Diarrhea in children

Diarrhea in children

One of the more difficult topics to write about.
How may we start? This is such a common complaint with children. But when does it start to be of importance? And when is it viral? And when bacterial? And how do you know the child is not dehydrated?
In short, this is a large topic.
I’m glad that there are international clinical guidelines which I could rely on.
Again, the aim of this chapter as the entire website, is to lend parents the tools to understand and manage a case and lead to better treatment for their child’s gastroenteritis.
As much as I want this chapter to be internationally relevant, I understand that gastroenteritis in Texas is not equal to that in India. However, I will try to stay in the concept and not get into the name of a specific bacterium or parasite.

What is acute gastroenteritis and how common is it?

Gastroenteritis, commonly referred to as ‘stomach bug’, equals a child with diarrhea.
Acute equals an abrupt, current disease lasting less than two weeks.
Not a child with a three-week or chronic diarrhea.
Prevalence? One of the most common childhood illnesses. Prevalence is up to two episodes per year under the age of three. A common cause of illness and even hospitalization.

What is the definition of diarrhea?

The definition of diarrhea is a decrease in viscosity and/or an increase in frequency compared to the normal

Diarrhea with mucus
Diarrhea with mucus

habits of the child.
Another definition – three or more soft bowel movements a day.
What about additional symptoms to diarrhea? Are fever and vomiting a must?
Sometimes there’s fever, low or high, sometimes not.
Vomiting? Sometimes the illness starts with vomiting and the diarrhea appears late.
What’s important is, additional symptoms are not mandatory for a diagnosis of gastroenteritis in children.

What is the deal with isolated vomiting?

Please note, this is very important. It’s true that in the beginning of acute gastroenteritis (diarrhea) there may be

Diarrhea with mucus
Diarrhea with mucus

vomiting. However, a child that is only vomiting, with absent or regular stools with or without fever, should be examined by a pediatrician.
Vomiting may conceal diseases that pediatricians don’t like, such as head injuries, bowel obstruction, severe infection and other less pleasant diagnoses.
That’s why many pediatricians like it better when children have both diarrhea and vomiting rather than isolated vomiting.

What causes acute gastroenteritis (diarrhea) in children?

Mainly viruses but also bacteria and parazites.
In terms of viruses, Rota virus was the most common cause in small children prior to the era of the vaccine that we will discuss later. Rota virus typically caused both vomiting and diarrhea and was therefore the most common cause for dehydration in children. In recent years, the Norovirus took Rota’s place as the most common virus.
Obviously, there are many more other viruses that cause diarrhea in children.
A bacterial cause – three main ones should be noted although they are not the only ones:
A. Campylobacter species – the most common bacterial pathogen in many developed countries.
B. Shigella species – several strains that cause diarrhea in children and adults.
C. Salmonella species– still common worldwide.
In terms of semantics, diarrhea caused by a bacterial infection may be referred to as ‘bacterial gastroenteritis’, ‘bacterial colitis’ or ‘dysentery’.
Parasite cause – again, many option. However, one of the main causes is Giardia lamblia.

Is it possible and how does one distinguish between the different causes of acute gastroenteritis in children?

Yes and no.
Symptoms like high fever, blood or mucus in the stool (as opposed to only watery diarrhea) and stomach ache are more strongly tied to bacterial pathogens.
Age is also a clue. A one-year-old with watery diarrhea will usually suffer from diarrhea of a viral cause that was spread in kindergarten, while the odds of a 15 year-old to catch a virus is lower. This is naturally not always the case but it’s a clue.
Most important and noteworthy – blood or mucus in the stool. Diarrhea with blood or mucus indicates a bacterial etiology in many cases. For those with a strong stomach, see the photos at the end of this chapter if you can identify correctly bloody or mucus containing diarrhea.
How can gastroenteritis be prevented in children?
Several ideas:
A vaccine against Rota virus is administered to many children in developed countries beginning in the age of 2 months. Since Rota used to be the most common cause for gastroenteritis in children before the era of the vaccine, the vaccine greatly decreased its prevalence.
Breastfeeding – breastfeeding as a main source of nutrition reduces the occurrence of acute gastroenteritis in children. In this link you may read about the importance of breastfeeding.
Attendance in day-care is related to higher prevalence of diarrhea in children as well.

When to visit a doctor with a child with diarrhea?

Again, it’s difficult to give clear cut signs and symptoms. At any case of doubt, turn to a doctor for examination. But these are the highlights:
A baby under the age of two months with diarrhea has to be examined by a pediatrician.
Repeated vomiting – as I mentioned before, in particular when there’s fever or no bowel movements.
Frequent bowel movements – the guidelines refer to more than 8 bowel movements a day, especially large volume diarrhea. The fear is naturally of dehydration.
A child who is generally unhealthy – a significant disease in the medical background puts the child at higher risk for dehydration and complications due to dehydration, and this these children need to arrive to their doctor earlier.
Signs of dehydration – see below.

