Update on Diarrhea Nicholas J. CaJacob, MD,* † Mitchell B. Cohen, MD* † *Departments of Pediatric Gastroenterology, Hepatology, and Nutrition and † Pediatrics, University of Alabama at Birmingham, Birmingham, AL. Practice Gaps The mainstay of management of infectious diarrheal illness in children remains supportive care with oral or intravenous rehydration. In the postvaccine era, norovirus has supplanted rotavirus as the leading cause of gastroenteritis presenting to medical facilities in the United States. Objectives After reading this article, the reader should be able to: 1. Recognize the common pathogens associated with infectious diarrhea and develop a management plan. 2. Identify the key differences between infectious and noninfectious causes of diarrhea. 3. Effectively treat a child with cow milk protein intolerance. 4. Recognize that antidiarrheal and antimotility agents are not indicated or recommended in the treatment of infectious diarrhea. 5. Understand the changing epidemiology of infectious diarrhea in the postvaccine era. INTRODUCTION Diarrhea is a worldwide problem that is frequently encountered in the practice of pediatric medicine. According to the World Health Organization, diarrheal illness is the second leading cause of death in children younger than age 5 years, accounting for 760,000 deaths per year in this age group. (1) The overwhelming majority of diarrheal illnesses are due to acute infec- tious diarrhea, commonly referred to as acute gastroenteritis (AGE). The degree of dehydration, assessed by both history and physical examination, is the most important indicator of disease severity. However, most children who have infectious diarrhea are not dehydrated and can be successfully treated at home with replacement of ongoing fluid losses using oral rehydration solution (ORS). The routine use of antibiotics and antidiarrheal agents is not recommended for treatment of acute diarrhea and may cause harm. Restrictive diets are not necessary; the adverse effects on nutritional status during diarrheal illness can be AUTHOR DISCLOSURE Drs CaJacob and Cohen have disclosed no financial relationships relevant to this article. This commentary does not contain discussion of an unapproved/investigative use of a commercial product/device. Vol. 37 No. 8 AUGUST 2016 313 by guest on October 4, 2017 http://pedsinreview.aappublications.org/ Downloaded from
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Update on DiarrheaNicholas J. CaJacob, MD,*† Mitchell B. Cohen, MD*†
*Departments of Pediatric Gastroenterology, Hepatology, and Nutrition and†Pediatrics, University of Alabama at Birmingham, Birmingham, AL.
Practice Gaps
The mainstay of management of infectious diarrheal illness in children
remains supportive care with oral or intravenous rehydration. In the
postvaccine era, norovirus has supplanted rotavirus as the leading cause
of gastroenteritis presenting to medical facilities in the United States.
Objectives After reading this article, the reader should be able to:
1. Recognize the common pathogens associated with infectious diarrhea
and develop a management plan.
2. Identify the key differences between infectious and noninfectious
causes of diarrhea.
3. Effectively treat a child with cow milk protein intolerance.
4. Recognize that antidiarrheal and antimotility agents are not indicated
or recommended in the treatment of infectious diarrhea.
5. Understand the changing epidemiology of infectious diarrhea in the
postvaccine era.
INTRODUCTION
Diarrhea is a worldwide problem that is frequently encountered in the practice
of pediatric medicine. According to the World Health Organization, diarrheal
illness is the second leading cause of death in children younger than age 5 years,
accounting for 760,000 deaths per year in this age group. (1)
The overwhelming majority of diarrheal illnesses are due to acute infec-
tious diarrhea, commonly referred to as acute gastroenteritis (AGE). The
degree of dehydration, assessed by both history and physical examination, is
the most important indicator of disease severity. However, most children who
have infectious diarrhea are not dehydrated and can be successfully treated
at home with replacement of ongoing fluid losses using oral rehydration
solution (ORS).
The routine use of antibiotics and antidiarrheal agents is not recommended
for treatment of acute diarrhea and may cause harm. Restrictive diets are not
necessary; the adverse effects on nutritional status during diarrheal illness can be
AUTHOR DISCLOSURE Drs CaJacob andCohen have disclosed no financialrelationships relevant to this article. Thiscommentary does not contain discussion ofan unapproved/investigative use of acommercial product/device.
