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Chronic diarrhea: Management in pediatrics
Margaret Brady, MS, RN, CPNP California State University, Long Beach Department of Nursing
n
Chronic Diarrhea: Management in Pediatrics Marianne
Buzby,
n
L/’ mr h ea is defined as an increase in the volume, frequency, or water content of a stool as compared to a normal stool. The World Health Organization has defined diarrhea as any stool that conforms to the shape of the container in which it is placed (Farrell, 1986). Diarrhea becomes chronic when it persists for more than 14 days (Schwarz, 1987). The managementof chronic diarrhea must be approached in an organized manner, focusing on the most likely causeof this problem. Chronic diarrhea poses a perplexing problem for the pediatric practitioner. The differential diagnoses range from potentially serious diseasesto rather benign illnesses that are easily treated (see Box). Dehydration and malnutrition, the sequelaeof severe chronic diarrhea may further complicate identifjring the cause of the problem. Despite this, the primary practitioner will be able to determine the appropriate management plan if a careful history and physical examination are obtained in addition to a few screening laboratory studies (Schwarz, 1987). EVALUATION History
n
A comprehensivehistory will include an accuratediet record, specifically the type and the quantity of food the child is being offered. Frequently episodes of diarrhea follow viral illnesses and courses of antibiotics, at which time the child is placed on clear liquids or a restricted diet (Barclay, 1982). This diet generally consists of a large volume of fruit juices and minimal milk products. As a result the child is receiving inadequate calories, an imbalance of fluids, and an inadequate fat content in the diet (Barclay,
Marianne Buzby is a nurse practitioner with the Division of Castroenterology and Nutrition at Children’s Hospital of Philadelphia. JOURNAL
OF PEDIATRIC
HEALTH
Margaret Crey, Dr PH, RN, CPNP University of Pennsylvania School of Nursing Philadelphia, Pennsylvania
CARE
RN, MSN,
9
CPNP
1982). Inadequate caloric intake is often the cause for the weight loss associatedwith chronic diarrhea (Ament & Barclay, 1982). The practitioner may find it helpful to ask the family what foods have been restricted from the child’s diet in addition to what the child has actually been eating. A description of the child’s usual or normal stooling pattern and how that has changed is very important. The frequency and consistencyof the stools, in addition to the presenceof blood and mucus, are important in guiding the practitioner through the differential. Having parents describe the volume of the stools in terms of containment in the diaper may provide helpful information. The history should include possible exposuresto infectious agents. For infants and toddlers, the daycare setting presents a strong possibility of exposure to Giardia. A travel history is important in terms of exposure to contaminated food and water supplies. Recent courses of antibiotics for other illnesses increase the likelihood of CMri$c& as the cause for chronic diarrhea. A review of the family history focusing on diseases that cause chronic diarrhea, such as celiac disease, cystic fibrosis, and inflammatory bowel disease, will aid in planning the appropriate workup and therapeutic interventions. Physical Examination
An accurate measurement of height and weight is absolutely essential in planning the management course for the child with chronic diarrhea. The type of failure to thrive typically seen with chronic diarrhea is a normal height and head circumference on the growth curve, with weight falling off the growth curve. This pattern generally indicates inadequatecalories or malabsorption (Silverman & Roy, 1983). The child’s general appearanceshould be assessedfor 163
164
Patient Management
Volume 3. Number 3 May-June 1989
Exchange
Newbornto3months Postinfectious Transport, enzyme defects Malnutrition “Intractable diarrhea” Cowmilklsoy protein intolerance Cystic fibrosis Short bowel syndrome 3~~~36~~ Postinfections: C. difficile, Chronic nonspecific diarrhea Celiac disease Sucrose-isomaltase deficiency
lactose intolerance Giatdiasis Protein intolerance Hirschsprung’s disease
3year-s to 18yean Giardiasis Celiac disease Late-onset lactose intolerance inflammatory bowel disease: Crohn’s disease, ulcerative colitis (Schwarz, 1987)
signs of chronic wasting, such as loose skin around the buttocks. Assessing the child’s degree of dehydration is important in determining whether immediate hospitalization is necessaryto properly meet the child’s needs. A rectal examination should be included in the complete physical to rule out the possibility of encopresis being m istaken as chronic diarrhea. Initial laboratory
Studies
