The Infant
Case 2.6 Diarrhea
50 The Infant
Daniel is currently taking no prescription or herbal medications. His mother gave him an over - the - counter antiemetic, Emetrol ® , to help reduce nausea and vomiting. She has not given him any antidiarrheal agents. Daniel has no known allergies to food, medications, or the environment. He is up to date for required vaccinations, but he did not receive a rotavirus vaccination due to a recall of the vaccination.
OBJECTIVE
Daniel ’ s vital signs were taken in the offi ce today. His weight is 6.8 kg, and his length is 69 cm. Daniel ’ s temperature is elevated at 38 ° C (rectal). When observing Daniel ’ s general appearance, he is alert and consolable by his mother when crying.
Skin: The skin on Daniel ’ s buttocks is mildly erythematous. There is no cyanosis of his skin, lips, or nails. There is no diaphoresis noted. Daniel has good skin turgor on examination.
HEENT : Daniel ’ s head is normocephalic. His anterior fontanel is open and fl at (0.5 cm × 0.5 cm).
Upon examination of Daniel ’ s eyes, his red refl exes are present bilaterally and his pupils are equal, round, and reactive to light. There is no discharge noted, and tears are present when crying.
Daniel ’ s external ear reveals that the pinnae are normal. On otoscopic examination, the tympanic membranes are pink bilaterally with positive light refl ex. Bony landmarks are visible, and there is no fl uid noted behind the tympanic membrane. Both nostrils are patent. There is no nasal discharge, and there is no nasal fl aring. Daniel ’ s mucous membranes are noted to be moist when examining his oropharynx. He has 4 teeth present without evidence of caries. There are no lesions present in the oral cavity.
Neck: Daniel ’ s neck is supple and able to move in all directions without resistance. There is no cervi- cal lymphadenopathy.
Respirations: Respiratory rate is 28 breaths per minute, and lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformi- ties of the thoracic cage are noted.
Cardiovascular: Heart rate is 110 beats per minute with a regular rhythm. There is no murmur noted upon auscultation. Brachial and femoral pulses are present and 2 + bilaterally.
Abdomen: Hyperactive bowel sounds are present throughout. Daniel has diffuse tenderness on abdominal palpation. His abdomen is mildly distended; there is no evidence of hepatosplenomegaly.
Genitourinary: Genitourinary examination revealed normal male genitalia. Daniel is circumcised, and his testes are descended bilaterally.
Neuromusculoskeletal: Daniel was noted to have good tone in all extremities. He has full range of motion of all extremities. His extremities are warm and well perfused. Capillary refi ll is less than 2 seconds. Daniel ’ s spine is straight.
CRITICAL THINKING
Which laboratory or imaging studies should be considered to assist with or confi rm the diagnosis?
___ Complete blood count ( CBC ) ___Stool culture
___Electrolyte levels ___Hydrogen breath test ___Lactose tolerance test
Diarrhea 51
What is the most likely differential diagnosis and why?
What is your plan of treatment, referral, and follow - up care?
Are there any demographic factors that should be considered?
Are there any standardized guidelines that you should use to assess or treat this case?
RESOLUTION
Diagnostic t ests: A CBC would not provide any clinically useful information in this case. The white blood count ( WBC ) may be elevated but that is a nonspecifi c fi nding as the WBC is likely to be ele- vated with most infectious processes. A stool culture may provide identifi cation of an infectious organism that is causing the diarrhea. They are not done routinely for acute cases of pediatric diar- rhea that is being treated in the outpatient setting. Electrolyte levels can be obtained if there is a concern of dehydration. A hydrogen breath test may be helpful in diagnosing older children with lactose intolerance, but this test is not usually done on babies and very young children because it can cause severe diarrhea. Similarly, a lactose tolerance test can aid in the diagnosis of lactose intolerance, but it is usually not performed on babies and very young children.
What is the most likely differential diagnosis and why?
