Pediatric presentation
Diarrhea and dehydration in children
The assessment is clinical, the treatment is usually oral, and the weight is the best measurement in the building.
What are you worried about?
- Hypovolemic shock
- Hypernatremic or hyponatremic dehydration and the speed of correction
- The non-gastroenteritis cause: intussusception, hemolytic uremic syndrome, appendicitis
- Bloody diarrhea with pallor and oliguria: hemolytic uremic syndrome
Differential, by age
Infant 1 to 12 months
- Viral gastroenteritis (rotavirus, norovirus)
- Urinary tract infection
- Intussusception
- Cow's milk protein allergy
- Overfeeding or formula errors
Toddler 1 to 3 years
- Viral gastroenteritis
- Bacterial enteritis (Salmonella, Campylobacter, E. coli O157)
- Hemolytic uremic syndrome
- Toddler's diarrhea (thriving)
- Intussusception
Preschool 3 to 5 years
- Viral gastroenteritis
- Bacterial enteritis
- Appendicitis with pelvic irritation
- Giardia after travel or daycare
- Antibiotic-associated diarrhea
School age 6 to 11 years
- Gastroenteritis
- Inflammatory bowel disease (chronic, weight loss, blood)
- Celiac disease
- Constipation with overflow
Adolescent 12 to 17 years
- Gastroenteritis
- Inflammatory bowel disease
- Irritable bowel syndrome
- Laxative use in an eating disorder
- Sexually transmitted enteric infection
Key history
- Number and character of stools and vomits; blood or mucus
- Intake: what, how much, tolerated or not; oral rehydration attempted
- Urine output as wet diapers or trips to the toilet; the last one
- Weight before the illness; a recent measured weight
- Sick contacts, daycare, travel, undercooked food, antibiotics, immune status
- Behaviour: playful, irritable, listless
Key examination
- Mental status: alert, irritable, lethargic
- Mucous membranes, tears, sunken eyes and fontanelle, skin turgor
- Heart rate for age, capillary refill, peripheral temperature, pulse quality
- Weight now, against the last known weight
- The abdomen for a mass or tenderness beyond gastroenteritis; pallor and petechiae for hemolytic uremic syndrome
Red flags
- Lethargy or reduced consciousness
- Capillary refill above 3 seconds, weak pulses, cool extremities, hypotension for age
- No urine in 8 to 12 hours
- Bloody diarrhea, especially with pallor, oliguria or petechiae
- Bilious vomiting or a distended abdomen
- Weight loss over about 10 percent
Initial investigations
- None for uncomplicated gastroenteritis treated orally
- Electrolytes, urea, creatinine, glucose and a gas for severe dehydration, intravenous fluids, or an altered mental status
- Stool culture for bloody diarrhea, travel, outbreaks or the immunocompromised; do not give antibiotics for suspected E. coli O157
- Blood count, film, creatinine and urinalysis if hemolytic uremic syndrome is a question
How to interpret them
- Dehydration is graded clinically: none or minimal, mild to moderate (some signs), severe (shock and altered mental status)
- Sodium decides the speed of correction: hypernatremia is corrected slowly over 48 hours or more
- A high urea with a normal creatinine is volume; a rising creatinine with fragmented cells is the kidney under attack
When the child is deteriorating
- Severe dehydration or shock: isotonic bolus of 20 mL/kg, reassess after each, repeat
- Then deficit plus maintenance plus ongoing losses, replaced over the appropriate time for the sodium
- Reassess every few hours: weight, urine, mental status, and the electrolytes if intravenous fluids are running
Cases and practice
Vomiting and diarrhea, and only two wet diapers18 months old · An 18-month-old has had two days of vomiting and watery stools. Her father counts diapers, and today's count is two.Thirsty for weeks, vomiting since this morning12 years old · A 12-year-old has been drinking litres, wetting the bed again, and losing weight. Today he cannot keep water down and is breathing strangely.
Conditions under this presentation
The adult frame, for contrast