Pediatric Diarrhea

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Pediatric Diarrhea

• Angela DAlessandro, DO
• Michael Canarie, MD

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CASE 1

• A 10 kg, 3 ½ month old former term baby comes to
  your office on the second day of watery stools
  (5-6 the previous day, two already that am). Low
  grade fever, emesis x 2. How would you evaluate
  this child?

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Verbiage

• Diarrhea from Greek diarrhoia meaning to
  flow though. Indeed.
• Dysentery bloody diarrhea
• Malabsorption can be the cause or result of
  diarrhea

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Epidemiology

• WHO estimated 2.2 children died from diarrhea in
  1999 (down from 5 million in 1980) as well as
  incalculable morbidity
• In US, children lt 5 yrs old 1-2 episodes/year
  with 2-4 million cases/year requiring 220,000
  hospitalizations
• Etiology varied and often multifactorial

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Epidemiology

• Childhood death from diarrheal illness decreased
  worldwide since 1980.
• From 5 million-gt2 million/yr
• Attributed to
• Global improvements in sanitation
• Oral rehydration therapy

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Importance in Pediatrics

• Dehydration and Electrolyte Disturbances
• Hyper-, hyponatremia, metabolic acidosis
• Acidosis from stool bicarb losses,
• Lactic acidosis resulting from fermentation of
  malabsorbed carbos or shock
• Phosphate retention from prerenal renal
  insufficiency

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Importance contd

• Chronic Diarrhea
• Malabsorption
• Vitamin D
• Vitamin K
• Vitamin B12, folate, iron
• Calcium

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Importance contd

• Infants at increased risk
• High water turnover
• Incomplete colonic salvage
• Immature renal tubules, suboptimal concentration
  ability
• Increased BSA/wt with increased insensible loss
• Extreme fevers
• Increased intestinal response to toxins

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Water homeostasis

• Intestines highly effective at absorption with
  small bowel predominant in adults of 8 L
  ingested, 7.4L absorbed in small bowel, 400cc in
  colon
• Mechanisms
• -neutral exchanger (ileum) with Na/H anion and
  Cl-/HCo3- cation exchangers
• -electrogenic Na absorbed via
  electrochemical gradient, predominates in colon,
  frequently impaired in diarrhea
• -Na co-transporter, particularly in small
  bowelusually spared in diarrhea permitting ORT

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Water Homeostasis

• Pathophysiology
• Intestinal villous cells (lost during diarrheal
  illness) responsible for absorption of luminal
  contents
• Secretion of electrolytes by crypt cells
• Water follows osmotic gradient with these
  secretions malabsorbed contents

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Water Homeostasis

• Sodium
• Actively pumped out of enterocyte at apical
  surface (creates gradient)
• Sodium absorbed from lumen by cotransporter,
  driven by gradient
• Most common transporter -gt Glucose
• This capacity exists even in severe GE -gt makes
  ORT possible

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Mechanism of Diarrhea

• Secretory/malabsorptive (e.g cholera)
• Osmotic (e.g. lactose intolerance)
• Increased motility (e.g. IBS)
• Reduced surface area (e.g. rotavirus)
• Invasive (e.g. shigella)

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Mechanisms

• SECRETORY
• Continues even when oral intake stopped
• Increased secretion of electrolytes and water
  into gut lumen
• Typically no intestinal inflammation (stool WBCs
  , blood negative)
• Examples cholera, tumors, laxatives

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Mechanisms

• Osmotic
• Common in children
• Occurs when absorbable solute not absorbed,
  increased fluid load in gut lumen -gtfluid losses
• Example hypertonic juices by toddlers
• Diarrhea ceases when oral agent stopped

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Mechanisms

• MOTILITY
• Increased irritable colon of infancy or chronic
  nonspecific diarrhea of infancy
• Decreased Hirschprungs

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Mechanisms

• INFLAMMATORY (reduced surface area, invasive)
• Acute, likely infectious
• VIRUS injures absorptive surface of mature
  villous cells, decreased fluid absorption,
  disaccharidase deficiency
• BACTERIA Intestinal injury via direct invasion
  of mucosa, damage to villous surface, elucidation
  of toxin

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Mechanisms

• INFLAMMATORY contd
• Chronic ex. IBD
• Mucous, protein, blood into GI lumen
• Often accompanied by other mechanisms

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Differential Diagnosis

• Infectious (viral, bacterial, parasitic)
• Feeding Difficulty
• Anatomic Defects
• Malabsorption
• Endocrinopathies
• Food Poisoning
• Neoplasms
• Miscellaneous