What are the highlights about dehydration in children?

Again, a difficult question to answer and give clear cut signs. But here are a few important points:
A. The smaller the child is, the higher the risk for dehydration. A 5-month-old child that vomited and had 6 loose bowel movements and a 5-year-old that vomited and had the same amount of diarrhea, are not alike. The younger the child is, the risk of dehydration is higher and the need for an early check-up gains importance.
B. The number of times the child has vomited or had diarrhea – although I’ve seen children dry as a raisin after only 3 times they’ve vomited and had loose bowels, it’s clear that the higher the number the higher the risk for dehydration.
C. Vomiting? Diarrhea? Or vomiting with diarrhea? Pay attention to the difference. A vomiting child sometimes cannot get anything in their mouths and may therefore get dehydrated pretty quickly. A child that has isolated diarrhea, can drink and avoid dehydration.
D. Does the child eat or drink? In addition to the loss of water in vomiting and diarrhea, one should note whether the kid has out anything in their mouths at all. If they ate soup and marmalade, the chance they would get dehydrated is lower as compared to not having put anything in their mouths at all.
E. Salt and sugar – dehydrated children are prone to hypoglycemia and abnormal levels of electrolytes in the blood. That’s why, as you’ll see below, emphasize giving salt and sugar as part of the treatment.

What are the signs in physical examination that may indicate dehydration?

These are the most important signs:
Loss of weight – this is obviously only relevant for small children whose recent weight measurement is known, and whoever owns a weight at home.
Prolonged capillary refill time – when the child’s arm is at level with the heart, press on one of the fingertip cushions. The finger turns pale and then returns to normal color after three seconds. If it takes longer than that, there might be dehydration.
Reduced skin turgor – pull the excess skin on the sides of the abdomen at the level of the umbilicus. When released, the elastic skin should return quickly to its place. If it doesn’t (as with older people whose skin has lost its elasticity), it’s possible that the child is dehydrated.
Reduced amount of urine – usually, a child urinating normal amounts is not dehydrated. However, this rule does not apply with small babies who do not concentrate the urine well enough and may proceed with urination even though they are dehydrated. Remember that sometimes, a child with diarrhea and diapers, urine and stool both look watery and it’s not easy to recognize the urine.
Other signs that may be helpful are abnormal breathing, cold limbs, weak pulse, dry mucosal surfaces, sunken eyes, general ill state and lack of tears.

Is it obligatory to take blood tests when dehydration is suspected or in any case of gastroenteritis?

An experienced eye of a doctor is more valuable to my opinion in these cases, than are blood tests.
In case the doctor suspects a bacterial infection, stool culture or PCR may be recommended.
In case of a child with risk of dehydration, the doctor may recommend blood tests for blood sugar level, minerals and kidney function.

What is the treatment of a child with diarrhea?

There are several things that one may and should do, to reduce the child’s suffering and to minimize the need for hospitalization:
Fever reduction – if the child has high fever, treatment with antipyretics may be administered. Bear in mind, that a in child with diarrhea and reduced hydration Paracetamol is preferred over Ibuprofen.
Stopping the vomiting using medications – is less commonly practiced in children.
Stopping the diarrhea using medications – is less commonly practiced in children.
Probiotics – there are several species that were proven as mildly beneficial in improving symptoms of diarrhea in children however the commercial preparations which are usually sold are different in types of bacteria and their concentration. Therefore, at this stage, I do not recommend the routine use of probiotics in children with diarrhea.
Nutrition – with most children, there’s no need to change nutrition (normal, breastfeeding or formula) during diarrhea. Naturally, I would not give a child with diarrhea a steak and would recommend a more ‘stopping’ nutrition taught to us by our grandmas (toast, rice, apple) but scientifically, it has no benefit.
Lactose free formulas – with most children, there’s no need to change the formula of the first days of diarrhea. In children with diarrhea over five days, or that had experienced improvement and then another worsening of symptoms, a temporary reduction in lactose intake may be appropriate. All firms have lactose-free formulas (this doesn’t mean vegetarian formulas). 

I did not encounter any benefit with other products sold for this purpose worldwide. I recommend to treat with fluid and electrolyte replacement and not so much to buy these commercial products in this context.
Replenishing fluids and electrolytes (Oral rehydration solutions) – the most important thing that can be done with a child with diarrhea. See below.

How does one replenish fluid and electrolytes in a child with diarrhea?

