Diarrhea and Dehydration

Diarrhea refers to stools that are abnormally frequent and liquid. The modifier abnormal is critical because stools can normally be frequent and liquid in young children. Acute diarrheal illnesses account for more than 3 million ambulatory pediatric visits, 10 million sick days, and 100,000 hospital admissions per year in the United States. In the United States, rotavirus predominantly affects infants between 3 to 15 months. The peak incidence is in the winter months, and rotavirus accounts for as many as 50 percent of the cases of acute diarrhea in winter. Enteric adenoviruses (serotypes 40 and 41) are the second most common viral pathogen in infants. In summer most of the cases of diarrhea are caused by bacteria (including Escherichia coli, Salmonella, and Shigella). Parasitic causes of diarrhea are rare in neonates. A history of bloody diarrhea strongly suggests a bacterial pathogen, particularly in an older infant or a child. It is important to know that, in infants less than 6 months of age, the most common causes of blood in the stool are cow's milk intolerance and anal fissures.

In diarrheal illness, the history and physical examination serve as an initial screen to narrow the diagnostic possibilities. The choice of laboratory tests depends on the results of the history and physical examination. The history should assess the infant's state of hydration and possible causative agents. Information regarding oral intake, frequency and volume of stools, general appearance of the infant, mental status, and frequency of urination can help in assessing hydration. The parent should be asked about fever, antibiotic therapy, and exposure to day care or other children and adults with diarrheal illness.

All children with diarrhea should be carefully weighed unclothed for comparison of previous weight and to provide a baseline for monitoring subsequent weights during the course of the disease. In an infant, the normal extracellular fluid volume is 25 percent of body weight; therefore, a loss of 8 percent of body weight as extracellular fluid would result in manifestations of severe dehydration. The actual weight loss is greater than that because of concomitant loss of cellular water.

The physical examination should begin with a global assessment, with particular attention to the state of hydration ( Table 112.-3.). Mucous membranes, more than the lips, should be evaluated for moistness. The appearance of the anterior fontanel and eyes should be assessed. The skin hydration and turgor may give a sense of the degree of dehydration. The finding of doughy and tented skin is associated with hypernatremic dehydration. Finally, the child's mental status with regard to interaction with the examiner and the parent can be used as a measure of seriousness of illness and dehydration.

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