MSD MANUAL

Professional Version
Professional / Pediatrics / Symptoms in Infants and Children

Diarrhea in Children
By Deborah M. Consolini, MD, Assistant Professor of
Pediatrics, Sidney Kimmel Medical College of Thomas
Jefferson University; Chief, Division of Diagnostic Referral,
Nemours/Alfred I. duPont Hospital for Children

Diarrhea is frequent loose or watery bowel movements that deviate from a child’s normal
pattern.

Diarrhea may be accompanied by anorexia, vomiting, acute weight loss, abdominal pain,
fever, or passage of blood. If diarrhea is severe or prolonged, dehydration is likely. Even in the
absence of dehydration, chronic diarrhea usually results in weight loss or failure to gain
weight.

Diarrhea is a very common pediatric concern and causes about 1.5 million deaths/yr
worldwide. It accounts for about 9% of hospitalizations in the US among children aged < 5 yr.

Diarrhea in adults is discussed elsewhere.

Pathophysiology
Mechanisms of diarrhea may include the following:

Osmotic

Secretory

Inflammatory

Malabsorptive

Osmotic diarrhea results from the presence of nonabsorbable solutes in the GI tract, as with
lactose intolerance. Fasting for 2 to 3 days stops osmotic diarrhea.

Secretory diarrhea results from substances (eg, bacterial toxins) that increase secretion of
chloride ions and water into the intestinal lumen. Secretory diarrhea does not stop with
fasting.
Inflammatory diarrhea is associated with conditions that cause inflammation or ulceration
of the intestinal mucosa (eg, Crohn disease, ulcerative colitis). The resultant outpouring of
plasma, serum proteins, blood, and mucous increases fecal bulk and fluid content.

Malabsorption may result from osmotic or secretory mechanisms or conditions that lead to
less surface area in the bowel. Conditions such as pancreatic insufficiency and short bowel
syndrome and conditions that speed up transit time cause diarrhea due to decreased
absorption.

Etiology
The causes and significance of diarrhea (see Table: Some Causes of Diarrhea) differ depending
on whether it is acute (< 2 wk) or chronic (> 2 wk). Most cases of diarrhea are acute.

Acute diarrhea usually is caused by

Gastroenteritis

Antibiotic use

Food allergies

Food poisoning

Most gastroenteritis is caused by a virus; however, any enteric pathogen can cause acute
diarrhea.

Chronic diarrhea usually is caused by

Dietary factors

Infection

Celiac disease

Inflammatory bowel disease

Chronic diarrhea can also be caused by anatomic disorders and disorders that interfere with
absorption or digestion.
 Some Causes of Diarrhea

Cause Suggestive Findings Diagnostic Approach

Acute

Antibiotics (eg, br oad-spectrum

Temporal relationship of onset of
antibiotics, multiple concomitant Clinical evaluation
diarrhea with taking of antibiotics
antibiotics)

Fever, bloody stool, abdominal pain

Possibly petechiae or pallor (in

patients with hemolytic ur emic Stool culture
syndrome)
Fecal leukocytes
Bacteria (eg, Campylobacter sp,
History of contact with animals ( E.
Clostridium difficile , Escherichia coli [can If patients appear ill, CBC, r enal
coli) or reptiles (Salmonella)
cause hemolytic-ur emic syndrome], function tests, and blood cultur e
Salmonella sp, Shigella sp, Yersinia History of eating under cooked food
enterocolitica)* (Salmonella) If patient has recently been given
antibiotics, stool testing for C.
Recent (< 2 mo) antibiotic use ( C. difficile toxin
difficile)

Day care center outbreak

Allergy: Urticarial rash, lip swelling,

abdominal pain, vomiting, diarrhea,
difficulty breathing within minutes
to several hours after eating
Food allergy or food poisoning Clinical evaluation
Poisoning: Nausea, vomiting,
abdominal pain, diarrhea se veral
hours after ingestion of
contaminated food

Abdominal bloating and cr amping,

Microscopic examination of stool
Parasites (eg, Giardia intestinalis [lamblia] , foul-smelling stools, anor exia for ova and parasites
Cryptosporidium parvum )* Possibly history of tr avel, use of
Stool antigen tests
contaminated water sour ce

