Acute diarrhea is a common condition in children under 5 years old and is one of the leading causes of morbidity and mortality in this age group.
It is defined as the passage of three or more loose stools per day or twice more than the normal frequency of the infant and can be accompanied by fever, vomiting, and dehydration.
The most common cause of acute diarrhea in children is viral infections, but other etiologies can also be responsible.
Diagnosis of acute diarrhea in children is frequently clinical, although a blood test and stool culture should be considered depending on the etiology and the pathological history of the patient
Management of acute diarrhea in children involves rehydration, electrolyte replacement, and appropriate nutrition. The use of antibiotics is limited and the use of other medications should be weighted in a case-by case fashion.
Definition of Acute Diarrhea in Children
Acute diarrhea is one of the most frequent gastroenterological disorders and the main cause of dehydration in children. Diarrhea is not a disease but a symptom of several illnesses. It mainly occurs in children five years and younger. In the United States and Canada, young children have an average of two episodes of diarrhea per year. (3)
The definition of diarrhea is a loose and watery stool that has increased in frequency to twice the normal number per day in an infant or three or more loose stools per day in older children (sometimes accompanied by vomiting or fever).
We have to take into account that with age, the depositions of children change in consistency and color; that is why it is very important to know what is normal for our patients. The normal frequency in infants is usually between 3-10 stools per day, although this can vary depending on the diet.
The duration of acute diarrhea is one week or less. Cases where the symptom lasts more than a week, have to be studied and treated differently.
The primary causes are viral and bacterial infections which usually last for 7-14 days at most. Although diarrhea is common and rarely serious, dehydration and negative electrolyte balance (sodium, potassium, chloride, etc.) are the main complications.
Therapeutic measures are limited to supportive care, fluid replacement therapy provision, and minimizing depositions’ impact.
Etiopathology Acute Diarrhea in Children
References: (1-3, 6-9)
Acute diarrhea may be due to infections caused by bacteria, viruses, or parasites. The most frequent cause of Acute diarrhea disease (ADD) is viral, whereas bacterial and parasitic are rare. The infections are spread by fecal-oral transmission through contaminated food and water or direct or indirect contact with an infected individual. Particularly high contagiousness rates are shown by rotavirus, norovirus, and Shigella.
Diarrhea is more common in children attending daycare, is usually mild, and goes away independently.
Viral causes of diarrhea can be transmitted by aerogenic particles as well as the classical manner. The incidence of intestinal diseases depends mainly on age but also on the developmental stage of the child’s environment.
In developed countries such as Europe, North America, and Australia, the most common cause of diarrhea is an infection, especially between the ages of 6 months and 5 years. The bacteria that cause the illness (Campylobacter jejuni, Salmonella, Shigella, and pathogenic E. coli) usually take children in the first six months of life and after the age of five, although bacterial infections are rare. Parasitic infections are most frequently caused by Giardia lamblia, Entamoeba histolytica, and Cryptosporidium.
Acute diarrhea in children, in addition to gastrointestinal infections, can be caused by alimentary intoxications, wide-spectrum antibiotics, oral iron preparations, laxatives, cytostatic, gastric secretion suppressors, stress-related conditions, and severe extra intestinal infections in the infancy period, such as sepsis, urinary tract infection, otitis media, pneumonia and other. (2)
From the pathogenic point of view, infectious diarrheal disorders are classified into secretory, osmotic, exudative-secretory, and malabsorptive.
- Secretory: Result from substances like bacterial endotoxins that increase secretion of chloride ions and water into the intestinal lumen (i.e., vibrio cholera and toxigenic strains of E. coli). These cause a higher loss in sodium that may be greater than 70 mEq per liter of stool. (9)
- Osmotic: Results from the presence of no absorbable solutes in the gastrointestinal tract. This increased the osmolality in the lumen (i.e., viral infections like rotavirus or lactose intolerance).
- Exudative-secretory: is associated with conditions that cause inflammation or ulceration of the intestinal mucosa. This cause increased stool volume and frequency but alters the absorption of fluid and electrolytes (i.e., invasive enteric infections like Shigella, Salmonella, or Campylobacter.
- Malabsorption: may result from osmotic or secretory mechanisms or conditions that lead to less surface area for absorption in the bowel lumen (i.e., Enteropathogenic E. coli, Giardia lamblia, and Cryptosporidium).
Osmotic and secretory diarrhea are characterized by liquid stools and exudative by aqueous-mucilaginous and often blood-stained stools.
