pediatrics
Diarrhea in Children
Evaluation of Diarrhea in Children
History of present illnessfocuses 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 months) antibiotic use. Clinicians should establish elements of the diet (eg, amounts of juice, foods high in sugars orsorbitol). 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 systemsshould 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 historyshould assess known causative disorders (eg, immunocompromise, cystic fibrosis, celiac disease, inflammatory bowel disease) in the patient and family members. 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. The following findings are of particular concern: Tachycardia, hypotension, and lethargy (significant Dehydration in Children ) Bloody stools Bilious vomiting Extreme abdominal tenderness and/or distention Petechiae and/or pallor 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 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 ). 