Diarrhea in children
One of the most difficult topics to write about.
How do I get started? This is such a common complaint in children. But when does it become important? And when is it Virley? And when is it bacterial? And how do you know the child is not dehydrated?
A big topic in short.
To my delight, in 2015, clinical guidelines were published by a number of associations and respected physicians in the State of Israel. I relied quite a bit on these guidelines that make order in the field.
Again, the goal in this chapter as in the whole site, is to give parents tools to understand, manage a case and bring better treatment of gastroenteritis to their child.
What is acute gastroenteritis and how common is it?
Gastroenteritis or in the vernacular "stomach upset". Equals a child with diarrhea.
Sharp equals acute, current disease over a period of up to two weeks.
Not a child who has diarrhea for three weeks or chronically.
incidence? One of the most common causes of illness in children. The incidence is up to two episodes each year in children under 3 years of age. A common cause of illness and even hospitalization.
What is the definition of diarrhea?
Diarrhea is defined as a decrease in viscosity and / or an increase in the frequency of stool time relative to the child’s normal.
Another setting – three or more soft ports a day.
What about symptoms associated with diarrhea? Must there be fever or vomiting:
Sometimes there is a fever, low or high. Sometimes not.
Vomiting? Sometimes the onset of acute gastroenteritis is vomiting and only later is the diarrhea added.
What is important to understand is that there are not necessarily any additional symptoms in order to define gastroenteritis in children.
What is the law of only vomiting?
Please note, this is extremely important. It is true that the onset of acute gastroenteritis (diarrhea) is sometimes vomiting. But a child who only vomits, with no feces or with normal defecation, with or without fever should be examined by the pediatrician.
Vomiting can hide diseases that pediatricians do not like such as head injury, bowel obstruction, severe infection and all sorts of less beautiful diagnoses.
That’s why pediatricians prefer children with vomiting and diarrhea over children who just vomit.
What causes diarrhea (acute gastroenteritis) in Israel?
Basically, viruses and bacteria.
In terms of viruses – rota was the most common cause in young children before the vaccine era we will talk about later. The herpes virus also typically caused both vomiting and diarrhea and was therefore a very common cause of dehydration in children. In recent years, the norovirus has taken the place of herpes as a common virus.
Obviously there are lots of other viruses that cause diarrhea in children.
Bacterial source – three main ones should be mentioned, although they are not the only ones:
A. Campylobacter jaundice – the most common bacterial contaminant in Israel.
B. Shigella – a number of species that cause diarrhea in children and adults.
C. Salmonella – Decreased incidence in recent years but still common.
In terms of semantics of diarrhea of bacterial origin can also be called bacterial gastroenteritis or bacterial colitis or dysentery.
How and is it possible to differentiate between the different causes of acute gastroenteritis in children?
Yes and no.
Signs like high fever, blood or mucus in the stool (compared to watery diarrhea only) and abdominal pain are more related to bacterial pathogens.
Age is also a hint to me. A one-year-old boy who has watery diarrhea will most often suffer from a viral source caught in kindergarten while the chance of a 15-year-old boy catching a virus is lower. This is of course not a one-size-fits-all but it is a hint.
The most important and worth remembering – the presence of blood or mucus in the stool. Mucosal or bloody diarrhea often indicates a bacterial etiology. For those with an insensitive stomach, see the pictures at the end of the chapter and see if you correctly identify diarrhea that is mucous or bloody.
How can gastroenteritis be prevented in children?
The rubella vaccine has been given to all children in the State of Israel since 2011 at the ages of one month, 4 months and 6 months. Since rota was, before the era of vaccination against it, the most common cause of gastroenteritis in children, this vaccine greatly reduced the incidence.
Breastfeeding – Breastfeeding as a primary source of nutrition reduces the rates of acute gastroenteritis in children. On the importance of breastfeeding You can read more at the following link.
Staying in day care is also associated with a higher incidence of diarrhea in children.
When should you see a doctor with a child who has diarhea?
Again, it is difficult to give clear indications. In case of doubt, see a doctor. But here are the highlights:
A baby under the age of two months who has diarrhea must be examined by a doctor.
Recurrent vomiting – as I have already written. Especially when there are no defecations or there is fever.
Multiple defecations – The guidelines state over 8 defecations per day, mainly in large diarrhea volumes. The fear is of course dehydration.
A child who doesnt have a healthy background- a significant background disease that puts the child at risk for dehydration and injury from dehydration and therefore these children should see a doctor early.
Signs of dehydration – see below.
What are the emphases on dehydration in children?