Children are considered contagious (when the cause is viral, bacterial, or parasitic) until the diarrhea disappears. Also, some children can spread diarrhea even before they develop any symptoms, and a minority will continue to spread the infection after the symptoms resolve.
It is seen most commonly in the winter months in temperate climates, although we could see it all year round. Viral infections affect the small bowel causing invasion and destruction of the mature epithelium. The most common viral infection is due to Rotavirus.
Rotavirus infects enterocytes in the mature small intestine, leading to the destruction of these cells with impaired capacity for absorption of intestinal fluid and disaccharidase deficiency. Villous tips have the most damage with the sparing of the crypts. Excessive secretion can be because of the loss of the villous tips and the filling of crypts with rapidly multiplying cells or the rotavirus non-structural protein 4 (NSP4) that functions as an enterotoxin and leads to hypersecretion of intestinal fluid. This results in the malabsorption of carbohydrates resulting in osmotic diarrhea (watery and explosive), abdominal pain and distention, and in some cases, perianal hyperemia. (10)
It is hard to distinguish from viral infections. Bacterial infections are more common in locations where there is unsafe drinking water and poor handling of human waste. Most children do not require antibiotics and will improve with supportive measures, although some may need antimicrobial treatment in specific situations. Bacteria exert their pathogenic effect in the small and large intestines.
Traveler’s diarrhea is usually transmitted by contaminated food or water, usually self-limited. The majority are caused by bacteria, usually, Enterotoxigenic E. coli (ETEC), followed by Salmonella, Campylobacter jejuni, and Shigella. Children were found to be co-infected in 20% of cases. (11) Areas with the highest risk are Singapore, South Africa, and Central and South America. The Typhi serotype of Salmonella (the cause of typhoid fever) tends to be more invasive and more often results in bacteremia.
One type of bacteria that we should be careful of in children is Enterohemorrhagic E. coli (EHEC; Shiga toxin-producing) or E. coli O157:H7. These bacteria attack the epithelial cells of the cecum and the large bowel, and the Shiga-like toxin called verotoxin destroys the cells, leading to hemorrhagic colitis. Responsible for watery diarrhea that quickly becomes bloody and can develop into Hemolytic Uremic Syndrome. This syndrome is often seen in children younger than 4 years old, and long-term sequels include hypertension, proteinuria, decreased glomerular filtration rate, and, less commonly, seizure, coma, or motor deficit.
Alimentary intoxications are characterized by a secretory diarrheal disorder caused by the ingestion of contaminated food with enterotoxins of Staphylococcus aureus, Clostridium perfringens, and Bacillus cereus. These bacteria affect the small intestine and form the toxin before the food is consumed. Contrary to infections, there is no bacterial colonization of the bowels.
It is most commonly seen in developing countries where there is poor handling of sewage and unsafe drinking water. Diarrhea may last for weeks to months. Pathogenetically is classified as malabsorptive due to the parasite attaching to the lining of the bowel, blocking the absorption of electrolytes and fluid.
Prolonged usage of wide-spectrum antibiotics in children can cause Clostridium difficile (pseudomembranous) enterocolitis. Because of the disintegration of colonic bacterial flora. It is usually encountered in hospitalized patients with multiple uses of antibiotics.
Fluoroquinolones, clindamycin, cephalosporin, and penicillin are more often associated with C. difficile because they act on gastrointestinal motility. Usually mild and typically does not cause dehydration or weight loss, and it resolves one to two days after antibiotics are finished.
Epidemiology of Acute Diarrhea in Children
References: (8, 12-16)
ADD is a public health problem worldwide, especially in developing countries where many factors influence the incidence of mortality due to ADD (biological, environmental, and socio-cultural).
Each child below 5 years of age experiences an average of 3 annual episodes of acute diarrhea, being the second leading cause of death, and both the incidence and risk of mortality from diarrheal diseases are greatest in children below 5 years of age. (12)
However, assessing the precise incidence and cause of infectious ADD is difficult since not everyone seeks medical care. In addition, stool cultures are only positive in 1.5% to 5.6% of cases. (17)
Children consequently can become malnourished, have impaired cognitive development, have growth faltering, or have impaired immunity, posing more risk for life-threatening diarrhea.