Vol. 37 No. 8 AUGUST 2016 313 by guest on October 4, 2017http://pedsinreview.aappublications.org/Downloaded from
Summary• On the basis of recent epidemiologic evidence, norovirus hassupplanted rotavirus as the most common cause of infectiousdiarrhea in the postvaccine era in the United States.
• On the basis of some research evidence as well as consensus,infants with milk protein-induced proctocolitis (“cowmilk proteinintolerance”) may attempt reintroduction of milk- and soyprotein-containing products as early as age 6 months.
• On the basis of strong evidence, using a validated tool to assessand classify the severity of dehydration in children with acutediarrheal illness is recommended to guide managementdecisions.
• On the basis of strong evidence, rapid initiation of oralrehydration with oral rehydration solution is the preferredmethod for replacing fluid and electrolyte losses in the setting ofacute gastroenteritis.
• On the basis of strong evidence, reintroduction of regular age-appropriate feedings, including milk, after initial fluidresuscitation is the standard of care for acute diarrheal illnesses.
• On the basis of some research evidence as well as consensus,ondansetron therapy in select patients with vomiting related toacute gastroenteritis may be effective, but safety in childrenremains to be established.
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PIR QuizThere are two ways to access the journal CME quizzes:
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REQUIREMENTS: Learnerscan take Pediatrics inReview quizzes and claimcredit online only at:http://pedsinreview.org.
To successfully complete2016 Pediatrics in Reviewarticles for AMA PRACategory 1 CreditTM,learners mustdemonstrate a minimumperformance level of 60%or higher on thisassessment, whichmeasures achievement ofthe educational purposeand/or objectives of thisactivity. If you score lessthan 60% on theassessment, you will begiven additionalopportunities to answerquestions until an overall60% or greater score isachieved.
This journal-based CMEactivity is availablethrough Dec. 31, 2018,however, credit will berecorded in the year inwhich the learnercompletes the quiz.
1. A 6-month-old infant presents with a 2-day history of 6 to 8 loose stools per day. In the past,she typically had 1 to 2 formed stools per day. The stools are nonbloody yet contain someundigested food particles. She has been irritable these past 2 days, but there is no changein her appetite; she is eating and drinking. Review of her growth chart reveals she is at the50th percentile for height and weight. She is afebrile, has tears, and has moist mucousmembranes. The rest of her physical examination findings are unremarkable. Which of thefollowing is the best description of the patient’s presenting condition?
A. Acute watery diarrhea.B. Shigella diarrhea.C. Prolonged diarrhea.D. Diarrhea with severe malnutrition.E. Normal stool pattern.
2. A 3-year-old boy presents with a 2-day history of high temperature, malaise, and frequentwatery diarrhea. He periodically complains of acute, sharp abdominal pain. There is novomiting. On physical examination, he has a temperature of 40°C (104°F) and dry mucousmembranes. Findings on the remainder of his physical examination are unremarkable.Suddenly he complains of abdominal pain, which is followed by defecation of a watery,bloody, slimy stool. Which of the following is the most likely cause of this patient’s diarrhea?
3. A 1-year-old girl presents with a 3-month history of daily frequent loose, watery stools. Shehad a bout of acute viral gastroenteritis with mild fever, vomiting, and diarrhea thatresolved approximately 3.5months ago. She continues to grow and gainweight. Vital signsare normal for age. Her physical examination yields unremarkable findings. Which of thefollowing is the most likely reason for her loose, watery stools?
4. A 6-month-old boy presents with a 2-day history of mild fever, vomiting, and diarrhea. Vitalsigns include a temperature of 38°C (100.4°F), pulse of 120 beats per minute, andrespiratory rate of 40 breaths per minute. He is lethargic but arousable and has slightlydecreased periorbital skin turgor, “sticky”mucousmembranes, and decreased tears. Whichof the following is the infant’s Clinical Dehydration Score?
A. 0.B. 3.C. 4.D. 5.E. 8.
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5. For the 6-month-old boy described in the previous question, which is themost appropriatenext step in management?
A. Observation.B. Prescribe ondansetron therapy.C. Begin intravenous fluid bolus and ongoing fluid loss replacement.D. Begin oral rehydration and ongoing fluid loss replacement.E. Prescribe loperamide.
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DOI: 10.1542/pir.2015-00992016;37;313Pediatrics in Review
Nicholas J. CaJacob and Mitchell B. CohenUpdate on Diarrhea
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