< 5 days of diarrhea with no blood

Often vomiting
Viruses (eg, astrovirus, calicivirus, enteric
Possibly fever Clinical evaluation
adenovirus, rotavirus)*
Contact with infected people

Appropriate season for the infection

Chronic
Cause Suggestive Findings Diagnostic Approach

Delayed passage of stool > 48 h

after birth
Abdominal x-ray
Possibly long-standing history of
Hirschsprung enter ocolitis Barium enema
constipation
Rectal biopsy
Bilious vomiting, abdominal
distention, ill appear ance

History of bowel resection (eg, for

Short bowel syndrome necrotizing enterocolitis, volvulus, Clinical evaluation
or Hirschsprung disease)

Clinical evaluation
Abdominal bloating, flatus, Sometimes hydrogen breath test
explosive diarrhea
Lactose intolerance Sometimes test for r educing
Diarrhea after ingestion of dairy
substances in stool (to check for
products
carbohydrates) and stool pH ( < 6.0
indicates carbohydr ates in stool)

Vomiting

Diarrhea or constipation Symptom resolution when co w's

Cow's milk protein intolerance (milk milk protein is eliminated
Hematochezia
protein allergy) Sometimes endoscop y or
Anal fissures colonoscopy

Failure to thrive

History of excessive juice or sugary

Excessive juice intak e Clinical evaluation
drink intake (4–6 oz/day)

Age 6 mo–5 yr

3–10 loose stools/day typically

during the day while awak e and
sometimes immediately after eating
Chronic nonspecific diarrhea of
Clinical evaluation
childhood (toddler 's diarrhea) Sometimes undigested food visible
in stool

Normal growth, weight gain, activity ,

and appetite

History of recurrent skin, respiratory HIV test

Immunodeficiency (eg, HIV infection, IgA tract, or intestinal infections CBC
deficiency, or IgG deficiency)
Weight loss or poor weight gain
Immunoglobulin le vels
Cause Suggestive Findings Diagnostic Approach

Bloody stools, crampy abdominal

Inflammatory bo wel disease (eg, Crohn pain, weight loss, anor exia
Colonoscopy
disease, ulcerative colitis) Possibly arthritis, or al ulcerations,
skin lesions, rectal fissures

CBC for peripher al blood

eosinophilia
Abdominal pain, nausea, vomiting,
Eosinophilic gastr oenteritis
weight loss Sometimes IgE le vel

Endoscopy and/or colonoscop y

Symptom onset after intr oduction

of wheat into diet (typically after age
4–6 mo) CBC

Failure to thrive Serologic screening for celiac

Celiac disease (gluten enteropathy) disease (IgA antibody to tissue
Recurrent abdominal pain transglutaminase)

Bloating Endoscopy for duodenal biopsy

Diarrhea or constipation

Failure to thrive

Repeated episodes of pneumonia 72-h fecal fat excretion

or wheezing Sweat test
Cystic fibrosis
Fatty and foul-smelling stools Genetic testing
Bloating, flatus

Sometimes psoriasiform r ash,

Acrodermatitis enter opathica Zinc levels
angular stomatitis

History of hard stools

Constipation with encopresis Abdominal x-ray
Fecal incontinence

*Can also cause chr onic diarrhea.

Evaluation
History

History of present illness focuses on quality, frequency, and duration of stools, as well as on
any accompanying fever, vomiting, abdominal pain, or blood in the stool. Parents are asked
about current or recent (within 2 mo) antibiotic use. Clinicians should establish elements of
the diet (eg, amounts of juice, foods high in sugars or sorbitol). Any history of hard stools or
constipation should be noted. Clinicians should also assess risk factors for infection (eg, recent
travel; exposure to questionable food sources; recent contact with animals at a petting zoo,
reptiles, or someone with similar symptoms).

Review of systems should seek symptoms of both complications and causes of diarrhea.
Symptoms of complications include weight loss and decreased frequency of urination and
fluid intake (dehydration). Symptoms of causes include urticarial rash associated with food
intake (food allergy); nasal polyps, sinusitis, and poor growth (cystic fibrosis); and arthritis, skin
lesions, and anal fissures (inflammatory bowel disease).

Past medical history should assess known causative disorders (eg, immunocompromise,
cystic fibrosis, celiac disease, inflammatory bowel disease) in the patient and family members.

Physical examination

Vital signs should be reviewed for indications of dehydration (eg, tachycardia, hypotension)
and fever.

