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 220000
  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!