A stool specimen should be examined by the practitioner at the time of the visit. If possible,the parents should be askedto bring a fresh specimenwith them at this visit. The stool should be examined for consistency and appearance.The stool should be tested for fresh blood, if it is evident, and for occult blood by using a hemoccult card. A positive hemoccult card may indicate an infection, such as Salmonellaor ShiJella, i&mrnatory bowel disease,or a protein allergy. A simple test for identifying a possible carbohydrate malabsorption is a stool for reducing substancesor C&test. A stool specimenshould be obtained for a routine stool culture. If the child has been in a day-caresetting or there is a possibility of exposure to contaminated water, three stool specimensfor ova and parasitesshould be obtained. A history of antibiotic use indicates the necessityto rule out C. d@cile. A fresh stool specimen, obtained at the time of the visit, is ideal for this test, since there may be false negatives if the specimenis allowed to sit for extended periods of time. If this is impossible to obtain, the parents should be instructed to freeze a stool specimen and
deliver it to the laboratory. Finally, a stool specimen for white cells will determine the presenceof leukocytes, which indicate an infection, or the presence of eosinophils, which indicate the likelihood of a protein intolerance. The recommendations for hematologic studies vary greatly in the literature. It is a common practice to obtain a complete blood count (CBC) with differential and ESR to screen for an infectious or inflammatory etiology. If significant nutritional deficits are suspected, additional studies would include albumin, total protein, folate, and vitamin B12 (Schwarz, 1987). Electrolytes, BUN, and creatinine may also be necessaryif severedehydration is to be evaluated (Fitzgerald, 1982). . MANAGEMENT
Management of the child with chronic diarrhea is guided by the information obtained in the history and the assessmentof the child’s current nutritional status. The child who does not need to be hospitalized for dehydration or severechronic malnutrition should leave the practitioner’s office with guidelines for an age-appropriatediet. The most common cause for chronic diarrhea in infants is a postinfectious lactose intolerance (Schwarz, 1987). In this case,infants should be placed on a lactose-freeformula. If a m ilk protein allergy is suspected, the infant should be placedon a hypoallergenicformula, as 30% of infants with a m ilk protein allergy are also sensitive to soy protein (Silverman & Roy, 1983). Chronic nonspecific diarrhea is the most common causeof chronic diarrhea in toddlers (Barclay, 1982).
Journal of Pediatric Health Care
These children are usually on a diet that is high in fluids and provides inadequate calories. Guidelines for normalizing this diet include minimizing the total fluid intake to 16 to 20 ouncesper day, the majority of this fluid should be milk. Parents should be instructed to offer food first, then followup with fluids after the child has eaten. Parents should record what the child actually consumesover a 3-day span so that the diet may be further evaluatedfor a causeof diarrhea if the symptoms persist. The child should be seen in the office in 1 to 2 weeks. At that time the child should be assessed for resolution of symptoms and weight gain. The laboratory results should be reviewed with the family. With normal results and resolving symptoms, the parents need reassuranceregarding the ageappropriate diet they have been using. More importantly, they need reassurancethat their child is healthy. Positive stool specimensmust be treated with the appropriate antibiotics. The child’s diet should be kept age-appropriate.If the child’s symptoms persist after completion of therapy, repeat stool cultures should be obtained to determine if the therapy was effective. Should hematologic studies indicate that the child is significantly malnourished or that an inflammatory diseasemay be the causeof the chronic diarrhea, the child should be referred to a subspecialistfor further evaluation. Similarly, if the child’s chronic diarrhea
Patient Management
Exchange
165
persistsdespite normal laboratory studiesand an ageappropriate diet, the child should be referred for further evaluation. n
CONCLUSION
Chronic diarrhea is a common problem in pediatrics. Differentiating the cause of the diarrhea can be a confusing process.In most cases,the practitioner will be able to identify the diagnosis based on an accurate history, a thorough physical examination, and a few laboratory studies. Management of the symptoms should focus on normalizing the child’s diet and responding to positive findings in the laboratory studies. n REFERENCES Ament, M.E. & Barclay, G.N. (1982). Chronic diarrhea. Pediatric Anna& 11, 124-131. Barclay, G.N. (1982). Functional complaints and the pediatric gastroenterologist. l’ediatrit Annul, 11, 159-173. BeBenham, B.J., Ellet, M., Perez, KC., & Clark, J.H. (1985). Initial assessmentand management of chronic diarrhea in toddlers. Pediatric Nursing, 11, 281-285. Farrell, M.K. (1986). The diagnosis and treatment of diarrhea in children. Pediati Cmult, 5, l-8. Fitzgerald, J.F. (1985). Management of the infant with persistent diarrhea. Pediatric Znfectww Direme, 4, 6-9. Schwarz, S. (1987). Chronic diarrhea. In W.M. Schwartz, E.B. Chamey, T.A. Curry, & S. Ludwig (Eds.). Principh andpactice in clinical pe&& (pp. 177-184). Chicago: Year Book Medical Publishers. Silverman, A., & Roy, CC. (1983). Pediatric ptroenterology. St. Louis: C.V. Mosby.