Some measures that aim to reduce ADD cases aim for environmental condition improvement, like water supply, hand washing with soap, adequate treatment of human waste, education, and food safety. Exclusive breastfeeding until 24 months old, improved complementary feeding, and the use of zinc in the management of diarrhea have also been proven to help mortality and morbidity rates. (18)
Rotavirus was the leading etiology for diarrhea mortality among children of all ages (requiring frequent primary care consultations or care in emergency departments and/or hospital settings), so, the development of a vaccine and universal vaccine coverage will have an impact on ADD incidence. Norovirus causes the most outbreaks of nonbacterial acute gastroenteritis in all group ages, often in epidemic outbreaks in schools and other group settings.
A lot of progress has been made globally to reduce the burden of diarrheal diseases, although this reduction has not been equal in all regions. In industrialized countries, relatively few patients die from diarrhea, although it is an important cause of morbidity that has been constant through the years. But worldwide, 780 million individuals lack access to improved drinking water, and 2.5 billion lack improved sanitation, mostly in developing countries. (13)
Signs and Symptoms
References: (3, 19, 20)
The main symptom is diarrhea, that as we said before, is a sudden loosening of stool consistency and increased in frequency to more than 3 times per day or more than 2 times per day beyond the patient’s usual frequency.
Acute viral and bacterial diarrhea can’t be definitively told apart on clinical grounds alone. Bloody, mucous stools and high fever (higher than 40ºC or 104ªF) tend to be associated with a bacterial cause, while viral gastroenteritis is usually accompanied by respiratory manifestations and longer-lasting vomiting, beginning 12 hours or 5 days after exposure and resolving within seven days.
Accompanying symptoms in children are vomiting, fever, aching extremities, headaches, rectal pain, and weight loss. Some children develop a temporary “lactose intolerance” after an acute diarrhea illness that settles with time.
As we know, these symptoms can cause dehydration, whereas a mild one is common and usually easy to revert. Severe dehydration can be very serious and fatal.
Some symptoms of dehydration in children are:
- Dry mucous membranes
- Fewer tears when crying
- Sunken eyes
- Being irritable or lethargic
- Pale or mottled skin
- Cold extremities
- Capillary refill time over 2 seconds.
Diarrhea can cause a sudden onset of dehydration when:
- The infant is under 1 year of age, particularly under 6 months old.
- Low birth weight newborns that have not caught up to their expected weight.
- A breastfed baby who has to stop breastfeeding during the illness.
- Any children who have not drunk a lot of liquid during diarrhea.
- Any child that has passed 6 or more diarrheal stools and/or vomited three or more times in the previous 24 hours.
Diagnosis of Acute Diarrhea in Children
References: (3, 7, 8, 20, 21)
As the first step, vital signs should be reviewed for indications of dehydration (tachycardia, hypotension, and tachypnea), high fever, or pain. Epidemiological clues can be found by evaluating the incubation period, history of recent travel, unusual food or eating circumstances, recent use of antibiotics, institutionalization, and immunodeficiency.
A general exam looking for signs of lethargy/distress and growth parameters should be noted. It is advisable to begin the physical examination away from the focus of the pain since it may cause discomfort in the child.
The abdominal examination focuses on distention, tenderness, and quality of bowel sounds. Examination of the genitals region, looking for the presence of rashes and signs of anal fissures or ulcerative lesions.
Diarrhea due to acute infection usually does not require tests. Collection of stool samples can be done to identify the specific cause of diarrhea, especially if they have blood in their stools. Stools culture can also be done to look for parasites, although a precise cause will most likely not be identified despite testing. (14)
A test should be performed if symptoms are prolonged or severe, if the patient was recently hospitalized, has a bloody stool, systemic illness, antibiotic usage background, or daycare attendance.
- Fecal leukocytes and occult blood: The presence of these advocates for a bacterial cause of acute diarrhea. A meta-analysis reported that at 70% sensitivity, fecal leukocytes were only 50% specific for an inflammatory process. (8)
- Fecal lactoferrin: Used when there is tenesmus, fever, or bloody stool. It is more sensitive than the previous one, with specificity between 90% and 100%. This test is not widely available. (8)
- Stool cultures: According to IDSA recommendations, this test is useful if symptoms do not quickly resolve, if fever or bloody stools are present, if there are patient comorbidities, or if they are immunocompromised.
- Stool ova and parasites: It is appropriate if symptoms and epidemiology support a parasitic or protozoal etiology, bloody diarrhea without fecal leukocytes. In these cases, 3 samples, taken on 3 consecutive days, should be sent to catch parasite excretion. (8)
The most important part of the examination should be in the assessment of the dehydration of the patient focusing on the mucous membranes, skin turgor, capillary refill time, swollen joints, and the presence of skin lesions, like petechiae or purpura.