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Infectious Diarrhea

• The Usual Suspects
• Rotavirus
• ½ of all cases of AGE
• Peaks in winter months
• 4mo 24 mo of age
• 1 3 days of incubation -gtfever/vomiting then
  diarrhea (can last 3-4 days)
• U.S. -gt ER visit/hospitalization for 1 in 20
  children lt 5 yrs

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Infectious Diarrhea

• Adenovirus (40 41)
• Second leading cause
• Bacterial
• 1 Salmonella
• 2 Campylobacter

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Infectious Diarrhea

• Clinical Clues to Bacterial Gastroenteritis
• Blood in stool
• Large number of small volume stools
• Septic appearance
• High fever
• Known Exposure
• Leukocytes in stool

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Evaluation

• HISTORY
• Age of patient, location, time of year
• Onset
• Duration of symptoms (acute v chronic)
• Quality and quantity of stools (especially
  bloody vs. non-bloody)
• UOP
• Recent travel, sick contacts/exposures, daycare,
  pets (lizards, turtles?), co-morbidity, diet,
  stooling in relation to feeds, recent antibiotic
  use

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Physical exam

• Wt (previous wt)
• Hydration status
• -mild nl vitals, slightly dry mm, tears, nl
  cap refill
• -moderate tachycardic, tachypneic, prolonged
  cap refill, tenting, no tears, listless, sunken
  fontanelle
• -severe hypotensive, tachycardic/tachypneic,
  lethargic, cracked lips, dry mouth, cold/clammy
  skin
• Fissures?
• Remember hypotension late sign of shock in
  children
• Mental status, perfusion, HR better indicators

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Back to the case

• So we still have to evaluate the 3.5 month old
  with diarrhea
• Onset insidious over past day, no recent travel,
  breast fed, started daycare the week prior, no
  comorbidity, no travel
• On PE slightly dry MM, normal vital, crying
  tearfully, active on exam, no rashes,
• Rest of exam unremarkable

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Case 1 (cont.)

• What is he unlikely to have? (based on age, time
  of year, exposures, type of diarrhea)
• What is he likely to have ? (based on same
  criteria)
• What would your work-up consist of?
• How would you treat this child?

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Studies for diarrhea

• When and why would you get them?
• Rectal exam? Heme testing
• Stool cultures
• Stool leukocytes
• Reducing substances, etc
• Stool ova an parasites (stool op)
• C difficile antigen

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Treatment

• Eat, Drink and Get Better!
• Oral Rehydration Therapy
• Refeeding

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Oral Rehydration

• Pedialyte, Infalyte, etc.
• Omolarity250, 25g of carbs, Na 45meq/L, K
  20meq/L, HCO2 30meq/L
• Decrease juice/soda
• Poor electrolyte composition
• Osmolar loads gt300mosm/Laggravate diarrhea

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Oral Rehydration

• Recipe
• 1 quart clean H2O
• ½ tsp salt (or ¼ tsp NaCl, ¼ tsp baking soda)
• 4 8 tsp sugar

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RehydrationIV Fluids

• Usually 20cc/kg (if oral rehydration not
  possible) to start, then reassess
• NS or LR
• Correct electrolytes

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Treatment

• Antibiotics
• Usually not recommended
• Only small of infections that require abx
• Salmonella pts at risk for bacteremia including
  infants and immunocompromised
• Campylobacter severe cases can be tx with
  erythromycin or cipro
• Shigella Bactrim
• ETEC consider fluoquinolones

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Treatment

• Antibiotics contd
• Giardia Metronidazole
• BRAT?
• Fallen out of favor due to hypocaloric and low
  protein content
• Protein helps rebuild intestinal lumen

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Treatment

• Probiotics
• Alter or improve intestinal flora
• Active Yogurt CulturesLactobacillus GG
• Culturelle, Stoneyfield
• Zinc
• Ginger

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Case 2

• A 4.4 kg, 4 month old former 35 weeker, diarrhea
  all his life, started out on Enfamil, now on
  Prosobee. 100 gram wt loss over passed week.
  Bloody, loose stools. How would you proceed?

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Case 3

• 3 year old girl with bloody diarrhea x 2 days,
  with fever, irritability, crampy abdominal pain.

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Case 4

• 14 month old with 2 month h/o 2-6 foul smelling
  stools a dayat time with undigested food in
  feces. Parents have tried multiple dietary
  changes now eating low fat, non-diary, lots of
  fruit juice, low protein diet. He has had
  extensive w/u including negative stool cxs for
  bacteria/virus, o p and parasites, no blood.

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Case 5

• 7 yo boy with with rapid onset profuse diarrhea,
  this afternoon non-bloody.

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Case 6

• 14 yo boy with crampy, bloody diarrhea x 2 months.

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Take Home Message Eat, Drink and Get
BetterPepto-Bismol is your friend!