n
Chronic Diarrhea: Management in Pediatrics Marianne
Buzby,
n
L/’ mr h ea is defined as an increase in the volume, frequency, or water content of a stool as compared to a normal stool. The World Health Organization has defined diarrhea as any stool that conforms to the shape of the container in which it is placed (Farrell, 1986). Diarrhea becomes chronic when it persists for more than 14 days (Schwarz, 1987). The managementof chronic diarrhea must be approached in an organized manner, focusing on the most likely causeof this problem. Chronic diarrhea poses a perplexing problem for the pediatric practitioner. The differential diagnoses range from potentially serious diseasesto rather benign illnesses that are easily treated (see Box). Dehydration and malnutrition, the sequelaeof severe chronic diarrhea may further complicate identifjring the cause of the problem. Despite this, the primary practitioner will be able to determine the appropriate management plan if a careful history and physical examination are obtained in addition to a few screening laboratory studies (Schwarz, 1987). EVALUATION History
n
A comprehensivehistory will include an accuratediet record, specifically the type and the quantity of food the child is being offered. Frequently episodes of diarrhea follow viral illnesses and courses of antibiotics, at which time the child is placed on clear liquids or a restricted diet (Barclay, 1982). This diet generally consists of a large volume of fruit juices and minimal milk products. As a result the child is receiving inadequate calories, an imbalance of fluids, and an inadequate fat content in the diet (Barclay,
Marianne Buzby is a nurse practitioner with the Division of Castroenterology and Nutrition at Children’s Hospital of Philadelphia. JOURNAL
OF PEDIATRIC
HEALTH
Margaret Crey, Dr PH, RN, CPNP University of Pennsylvania School of Nursing Philadelphia, Pennsylvania
CARE
RN, MSN,
9
CPNP
1982). Inadequate caloric intake is often the cause for the weight loss associatedwith chronic diarrhea (Ament & Barclay, 1982). The practitioner may find it helpful to ask the family what foods have been restricted from the child’s diet in addition to what the child has actually been eating. A description of the child’s usual or normal stooling pattern and how that has changed is very important. The frequency and consistencyof the stools, in addition to the presenceof blood and mucus, are important in guiding the practitioner through the differential. Having parents describe the volume of the stools in terms of containment in the diaper may provide helpful information. The history should include possible exposuresto infectious agents. For infants and toddlers, the daycare setting presents a strong possibility of exposure to Giardia. A travel history is important in terms of exposure to contaminated food and water supplies. Recent courses of antibiotics for other illnesses increase the likelihood of CMri$c& as the cause for chronic diarrhea. A review of the family history focusing on diseases that cause chronic diarrhea, such as celiac disease, cystic fibrosis, and inflammatory bowel disease, will aid in planning the appropriate workup and therapeutic interventions. Physical Examination
An accurate measurement of height and weight is absolutely essential in planning the management course for the child with chronic diarrhea. The type of failure to thrive typically seen with chronic diarrhea is a normal height and head circumference on the growth curve, with weight falling off the growth curve. This pattern generally indicates inadequatecalories or malabsorption (Silverman & Roy, 1983). The child’s general appearanceshould be assessedfor 163
164
Patient Management
Volume 3. Number 3 May-June 1989
Exchange
Newbornto3months Postinfectious Transport, enzyme defects Malnutrition “Intractable diarrhea” Cowmilklsoy protein intolerance Cystic fibrosis Short bowel syndrome 3~~~36~~ Postinfections: C. difficile, Chronic nonspecific diarrhea Celiac disease Sucrose-isomaltase deficiency
lactose intolerance Giatdiasis Protein intolerance Hirschsprung’s disease
3year-s to 18yean Giardiasis Celiac disease Late-onset lactose intolerance inflammatory bowel disease: Crohn’s disease, ulcerative colitis (Schwarz, 1987)
signs of chronic wasting, such as loose skin around the buttocks. Assessing the child’s degree of dehydration is important in determining whether immediate hospitalization is necessaryto properly meet the child’s needs. A rectal examination should be included in the complete physical to rule out the possibility of encopresis being m istaken as chronic diarrhea. Initial laboratory
Studies