Blood test assessing serum electrolytes, creatinine, and urea to evaluate hydration and acid-base status. If eosinophils are elevated, a parasitic infection could be the cause. If the patient is dehydrated, levels of sodium, potassium, glucose, creatine, and blood urea nitrogen will be elevated, as well as acidosis in acid-base status.
Although a blood test is useful to judge the degree of dehydration, the percentage of lost body weight is the most useful tool. However, the child’s weight before the illness is usually not precise, so physical findings should be used for this objective.
Clinical Criteria Commonly Used for Classifying Dehydration Severity (20)
- Weight loss (%): Infant <5; Older child < 3
- Behavior: Normal
- Thirst: Slight
- Mucous membranes: May be normal
- Anterior fontanelle: Flat
- Eyes: Normal
- Skin turgor: Normal
- Blood pressure: Normal
- Heart rate: Normal rate
- Capillary refill time: <2 sec (normal)
- Pulse: Normal
- Breathing: Normal
- Tears: Present
- Extremities: Warm
- Urine output: Decreased
- Weight loss (%): Infant 6-9; Older Child 4-6
- Behavior: Normal to listless
- Thirst: Moderate
- Mucous membrane: Dry
- Anterior fontanelle: Sunken
- Eyes: Sunken
- Skin turgor: Decreased
- Blood pressure: Normal
- Heart rate: Increased
- Capillary refill time: Prolonged 2-3 sec
- Pulse: Normal to decreased
- Breathing: Normal to increased depth
- Tears: Decreased
- Extremities: Cool
- Urine output: Markedly decreased
- Weight loss (%): Infant >10; Older child > 6
- Behavior: lethargic or comatose
- Thirst: Intense
- Mucous membranes: Dry
- Anterior fontanelle: Sunken
- Eyes: Deeply sunken
- Skin turgor: Decreased
- Blood pressure: Normal to decreased
- Heart rate: Increased: tachycardia, with further worsening to bradycardia
- Capillary refill time: Increased >4 sec
- Pulse: Weak to absent
- Breathing: Deep acidotic breathing
- Tears: Absent
- Extremities: Cyanotic, cool
- Urine output: Anuria
The main differential diagnosis in children is other infectious diseases, metabolic disturbances, intestinal obstruction, and appendicitis. If a urinary tract infection is suspected, a urine sample should be taken for testing, and ultrasonography or other types of studies are indicated when there is a clinical suspicion of intussusception. Endoscopic procedures are reserved for children with other lingering pathologies.
Treatment of Acute Diarrhea in Children
Regardless of the etiology of the majority of infectious diarrhea, therapeutic management is based on hydration maintenance and nutritional status. Acute diarrhea stops when the body has cleared the toxins causing it.
References (3, 12, 24)
The maintenance of an adequate diet is important for the regeneration of the intestinal mucosa since dieting restrictions or fasting can slow down the renewal process of the cells damaged by the infectious process. A special diet, called “Heilnahrung” and “diarrhea diets,” micronutrients, dilution of baby formula, and fasting are not recommended.
In a child who is otherwise healthy, it is important to start feeding them their regular diet as soon as possible. Breastfeeding infants should be nursed normally and formula-fed infants can continue their regular diet.
In older children with watery diarrhea, boiled rice, potatoes, noodles, bananas, apple sauce, rice, and soup are recommended, often referred to as the BRAT diet (banana, rice, applesauce, and toast). Patients should avoid high-fat foods until normal bowel function returns. To prevent malnutrition, the WHO recommends a dietary supplementation with vegetable oil to increase the caloric density of foods, preventing malnutrition. The intake of fiber has been shown to reduce the duration of diarrhea.
Anorexia can affect the child, but we must remember that this disorder is transient, and the appropriate food should be available to promote nutritional recovery at the earliest opportunity. Food should be offered in small portions, often respecting the patient’s wishes.
References: (12, 20, 23)
Probiotics are live microorganisms (Lactobacillus GG ATCC 55730, Lactobacillus rhamnosus GG, Lactobacillus casei DN-114001, and Saccharomyces cerevisiae) with demonstrated beneficial health effects in humans and have been proven to reduce the severity and duration of acute diarrhea in children.
The evidence on viral gastroenteritis is more convincing than the evidence on bacterial or parasitic diarrhea, being controlled by clinical intervention studies and meta-analyses that support the use of probiotics in the prevention and treatment of rotavirus diarrhea in infants.
