Update on pediatric diarrheal illnesses
Update on pediatric diarrheal illnesses
Diarrhea is a common condition that causes children to have frequent, watery stools. Most cases are triggered by viral gastroenteritis, an inflammation of the stomach and intestines. But other causes include food-borne bacteria, parasites and even a food intolerance or allergy.
Many misconceptions exist about what type of bowel movement constitutes diarrhea. With this in mind it's important to assess whether a child actually has diarrhea before looking for causes or considering treatment, advised Charles Shubin, MD, associate professor of pediatrics at the University of Maryland and Johns Hopkins University, both in Baltimore.
For example, parents are often concerned about the bowel movements of breastfed babies, which are almost exclusively loose, yellow and seedy. But this is completely normal. In other cases, a child may have one loose stool, but that is not necessarily a problem either, Shubin said.
The most common cause of diarrhea is viral gastroenteritis, but there are other culprits, including bacterial infections and food-borne illnesses such as Salmonella, Escherichia coli or Campylobacter, according to the American Academy of Pediatrics. Parasites, such as Giardia, may also cause diarrhea.
In other cases, diarrhea results from causes that are neither viral nor bacterial. A child might experience diarrhea from malabsorption due to lactose intolerance or a gluten allergy, Shubin said. Performing a food challenge can determine if this is the cause of the problem.
Rotavirus-associated diarrhea declining
Since the introduction of rotavirus vaccine, the number of diarrhea cases associated with rotavirus illness has drastically declined, the CDC reports. As this happens other diarrhea causing organisms are becoming more prevalent, chairman of the American Academy of Pediatrics division of gastroenterology, hepatology and nutrition, Leo Heitlinger, MD, said in an interview.
CDC statistics indicate that prior to 2006, rotavirus killed 20 to 60 children each year, put 55,000 to 70,000 in the hospital and sent 205,000 to 272,000 to the ED. A rotavirus vaccine had been introduced to the market earlier, but was withdrawn in July of 1999, due to fears that it raised the risk of intussusception, a condition in which a portion of the bowel folds onto itself.
Studies have shown that the two licensed rotavirus vaccines on the market today prevent between 85% and 98% of rotavirus cases. "I don't remember the last case of rotavirus at my organization, but in the past, 20% to 30% of hospital admissions were for rotavirus," says Heitlinger. The vaccine has also greatly reduced the number of missed workdays for parents of young children, he added.
While rotavirus cases are declining clinicians must now worry about other diarrhea-causing organisms, including:
- Norovirus — Also know as the "cruise ship virus," norovirus can cause vomiting and diarrhea similar to that seen in rotavirus, but its duration is typically shorter. It can occur with or without fever. If fever does occur it is typically low grade
- Enteroviruses —These viruses are prevalent during summer months and may be associated with a rash and fever
- E. coli — infections are caused by a gram-negative bacteria transmitted through contaminated food or water
- Clostridium difficile — C. difficile spores are typically spread via person-to-person, with infection triggered during or after antibiotic treatment
Investigating the cause of diarrhea
When looking for the cause of diarrhea, it is important to find out whether the child has been travelling, and to ask about his or her food history, according to Heitlinger. Also ask about any pets the child may have. Reptiles, for instance, are common carriers of Salmonella, he added.
Food habits and preparation are another issue to consider. "Here in Pennsylvania, there are a lot of hunters. I've had a bunch of kids over the years get parasites from game meat cooked in slow cookers," Heitlinger said.
Slow cookers do not cook meat to internal temperature high enough to kill diarrhea-causing parasites, Heitlinger explained. Remaining up-to-date with problematic organisms circulating in the local community and reminding parents about food safety are two ways clinicians can prepare to effectively counsel patients about diarrheal illnesses.
While most diarrhea cases do not require treatment, some will. If a child has a fever, or has blood in his or her stool, the clinician should recommend a culture to look for a bacterial cause that may require antibiotic treatment, Shubin said.
Dehydration is the primary risk related to diarrhea, so clinicians should address a child's hydration status to treat the condition as early as possible.
Dehydrations signs and symptoms include:
- Altered consciousness
- Not urinating
- Sunken eyes
- Dry mouth
The best way to prevent and treat dehydration is to use oral rehydrating solutions designed for children, Shubin advised. If a child balks at drinking one of these solutions, recommend that the patient try a popsicle version, he added. Delivering liquids via a frozen treat is actually beneficial because it forces the child to ingest the fluids slowly, and not gulp them down, which can lead to stomach upset.
Whenever possible, clinicians should avoid giving children intravenous fluids. Oral hydration should always be attempted first, Shubin said. But oral rehydration can be tedious and difficult because it requires caretakers to administer small sips of liquid every few minutes for a period of time. If a child is vomiting and not able to retain fluids, an IV may be necessary as a last resort.
Clinicians should educate parents about some common mistakes related to oral hydration, including offering drinks that have too much sugar, such as flat soda or juice. Other drinks, such as chicken broth, may contain too much salt, which can exacerbate the problem, Heitlinger said. Clinicians should also advise against the use of sports drinks, which are not designed to treat dehydration and diarrhea.
Add good bacteria to the gut
To shorten the duration of diarrhea, some clinicians recommend probiotics, which are supplements or food that boost the amount of healthy flora in the gut.
According to a 2010 American Academy of Pediatrics report, there's some evidence that treating diarrhea early with probiotics can resolve symptoms a day earlier. Probiotics were also found to have some value when it came to reducing antibiotic-associated diarrhea in children.
In addition, some clinicians are using the probiotic Saccharomyces boulardii in addition to antimicrobial therapies to treat patients with C. difficile infections. However, the CDC cautions that practitioners should be aware that probiotics are not evaluated by the FDA for safety and efficacy and may result in rare complications for seriously ill or immunocompromised patients.
A good natural source of probiotics is yogurt, Shubin said. He suggested checking different brands to determine which have the highest amount of probiotics and consider recommending those to patients.
Also keep in mind that patients who have diarrhea and vomiting may not always be able to tolerate yogurt. For these children, clinicians may consider probiotics in powdered or capsule forms, according to Pejman Katiraei, DO, associate professor of pediatrics in the Loma Linda University School of Medicine in Loma Linda, Calif.
“Clinicians should consider developing a list of reputable brands of probiotics to provide to patients because quality may be variable,” Katiraei said.
In most cases, diarrhea will resolve within five to seven days. But patients who have diarrhea that continues beyond that point should be advised to come back in for further evaluation.