Viral gastroenteritis:
The complaint of diarrhea can lead to several differential diagnoses. The most common differentials for someone with Daniel ’ s history are viral gastroenteritis, antibiotic - associated diarrhea, and lactose intolerance. Differentiating between these conditions requires a thorough history and review of systems. Viral gastroenteritis should be considered as Daniel has had diarrhea, vomiting, and fever.
He also recently started a new day care, which is a risk factor for viral gastroenteritis. Daniel recently fi nished a course of antibiotics which could be a possible source of diarrhea. Whole milk was intro- duced into the diet which may lead the health care provider to consider lactose intolerance.
Based on the history and physical exam, viral gastroenteritis due to rotavirus is the most likely of the differential diagnoses. The presence of fever likely rules out noninfectious causes of diarrhea.
Rotavirus is one of several viruses known to cause gastroenteritis. It commonly affects children in the winter months in the United States but may occur year - round in developing countries. Many children under the age of 5 years have come into contact with this virus at some point in their lives.
What is your plan of treatment, referral, and follow - up care?
In the majority of cases of viral gastroenteritis infection related to rotavirus, no medications are neces- sary. Antidiarrheal agents should typically be avoided in young children. Antibiotics are not indicated and may include diarrhea as a side effect — worsening the diarrhea. Hyperosmolar beverages such as sports drinks should be avoided because they may cause infants to develop hypernatremia. Excessive plain water intake may cause infants to develop hyponatremia. Beverages such as Pedialyte ® have the correct balance of glucose, sodium, and potassium and should be encouraged in small, frequent feedings for the child with viral gastroenteritis secondary to rotavirus. Because rotavirus is conta- gious, family members should be encouraged to practice good hand washing after changing diapers and before preparing meals. Daniel ’ s mother should be instructed that the diarrhea may last 1 full week. She should also be instructed about the signs and symptoms of dehydration and told to seek care immediately if any of these signs and symptoms develops. Based on the history and physical fi ndings, no referrals are needed at this time.
Daniel ’ s mother should be allowed to express her concerns regarding his illness status, especially since he is just recovering from acute otitis media and also since she believed that she may have con- tributed to the diarrhea with the introduction of food with curry or the introduction of whole milk.
Are there any demographic factors that should be considered?
There have been no racial/ethnic factors that contribute to the development of rotavirus, but it has been shown that it is more prevalent among those of lower socioeconomic status.
52 The Infant
Are there any standardized guidelines that you should use to assess or treat this case?
The Advisory Committee on Immunization Practices ( ACIP ) has developed guidelines for the preven- tion of rotavirus in infants and small children (Cortese & Parashar, 2009 ).
REFERENCES AND RESOURCES
Cortese , M. M. , & Parashar , U.D. ( 2009 Feb). Centers for Disease Control and Prevention ( CDC ). Prevention of rotavirus gastroenteritis among infants and children: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Report, 58(RR - 2): 1 – 25 .
Henker , J. , Laass , M. W. , Blokhin , B. M. , Maydannik , V. G. , Bolbot , Y. K. , Elze , M. , & De Morais , M. ( 2008 ).
Probiotic Escherichia coli Nissle 1917 versus placebo for treating diarrhea of greater than 4 days duration in infants and toddlers . The Pediatric Infectious Disease Journal , 27 , 494 – 499 .
Misra , S. , Sabui , T. K. , & Pal , N. K. ( 2009 ). A randomized controlled trial to evaluate the effi cacy of lactobacillus GG in infantile diarrhea . The Journal of Pediatrics , 155 , 129 – 132 .
Vernacchio , L. , Vezina , R. M. , Mitchell , A. A. , Lesko , S. M. , Plaut , A. G. , & Acheson , D. W. ( 2006 ). Diarrhea in American infants and young children in the community setting: Incidence, clinical presentation and micro- biology . The Pediatric Infectious Disease Journal , 25 , 2 – 7 .