References: (12, 20)
Fever should be treated when it is greater than 39 º C/ 102 ºF or when it is associated with symptoms that cause discomfort to the child. The antipyretic drug most commonly used is acetaminophen. Antispasmodic drugs and antiphysetics agents (e.g., simethicone) should not be indicated.
References: (12, 20)
In most cases, the vomiting ceases when the child is hydrated, so when episodes are sporadic, there is no indication of antiemetic use. When vomiting is intense, and the risk of dehydration increases H1-Histamine receptor blockers (dimenhydrinate), dopamine receptors antagonist (metoclopramide), and serotonin-5HT (ondansetron) are most frequently used. Ondansetron has been found to cause cardiac arrhythmia by prolonging the QT intervals, so its use is off-label. The risk of side effects rises in dehydrated infants or those with electrolyte disturbances.
References: (12, 20)
Loperamide, an antimotility drug, was forbidden from pediatric treatment because its toxic effects were identified as associated with the central nervous system and the risk of paralytic ileus. Among the adsorbent drugs, kaolin-pectin was used in the past but discontinued as its effectiveness was not demonstrated. The international guidelines state there is no indication for the use of these drugs in ADD.
References: (12, 20)
The use of racecadotril (a drug with antisecretory properties) can help by reducing fecal loss and disease duration, it facilitates hydration status maintenance. Smectite, an intestinal adsorbent, has been shown to shorten the duration of diarrhea. Both of these drugs have been given reserve recommendations for use as a supplementary treatment alongside oral rehydration therapy.
Zinc has been shown to reduce the severity of diarrheal episodes and the number of subsequent episodes in patients under 5 years of age. Currently, the indication is restricted to children belonging to risk groups from poor regions, malnourished children under 5 years old, and those with previous episodes of ADD or hospitalization. The recommended dose is 20 mg of zinc per day for 10 days, and in infants aged 2 months or younger 10 mg/d for 10 days. (12)
Oral Rehydration Therapy (ORT)
References: (8, 12, 14, 20, 22)
- As we said before, we have two types of diarrhea, osmotic and secretory. It’s important to differentiate which is the one that the patient has to provide the appropriate replacement. Rehydration should be a priority in the first 2-4 hours.
- ORT should be preferably used for rehydration, whereas Intravenous Rehydration Therapy should be used only if ORT fails or the child is severely dehydrated. The solution used is a hypo-osmolar (<270 mOsm/L) rehydration solution on a glucose or starch basis (carrot or rice). Household drinks like tea, cola, and apple juice are inappropriate for use in the rehydration of children.
- The oral rehydration solution prepared on a glucose base recommended by the WHO has 75 mmol/L of sodium, 20 mmol/L of potassium, 65 mmol/L of chloride, 10 mmol/L of citrate 13,5 g/L (75 mmol/L) of glucose with an osmolarity of 245 mOsm/L.
- Oral rehydration therapy can be initiated immediately after the patient has been examined and weighed. The estimated fluid loss is replenished within 3-4 hours; in toddlers, this usually corresponds to 40-50 mL/kg of body weight.
- The ORT is administered in small portions. If the patient is vomiting and oral rehydration fails, the placement of a nasogastric tube for continuous administration of the oral rehydration solution is recommended, as well as in situations where intravenous or intraosseous hydration is impossible. It has been demonstrated that NGT is as effective as Intravenous hydration in case of moderate dehydration.
Intravenous Rehydration Therapy (IRT)
References: (8, 12, 14, 20, 22)
- IRT should be indicated when ORT or NGT have failed, the patient manifests symptoms of ileus or bilious vomiting, when the patient is suffering severe dehydration, or when the child is in shock.
- We should take into consideration that the hospital stay will be longer than with oral rehydration and that it has more unfavorable outcomes like phlebitis in the site where the line is placed.
- Isotonic saline solution (0.9%) is preferable since it prevents the occurrence of hyponatremia without causing hypernatremia.
- Whenever there is clinical evidence that suggests circulatory centralization or kidney failure of pre-renal origin, rapid administration is crucial (20-40 mL of normal saline per Kg of body weight). IRT is begun with 20 mL/kg/h of normal saline in 1-4 hours, adapted thereafter depending on the laboratory findings, the amount of diuresis.
- Intravenous hydration should be suspended as soon as the child is hydrated and alert, restoring the ORT.
The author does not report any conflict of interest
This information is for educational purposes, not to treat disease or supplant professional medical judgment. Physicians should follow local policy regarding the diagnosis and management of medical conditions.
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