Overview
Diarrhoea in children is most commonly caused by infection with rotavirus. It is generally self-resolving, however, severe diarrhoea can cause dehydration which may be life-threatening.
Epidemiology
- Gastroenteritis is very common and children may have more than one episode a year
- Rotavirus and norovirus are two of the most common causes of gastroenteritis in children
Causes
Acute diarrhoea
- Gastroenteritis
- Systemic infection (e.g. UTI, pneumonia, otitis media, meningitis, sepsis)
- Food allergy/intolerance
- Gastrointestinal disorders:
- Appendicitis
- Intussusception
- Hirschsprung’s disease
- Meckel’s diverticulum
- Inflammatory bowel disease
- Haemolytic uraemic syndrome
Chronic diarrhoea
- Cows’ milk intolerance
- Toddler’s diarrhoea
- Coeliac disease
- Inflammatory bowel disease
- Lactose intolerance
Presentation
Diagnosis
Gastroenteritis generally presents with one or both of the following:
- A sudden change in stool consistency to loose/watery stools
- Diarrhoea usually lasts for 5-7 days and stops within 2 weeks
- Sudden onset of vomiting
- Vomiting usually lasts 1-2 days and stops within 3 days
Any of the following features suggest an alternate diagnosis to gastroenteritis:
- Fever – high-grade fevers can suggest bacterial gastroenteritis
- ≥38°C in children <3 months
- ≥39°C in children ≥3 months
- Shortness of breath or tachypnoea
- Neurological features:
- Neck stiffness
- Non-blanching rash
- Altered consciousness
- Bulging fontanelle in infants
- Other gastrointestinal features:
- Blood and/or mucus in the stool
- Bilious vomit
- Severe or localised abdominal pain
- Abdominal distention or rebound tenderness
Investigations
Overview
Stool microbiological investigations are:
- Considered if:
- The child has recently been abroad or
- Diarrhoea has not improved by day 7 or
- There is uncertainty about the diagnosis of gastroenteritis
- Performed if:
- Septicaemia is suspected or
- There is blood and/or mucus in the stool or
- The child is immunocompromised
Other investigations may include:
- Blood culture
Assessment of dehydration and shock
NICE has the following categories to assess dehydration:
| No clinically detectable dehydration | Clinical dehydration | Clinical shock |
| Alert and responsive | Red flag Altered responsiveness (for example, irritable, lethargic) | Decreased level of consciousness |
| Skin colour unchanged | Skin colour unchanged | Pale or mottled skin |
| Warm extremities | Warm extremities | Cold extremities |
| Eyes not sunken | Red flag Sunken eyes | – |
| Moist mucous membranes (except after a drink) | Dry mucous membranes (except for ‘mouth breather’) | – |
| Normal heart rate | Red flag Tachycardia | Tachycardia |
| Normal breathing pattern | Red flag Tachypnoea | Tachypnoea |
| Normal peripheral pulses | Normal peripheral pulses | Weak peripheral pulses |
| Normal capillary refill time | Normal capillary refill time | Prolonged capillary refill time |
| Normal skin turgor | Red flag Reduced skin turgor | – |
| Normal blood pressure | Normal blood pressure | Hypotension (decompensated shock) |
Features suggesting dehydration and hypernatraemia include:
- Jittery movements
- Increased muscle tone
- Hyperreflexia
- Seizures
- Drowsiness
- Coma
Management
Overview
- If no dehydration:
- Continue breastfeeding and encourage fluid intake
- Discourage fruit juice and carbonated drinks – they can worsen diarrhoea
- If dehydration present:
- 50 mL/kg oral rehydration solution (ORS) over 4 hours and ORS maintenance solution
- Continue breastfeeding
- Encourage oral fluid intake, but avoid fruit juice and carbonated drinks