Again, a question that is very difficult to answer and give clear indications for. But a few points:
A. The smaller the child, the higher the chance of dehydration. A 5-month-old child who vomits and stools six times is not the same as a 5-year-old child who vomits and stools the same amount. The younger the child, the greater the chance of dehydration and the need for an earlier medical examination becomes more valid.
B. The amount of vomiting and diarrhea – although I have seen dehydrated children like radish after only 3 times vomiting and stoools, then it is clear that the higher the number the chance of dehydration increases.
C. Vomiting? Diarrhea? Or vomiting and diarrhea? Notice the difference. A vomiting child sometimes fails to put anything in his mouth and may dry out quickly. A child who only has diarrhea can drink and avoid dehydration.
D. Does the child drink or eat? In addition to water loss in vomiting and diarrhea, consideration should be given to whether the child has put anything in their mouth at all. If he drank chicken soup and ate marmalade, he was less likely to have dehydration than a child who did not put anything in his mouth.
E. Sugar and salt – dehydrated children are prone to hypoglycemia and abnormal levels of salts in the blood. Therefore, as you will see below, place the emphasis on providing sugar and salt as part of the treatment.
What are the signs on physical examination that can indicate dehydration in children?
These are the most important signs:
Weight Loss – Of course only relevant for small children whose weight we have known recently, and for those who have a weight at home.
Elongated capillary return time – With the child’s hand at heart level, press one of the child’s fingers on a pillow. The finger pales and then returns to normal color after up to 3 seconds. If the time is longer there may be dehydration.
Poor skin turgor – Pull the underbelly to the side at navel height. When you leave what you have pulled the elastic skin should quickly return to its former state. If not (as in older people where the skin loses its elasticity), the child may be dehydrated.
Minority in urination – Usually a child who urinates properly is not dehydrated. However this rule is not true for small babies who do not urinate properly and can urinate even though they are dehydrated. Remember that sometimes a child has diarrhea and is wearing a diaper, the pee and feces look equally watery and it is difficult to know that the child has urinated.
Other signs that can help are poor breathing, cold limbs, weak pulse, dry mucous membranes, sunken eyes, poor general condition and lack of tears.
Is it obligatory to perform blood tests on suspicion of dehydration or gastroenteritis?
The eye of a skilled physician in my opinion is more important in these cases than laboratory tests.
In case the doctor thinks of a bacterial infection, he can ask to perform a stool culture.
In the case of a child with a suspicion of dehydration, the doctor may recommend blood tests to check blood sugar levels, salts in the blood and kidney function.
What is the treatment for children with diarrhea?
There are a number of things that can and should be done to reduce a child’s suffering and minimize the chance of hospitalization:
Fever reduction – If the child has a high fever, there is room for treatment with antipyretics. The following calculator can be used. Remember that in a child who has diarrhea with less hydration, there is a preference for acetaminophen rather than ibuprofen (Nurofen, Ivo or Advil).
Stopping vomiting by medication – less common in children.
Cessation of diarrhea by medication – less common in children.
Probiotics – There are several strains that have been proven to be somewhat effective in improving the symptoms of diarrhea in children, but the commercial preparations sold in Israel differ in the types of bacteria and their concentration. So at this point I do not recommend using routine probiotics for children with diarrhea.
Nutrition – Most children do not need to change their diet (normal, breastfeeding or formula) during diarrhea. It is true that I would not give a child with diarrhea shawarma in a pita and I would recommend more of a stop diet that our grandmothers taught us (toast, rice, apple) but scientifically there is no advantage to this.
Lactose-free formula – In most children there is no need to change the formula in the first days of diarrhea. In children with diarrhea for over five days and for those whom an improvement has been observed and then re-exacerbation there may be room for lowering lactose for a short period. All companies have lactose-free formulas (no reference to herbal formulas).
I have not seen an improvement in diarrhea with any of the other remedies sold on this label in Israel. I recommend taking care, as you will see below, of returning liquids and salts and less buying commercial preparations in this regard.
Returning fluids and salts – the most important thing that can be done for a child with diarrhea . See below.
How do you return fluids and salts to a child with diarrhea ?
I’ll tell you a story:
The cholera epidemic (incessant watery diarrhea leading to severe dehydration and death) that occurred in 1971 in a Bangladesh refugee camp. Due to the lack of solutions for infusion of fluids, one of the local doctors produced a solution for drinking that included water, salt and sugar. Mortality rates in his camp were extremely low among all refugee camps. Since then the solution he invented has been used all over the world and has saved the lives of many millions, especially in developing countries.