General assessment includes checking for signs of lethargy or distress. Growth parameters
should be noted.

Because the abdominal examination may elicit discomfort, it is advisable to begin the
examination with the head. Examination should focus on the mucous membranes to assess
whether they are moist or dry. Nasal polyps; psoriasiform dermatitis around the eyes, nose,
and mouth; and oral ulcerations should be noted.

Examination of the extremities focuses on skin turgor, capillary refill time, and the presence of
petechiae, purpura, other skin lesions (eg, erythema nodosum, pyoderma gangrenosum),
rashes, and erythematous, swollen joints.

Abdominal examination focuses on distention, tenderness, and quality of bowel sounds (eg,
high-pitched, normal, absent). Examination of the genitals focuses on presence of rashes and
signs of anal fissures or ulcerative lesions.

Red flags

The following findings are of particular concern:

Tachycardia, hypotension, and lethargy (significant dehydration)

Bloody stools

Bilious vomiting

Extreme abdominal tenderness and/or distention

Petechiae and/or pallor

Interpretation of findings
Antibiotic-related, postinfectious, and anatomic-related causes of diarrhea are typically clear
from the history. Determination of the time frame helps establish whether diarrhea is acute or
chronic. Establishing the level of acuity is also important. Most cases of acute diarrhea have a
viral etiology, are low acuity, and cause fever and nonbloody diarrhea. However, bacterial
diarrhea can lead to serious consequences; manifestations include fever, bloody diarrhea, and
possibly a petechial or purpuric rash.

Symptoms associated with chronic diarrhea can vary and those of different conditions can
overlap. For example, Crohn disease and celiac disease can cause oral ulcerations, a number
of conditions can cause rashes, and any condition can lead to a poor growth pattern. If the
cause is unclear, further tests are done based on clinical findings (see Table: Some Causes of
Diarrhea).

Testing

Testing is unnecessary in most cases of acute self-limited diarrhea. However, if the evaluation
suggests an etiology other than viral gastroenteritis, testing should be directed by the
suspected etiology (see Table: Some Causes of Diarrhea).

Treatment
Specific causes of diarrhea are treated (eg, gluten-free diet for children with celiac disease).

General treatment focuses on hydration, which can usually be done orally. IV hydration is
rarely essential. (Caution: Antidiarrheal drugs [eg, loperamide] are not recommended for
infants and young children.)

Rehydration

Oral rehydration solution (ORS) should contain complex carbohydrate or 2% glucose and 50 to
90 mEq/L sodium. Sports drinks, sodas, juices, and similar drinks do not meet these criteria
and should not be used. They generally have too little sodium and too much carbohydrate to
take advantage of sodium/glucose cotransport, and the osmotic effect of the excess
carbohydrate may result in additional fluid loss.

ORS is recommended by the WHO and is widely available in the US without a prescription.
Premixed solutions are also available at most pharmacies and supermarkets.

If the child is also vomiting, small, frequent amounts are used, starting with 5 mL q 5 min and
increasing gradually as tolerated (see Oral Rehydration). If the child is not vomiting, the initial
amount is not restricted. In either case, generally 50 mL/kg is given over 4 h for mild
dehydration, and 100 mL/kg is given over 4 h for moderate dehydration. For each diarrheal
stool, an additional 10 mL/kg (up to 240 mL) is given. After 4 h, the patient is reassessed. If
signs of dehydration persist, the same volume is repeated.

Diet and nutrition

Children with an acute diarrheal illness should eat an age-appropriate diet as soon as they
have been rehydrated and are not vomiting. Infants may resume breast milk or formula.
For chronic nonspecific diarrhea of childhood (toddler's diarrhea), dietary fat and fiber should
be increased, and fluid intake (especially fruit juices) should be decreased.

For other causes of chronic diarrhea, adequate nutrition must be maintained, particularly of
fat-soluble vitamins.

Key Points
Diarrhea is a common pediatric concern.

Gastroenteritis is the most common cause.

Testing is rarely necessary in children with acute diarrheal illnesses.

Dehydration is likely if diarrhea is severe or prolonged.

Oral rehydration is effective in most cases.

Antidiarrheal drugs (eg, loperamide) are not recommended for infants and young
children.

Last full review/revision August 2016 by Deborah M. Consolini, MD

© 2018 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA