Pediatric emergency medicine trisk 133

In all types of dehydration and their methods of treatment, the patient must be
monitored closely. Physical examination and vital signs should be reassessed
continually, urine output monitored closely, ongoing losses quantified and
replaced, and therapy individualized. Patients should be considered for admission
if they are severely dehydrated, unable to adequately keep up with the ongoing
losses, if they are persistently hypoglycemic, appropriate care cannot be provided
as an outpatient, or if the etiology of the dehydration is unclear and further
workup is required.
Suggested Readings and Key References
Allen CH, Etzwiller LS, Miller MK, et al. Subcutaneous hydration in children
using recombinant human hyaluronidase: safety and ease of use. Ann Emerg
Med 2008;52(4 suppl):S75–S76.
American Academy of Pediatrics subcommittee on fluids and electrolyte therapy.
Clinical practice guideline: maintenance intravenous fluids in children.
Pediatrics 2018;142(6):e20183083.
Epifanio M, Portela JL, Piva JP, et al. Bromopride, metoclopramide, or
ondansetron for the treatment of vomiting in the pediatric emergency
department: a randomized controlled trial. J Pediatr (Rio J) . 2018;94:62–68.
Falszewska A, Szajewska H, Dziechciarz P. Diagnostic accuracy of three clinical
dehydration scales: a systematic review. Arch Dis Child 2018;103(4):383–388.
Freedman SB, Adler M, Seshadri R, et al. Oral ondansetron for gastroenteritis in
a pediatric emergency department. N Engl J Med 2006;354(16):1698–1705.
Freedman SB, Willan AR, Boutis K, et al. Effect of dilute apple juice and
preferred fluids vs electrolyte maintenance solution on treatment failure among
children with mild gastroenteritis: a randomized clinical trial. JAMA
2016;315(18):1966–1974.
Gray JM, Maewal JD, Lunos SA, et al. Ondansetron prescription for home use in
a pediatric emergency department. Pediatr Emerg Care . 2017 Nov 14.
Hartling L, Bellemare S, Wiebe N, et al. Oral versus intravenous rehydration for
treating dehydration due to gastroenteritis in children. Cochrane Database Syst
Rev 2006;3:CD004390.

Hew-Butler TD, Eskin C, Bickham J, et al. Dehydration is how you define it:
comparison of 318 blood and urine athlete spot checks. BMJ Open Sport Exerc
Med 2018;4:e000297.
King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among
children: oral rehydration, maintenance, and nutritional therapy. MMWR
2003;52(RR-16):1–16.


Lazzerini M, Wanzira H. Oral zinc for treating diarrhoea in children. Cochrane
Database Syst Rev 2016;12:CD005436.
Spandorfer PR, Alessandrini EA, Joffe M, et al. Oral vs. intravenous rehydration
of moderately dehydrated children: a randomized controlled trial. Pediatrics
2005;115:295–301.
Spandorfer PR, Mace SE, Okada PJ, et al. A randomized clinical trial of
recombinant human hyaluronidase facilitated subcutaneous versus intravenous
rehydration in mild to moderately dehydrated children in the emergency
department. Clin Therapeut 2012;34(11):2232–2245.
Steiner MJ, Nager AL, Wang VJ. Urine specific gravity and other urinary indices:
inaccurate tests for dehydration. Pediatr Emerg Care 2007;23(5):298–303.


CHAPTER 23 ■ DIARRHEA
FARIA PEREIRA, DEBORAH C. HSU

INTRODUCTION
Diarrhea, defined as a decrease in the consistency of the stool (loose/watery)
and/or greater than three stools in a 24-hour period, is a common presenting
complaint to the emergency department (ED). Infants and children have
variability in frequency and type of stools; therefore, any deviation from the usual
stooling pattern should arouse at least a mild concern, regardless of the actual

number of stools or their water content. An acute diarrheal illness typically lasts
less than 7 days. In the United States, diarrhea accounts for approximately 1.7
million annual outpatient visits. Although most bouts of illness are self-limited,
approximately 70,000 patients are hospitalized each year. Since the introduction
of the rotavirus vaccine in 2006, the number of children hospitalized due to
diarrheal disease has decreased significantly.

DIFFERENTIAL DIAGNOSIS
Diarrhea may be the initial manifestation of a wide spectrum of disorders as
outlined in Table 23.1 . The most common etiology for diarrhea in pediatric
patients presenting to the ED is viral gastroenteritis, with norovirus and rotavirus
being the most common agents. Other causes include bacterial and parasitic
infections, parenteral diarrhea (nongastrointestinal infection such as otitis media),
and antibiotic induced. The emergency physician must be vigilant in recognizing
the few children who have diseases that are likely to be life threatening from
among the majority of children who have self-limiting infections. Particularly
urgent
are
intussusception,
hemolytic
uremic
syndrome
(HUS),
pseudomembranous colitis, and appendicitis ( Table 23.2 ). In addition, children
may develop severe dehydration with diarrhea secondary to any etiology.
Intussusception is a potentially life-threatening condition that can present with
bloody diarrhea, although this is not the typical presenting complaint.
Intussusception peaks in frequency between 5 and 10 months of age and tapers
off rapidly after 2 years of age unless there is a predisposing pathologic condition.
This topic is covered in more detail in Chapter 53 Pain: Abdomen .

HUS should also be considered in a child presenting with bloody diarrhea.
HUS is an uncommon but potentially life-threatening disease that typically
presents with the classic triad of microangiopathic hemolytic anemia,


thrombocytopenia, and acute kidney injury. Children are affected most often in
the first 3 years of life. They often present with abdominal pain, vomiting, and
diarrhea that become bloody. Five to 10 days after onset of diarrhea, children with
HUS develop pallor, petechiae, and decreased urine output. The most common
cause of HUS is Shiga-like toxin-producing Escherichia coli (E. coli 0157:H7).
Pseudomembranous colitis is another serious disorder that may cause bloody
diarrhea. Clinically, the child with pseudomembranous colitis appears ill with
prostration, abdominal distention, and blood in the stool. This disease results from
an overgrowth of toxin-producing Clostridium difficile, usually as a result of
destruction of the normal intestinal microflora. It may occur at any age but is
uncommon in early childhood. Although the incidence of pseudomembranous
colitis is highest after treatment with clindamycin, studies have shown that
exposure to any antibiotic increases susceptibility to C. difficile infection. In fact,
because of its common use, amoxicillin is responsible for most cases of
pseudomembranous colitis in childhood, even though overall incidence of C.
difficile infection after therapy with this agent is low. Occasional cases occur in
children with no recent usage of antibiotics.