Listen to this story.
A cholera epidemic (endless watery diarrhea that causes severe dehydration and death) that occurred in a refugee camp in Bangladesh in 1971. Due to a shortage in intravenous (IV) fluids one of the local doctors created a drinkable solution consisting of water, salt and sugar. Incidence of death in this camp were the lowest out of all other refugee camps. Ever since, the solution he invented is in use across the globe and saved the lives of many millions, mostly in developing countries.
This solution is called ‘oral rehydration solution’ or in short, ORS, and its secret is to restore the fluid, salt and sugar deficits aiming to prevent dehydration and need for IV fluids.
Worldwide, there are many powders for ORS preparation. Drinking instruction will be given by the treating doctor according to the severity of dehydration.
For example, a child with mild dehydration is treated with 20 ml per Kg of body weight in the first 4 hours, and after that with 10 ml per Kg every bowel movement (diarrhea), and slowly return to normal nutrition.
Children who vomit should receive the solution (like any other sweetened solution, see below) in small portions of 5 ml every few minutes. A larger volume may cause more vomiting.
But not everyone wants to go to the pharmacy and buy ORS, and really, we are not in Bangladesh and therefore the equally practical recommendation for a child with diarrhea with or without vomiting, is to provide sweetened beverages and salty food.

What is the right thing to do with a child with acute gastroenteritis in terms of drinking?

A vomiting child – needs something sweet such as sweetened drink (cordial, coke) candy or popsicle. Should be given in small portions every few minutes to reduce up-chuck reflex.
A child with diarrhea – needs electrolytes (salts). Pretzel sticks or any other salt-rich snack. The best? Chicken soup.
In other words, the classic combination of cordial and salty pretzel sticks is the best you can do in a home.

What about antibiotics in a child with diarrhea?

There’s no need to treat diarrhea of a viral cause with antibiotics.
Antibiotics should be reserved for kids with diarrhea of bacterial cause and even in that case, it’s probably not always recommended.
It’s important to understand that empirically, the doctor stands in front of the mother and the child and needs to decide whether or not to treat with antibiotics whether or not to send a stool culture, the result for which may take days.
Hence in that meeting with the doctor, one must note high fever, stomach pains and most importantly, presence of blood or mucus in the stool. If you’ve noticed blood or mucus in the diaper before your visit to the doctor, you are welcome to take a picture and show it. In case the doctor suspect bacterial infection, they may recommend immediate treatment with antibiotics or to take a stool culture/PCR and wait for the result.
Be aware of the subtle differences between the different bacteria:
Campylobacter: antibiotic treatment shortens the disease and reduces transmission in day-care especially if given early. Azithromycin is the drug of choice.
Shigella: treatment shortens the disease substantially. Azithromycin is the drug of choice and although literature states a 5-day treatment, 3 days are usually enough. If the stool culture result comes back positive and the child is still ill and no treatment has been initiated, it’s possible to use other, narrower range antibiotics according to the specific bacterium’s sensitivity.
Salmonella: a bit confusing. On the one hand, treatment may prolong the duration of carriage and is therefore recommended only in children under the age of 3 months or with a medical history such as immune deficiency. On the other hand, treatment of salmonella improves the general state of the child and prevents various disease complications. Definitely no treatment should be initiated if the result for salmonella came back, and the child has already recovered at home. But there’s controversy regarding treatment of a child that still has fever or diarrhea. I leave this to the discretion of the treating doctor. If treated, the drug of choice is again, Azithromycin.
In short, I hope you understand the oral drug of choice in dysentery in children (diarrhea of bacterial cause) is Azithromycin.

What about diaper rash in children with diarrhea?

Indeed, especially in children with diapers, diarrhea may be accompanied with red and sensitive skin the bottom area, all the way to an unpleasant diaper rash that involves candida infection.
You may see pictures and read further in this link.

When can a child with diarrhea return to day care?

Each country / region may have its unique criteria. In general, the following children may not return to kindergarten:
A vomiting child – a child with 2 or more vomiting events a day should not return to kindergarten unless the doctor decides that there’s no infectious cause for vomiting and the child state allows return to an educational facility.
Diarrhea – a child should not be sent in these cases:
A. Two or more bowel movements a day, especially diarrhea containing mucus or blood that may indicate a bacterial infection.
B. In case of isolation of Shigella, Salmonella (non-thpyi), Campylobacter, Rota virus and Clostridium – the child may return after a day has passed from the last diarrhea.
C. In case Shigella or Campylobacter were isolated – it is recommendation is that the child receives at least two days of appropriate treatment before return to day-care.
D. Other strange bacteria: EColi O157:H7 or Salmonella typhi – more complicated, several negative cultures are required before return to kindergarten.

In summary:

To conclude this chapter – I am happy with this chapter, that was waiting in my gut for almost a year before emerging on the website.
Such a chapter contains a few clinical tips that may be given to parent as aiding tools when the aim is as always – a successful treatment of the children.

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