Due to high rates of asymptomatic Clostridium difficile colonization in children younger than 12 months, the American Academy of Pediatrics (AAP) advises clinicians to consider other causes of diarrheal disease in a new policy statement.

The organization released the new recommendations as C. difficile rates in U.S. hospitalized children continue to increase. The AAP emphasized that recent guidelines for disease management in adults do not necessarily reflect issues specific to infections in children.

About 37% of children younger than 1 month are colonized with C. difficile, 30% of those aged 1 to 6 months, and 14% of children aged 6 to 12 months. Because of high carriage rates in this age group, ” it is prudent to avoid routine testing … in children younger than 1 year” the AAP recommends.

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Among children aged 1 to 2 years, a positive C. difficile test is indicative of possible infection, whereas in children aged 3 years an older, a positive test signifies probable infection due to colonization rates in this age group similar to those in nonhospitalized adults (0% to 3%).

Antimicrobial therapy, proton pump inhibitor use, underlying bowel disease, renal insufficiency and impaired humoral immunity are considered C. difficile risk factors for older children. As in adults, endoscopic or histologic test results positive for pseudomembranous colitis indicates a definite C. difficile infection in children.

“Testing for C. difficile can be considered in children 1 to 3 years of age with diarrhea, but testing for other causes of diarrhea, particularly viral, is recommended first,” the authors wrote. “For children older than 3 years, testing can be performed in the same manner as for older children and adults.”

Testing in infants should be limited to those with Hirschprung disease or other severe motility diseases, or during an outbreak, the AAP advises.

The organization also offered guidelines for treatment, stating that discontinuing antimicrobial therapy is the first step and may be sufficient for resolving the infection. For children with moderate disease, oral metronidazole (30 mg/kg/day) in four divided doses (maximum of 2 g/day) is recommended for first episode or first recurrence.

Among children with severe disease or a second recurrence, oral vancomycin (40 mg/kg/day) given in four divided doses (maximum of 2 g/day), with or without metronidazole is the treatment of choice. Anti-peristaltic medications should be avoided as they may mask symptoms and cause complications.

A test of cure is not recommended following treatment, as C. difficile is shed for weeks after diarrhea is resolved. Testing for recurrences less than 4 weeks after initial testing is only useful when the results of repeat testing are negative, the guidelines state.

Infection control measures, including wearing gloves when treating symptomatic patients, washing hands thoroughly with soap and water rather than alcohol-based sanitizers, and using chlorinated products for environmental cleaning, are also recommended to prevent patient-to-patient spread.


  1. Committee on Infectious Diseases “Policy statement: Clostridium difficile infection in infants and children” Pediatrics 2013; 131: 196-200.