial therapy should 0. Vomiting before onset of diarrhea.
esses.
be reserved primarily for parasitic in- E. Frequent, mildly watery, small-volume
Finally, the most effective manage- fectious, pseudomembranous enter- stools.
ment for all infectious diarrheas is ocolitis, and the early stages of a
prevention. Good sanitation and Campylobacter dysentery. The eti- 3. Which of the following statements is least
careful hand washing, particularly in ology of acute pediatric diarrhea can
likely to be true?
situations such as day care, are criti- A. Use of oral hydration solutions represents
be predicted in most patients and a great advance in the treatment of diar-
cal in decreasing the spread of diar- early, appropriate treatment can be
rheal diseases. Although vaccines for rhea.
instituted. B. Oral hydration solutions should have a
Rotavirus have been developed and
glucose concentration of approximately
are currently being tested clinically, SUGGESTED READING 2%.
there is less progress on vaccines for C. Oral hydration solutions used for initial
Arbo A, Sands JI. Diarrheal diseases in the
other causative agents. Such vac- immune compromised host. Pediatr Infect fluid resuscitation should have a sodium
cines may ultimately be the best Dis. 1987;6:894-906 content of 70 to 90 mEq/L.

PIR 12 pediatrics in review #{149} vol. 11 no. 1 july 1989

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 Acute Diarrhea in Children
Thomas G. DeWitt
Pediatr. Rev. 1989;11;6-12
DOI: 10.1542/pir.11-1-6

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Hypoglycemia

REFERENCES Surg. 1982;143:1 16-119 feeding, at a time when the infant was
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1 Chaussain JL. Glycemic response to 24
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10. Chen Y-T, Comblath M, Sidbury JB. Corn-
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1976;58:1 0-17 175 Gierke).
3. Stanley CA, Baker L. Hyperinsulinism in D. Accelerated fasting.
infancy: diagnosis by demonstration of ab-
E. Phosphoenolpyruvate carboxykinase de-
normal response to fasting hypoglycemia. SUGGESTED READING
ficiency.
Pediatrics. 1 976;57:702-71 1
4. Phillip M, Bashan N, Smith CP, Moses SW. Aynsley-Green A, Soltesz G. Hypoglycaemia
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An algorithmic approach to diagnosis of in Infancy and London, England:
Childhood.
Churchill-Livingstone; 1985 hypoglycemia, among the following findings
hypoglycemia. J Pediatr. 1987;1 10:387-
390 Comblath M, Schwartz A, eds. Disorders of the least likely is:
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skemeti K, Kissane JM, White NH. The delphia, PA: WB Saunders; 1976 B. Tremor.
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Self-Evaluation Quiz
6. Chaussain J-L, Georges P, Gendrel D,
Donnadieu M, Job J-C. Serum branched- 13. An infant with hypoglycemia has appar-
10. In the evaluation of hypoglycemia in a
chain amino acids in the diagnosis of hy- young child, the least likely helpful diagnos- ently suppressed serum levels of insulin and
perinsulinism in infancy. J Pediatr. appropriately elevated levels of ketones at
tic test among the following would be:
1 980;96:923-926 a time when she is symptomatic as a resuft
7. Finegold DN, Stanley CA, Baker L. Gly- A. Oral glucose tolerance test.
B. Serum ketones level. of hypoglycemia. These findings suggest
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hypoglycemia: an aid in the diagnosis of C. Serum lacticacad level.
hyperinsulinism. J pediatr. 1980;96:257- D. Plasma insulin level. dition is most likely to be:
259 E. Plasma level of growth hormone. A. A disorder of fatty acid metabolism.
8. Kramer JL, Bell MJ, DeSchryver K, Bower B. Camitine deficiency.
RJ, Temberg JL, White NH. Clinical and 11. In an infant with hypoglycemia, simul- C. Glycogen storage disease, type I.
histologic indications for extensive pan- taneous measurement of serum glucose D. Hypennsulinism.
creatic resection in nesidioblastosis. Am J and growth hormone levels 4 hours after a E. Hypopituitarism.

Department of Corrections

In the article by Dewitt in the July 1989 issue of Pediatrics in Review, “Acute
Diarrhea in Children,” itisunfortunatethatin Table 3 on page lithe spelling of the
rehydration solution “Rehydralyte” was printed as “Rydrolute.” In addition, Hydra-Lyte
and Infalyte are no longer marketed.

PIR 124 pediatrics in review #{149} vol. 11 no.4 october 1989

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