The solution is called Oral rehydration solution or ORS for short and its secret in returning fluids, salts and sugar to the child with diarrhea when the goal is of course to prevent dehydration and the need for intravenous fluids.
There are ORS solutions in Israel ready for drinking or in powder form, the drinking doses will be given by the attending physician according to the degree of dehydration. And slowly return to a normal diet.
In vomiting children, the solution (like any sweet drink, see below) should be given in small doses of about 5 ml every few minutes. Giving larger doses may result in re-vomiting.
But not everyone wants to go to the pharmacy and buy an ORS solution and between us its not Bangladesh here, so the no less practical recommendation for child with diarrhea with or without vomiting is to provide a sweet drink and salty food.
What should be done with a child who suffers from acute gastroenteritis in terms of drinking?
Vomiting child – needs something sweet. At the level of sweet drink (raspberry, cola) or candy or popsicle. Small doses should be given every few minutes to lower the vomiting reflex.
Child with diarrhea – needs salts. Pretzel or any other high-sodium snack. Best? Chicken Soup.
This means that the classic combination of raspberry and salted pretzel is the best thing that can be done at the home level.
What about antibiotics for a child with diarrhea ?
In diarrhea of viral origin there is no reason to give antibiotics.
Antibiotics should be kept for children suffering from diarrhea that originates from bacteria, and even then is probably not recommended for everyone.
It is important to understand, at the empirical level, the doctor is facing the mother and the child with diarrhea and needs to decide whether or not to give antibiotics, or whether or not to send a fecal culture whose response can take several days.
Therefore, in the same appointment with the doctor, one should pay attention to the presence of high fever, abdominal pain and most importantly – the presence of blood or mucus in the stool. If you saw before the appointment with the doctor presence of blood or mucus in the diaper, you are welcome to take a photo and show. If the doctor suspects that there is a bacterial infection, he can recommend giving antibiotics in advance or decide to take a bacterial culture and wait.
Note the subtleties between the different bacteria:
Campylobacter – Antibiotic treatment shortens the disease and reduces infections in day care especially if given early. Aznyl is the drug of choice.
Shigla – treatment significantly shortens the disease. Aznyl is the drug of choice and although it is written in the book 5 days of treatment, 3 days of treatment is usually enough. If it has returned and the child is still ill and has not started treatment, another treatment that is narrower than the range of maznil can be given according to the sensitivity of the bacterium.
Salmonella – a bit confusing. On the one hand, treatment may prolong the duration of carrying the disease and is therefore only recommended in infants under 3 months of age or in children with background diseases such as immunosuppression. On the other hand, salmonella treatment improves the child’s condition and prevents various disease complications. Certainly should not be treated if a fecal culture was taken and by the time the answer came back (salmonella) the child was already healthy at home. But opinions are divided about caring for a child who is still having diarrhea or with a fever. I leave this to the discretion of the attending physician. If treated, the treatment of choice is, again, azanyl.
In short I hope you understand that the drug of choice for dysentery in children (diarrhea of bacterial origin) is Aznil .
What about diaper rash in children with diarrhea ?
Indeed, especially in infants with a diaper, diarrhea can be accompanied by red and sensitive skin in the groin area to the point of a bad diaper rash involving Candida infection.
You can see photos and expand reading on this topic In the attached link.
When can a child with diarrhea return to kindergarten?
As written In the episode of going back to these day cares, the children who cannot return to kindergarten:
Vomiting children – A child with two vomits should not be sent to kindergarten within a day unless a doctor has decided that there is no source of infection for vomiting and that the child’s condition allows return to the educational institution.
Diarrhea – Do not send a child with diarrhea in the following cases
A. Two or more stools a day, especially mucous or bloody diarrhea that can indicate the presence of a bacterium in the stool.
B. In case of isolation in the feces of the shigella bacterium, non-atypical salmonella, Campylobacter, a rotavirus or a bacterium called Clostridium – the child can return about a day after the last diarrhea.
C. In the case of Shigala or Campylobacter isolation, it is recommended that the child return to kindergarten after receiving appropriate antibiotic treatment at least two days before returning.
D. Other strange bacteria – Ultrasonic O157: H7 or Salmonella tipi – are more complex, several negative cultures are needed before returning to the kindergarden.
To sum up the episode – Im happy with this episode that has been waiting in my stomach for almost a year since it hit the site.
Precisely in such a chapter there are a number of clinical tips that can be given as a tool to parents when the goal in the end is as always – successful treatment of children.