A stool specimen should be examined by the practitioner at the time of the visit. If possible,the parents should be askedto bring a fresh specimenwith them at this visit. The stool should be examined for consistency and appearance.The stool should be tested for fresh blood, if it is evident, and for occult blood by using a hemoccult card. A positive hemoccult card may indicate an infection, such as Salmonellaor ShiJella, i&mrnatory bowel disease,or a protein allergy. A simple test for identifying a possible carbohydrate malabsorption is a stool for reducing substancesor C&test. A stool specimenshould be obtained for a routine stool culture. If the child has been in a day-caresetting or there is a possibility of exposure to contaminated water, three stool specimensfor ova and parasitesshould be obtained. A history of antibiotic use indicates the necessityto rule out C. d@cile. A fresh stool specimen, obtained at the time of the visit, is ideal for this test, since there may be false negatives if the specimenis allowed to sit for extended periods of time. If this is impossible to obtain, the parents should be instructed to freeze a stool specimen and
deliver it to the laboratory. Finally, a stool specimen for white cells will determine the presenceof leukocytes, which indicate an infection, or the presence of eosinophils, which indicate the likelihood of a protein intolerance. The recommendations for hematologic studies vary greatly in the literature. It is a common practice to obtain a complete blood count (CBC) with differential and ESR to screen for an infectious or inflammatory etiology. If significant nutritional deficits are suspected, additional studies would include albumin, total protein, folate, and vitamin B12 (Schwarz, 1987). Electrolytes, BUN, and creatinine may also be necessaryif severedehydration is to be evaluated (Fitzgerald, 1982). . MANAGEMENT
Management of the child with chronic diarrhea is guided by the information obtained in the history and the assessmentof the child’s current nutritional status. The child who does not need to be hospitalized for dehydration or severechronic malnutrition should leave the practitioner’s office with guidelines for an age-appropriatediet. The most common cause for chronic diarrhea in infants is a postinfectious lactose intolerance (Schwarz, 1987). In this case,infants should be placed on a lactose-freeformula. If a m ilk protein allergy is suspected, the infant should be placedon a hypoallergenicformula, as 30% of infants with a m ilk protein allergy are also sensitive to soy protein (Silverman & Roy, 1983). Chronic nonspecific diarrhea is the most common causeof chronic diarrhea in toddlers (Barclay, 1982).
Journal of Pediatric Health Care
These children are usually on a diet that is high in fluids and provides inadequate calories. Guidelines for normalizing this diet include minimizing the total fluid intake to 16 to 20 ouncesper day, the majority of this fluid should be milk. Parents should be instructed to offer food first, then followup with fluids after the child has eaten. Parents should record what the child actually consumesover a 3-day span so that the diet may be further evaluatedfor a causeof diarrhea if the symptoms persist. The child should be seen in the office in 1 to 2 weeks. At that time the child should be assessed for resolution of symptoms and weight gain. The laboratory results should be reviewed with the family. With normal results and resolving symptoms, the parents need reassuranceregarding the ageappropriate diet they have been using. More importantly, they need reassurancethat their child is healthy. Positive stool specimensmust be treated with the appropriate antibiotics. The child’s diet should be kept age-appropriate.If the child’s symptoms persist after completion of therapy, repeat stool cultures should be obtained to determine if the therapy was effective. Should hematologic studies indicate that the child is significantly malnourished or that an inflammatory diseasemay be the causeof the chronic diarrhea, the child should be referred to a subspecialistfor further evaluation. Similarly, if the child’s chronic diarrhea
Patient Management
Exchange
165
persistsdespite normal laboratory studiesand an ageappropriate diet, the child should be referred for further evaluation. n
CONCLUSION
Chronic diarrhea is a common problem in pediatrics. Differentiating the cause of the diarrhea can be a confusing process.In most cases,the practitioner will be able to identify the diagnosis based on an accurate history, a thorough physical examination, and a few laboratory studies. Management of the symptoms should focus on normalizing the child’s diet and responding to positive findings in the laboratory studies. n REFERENCES Ament, M.E. & Barclay, G.N. (1982). Chronic diarrhea. Pediatric Anna& 11, 124-131. Barclay, G.N. (1982). Functional complaints and the pediatric gastroenterologist. l’ediatrit Annul, 11, 159-173. BeBenham, B.J., Ellet, M., Perez, KC., & Clark, J.H. (1985). Initial assessmentand management of chronic diarrhea in toddlers. Pediatric Nursing, 11, 281-285. Farrell, M.K. (1986). The diagnosis and treatment of diarrhea in children. Pediati Cmult, 5, l-8. Fitzgerald, J.F. (1985). Management of the infant with persistent diarrhea. Pediatric Znfectww Direme, 4, 6-9. Schwarz, S. (1987). Chronic diarrhea. In W.M. Schwartz, E.B. Chamey, T.A. Curry, & S. Ludwig (Eds.). Principh andpactice in clinical pe&& (pp. 177-184). Chicago: Year Book Medical Publishers. Silverman, A., & Roy, CC. (1983). Pediatric ptroenterology. St. Louis: C.V. Mosby.