Practice scenario: Childhood diarrhoea

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Hypothesis generation

Childhood diarrhoea can be acute or chronic and is very common. In this case, you are dealing with an acute episode (acute being defined as diarrhoea lasting less than 14 days). This means that chronic causes of childhood diarrhoea can be eliminated from your early thinking. These include coeliac disease, dietary causes (e.g. drinking too much juice), inflammatory bowel disease, irritable bowel syndrome and lactose intolerance.

With regard to acute causes of diarrhoea, there are a number of causes that need to be considered, although infection through viral pathogens is responsible for more than 75 per cent of cases.

Likely diagnosis 

• Viral gastroenteritis

Possible diagnosis

• Antibiotic-induced diarrhoea
• Bacterial gastroenteritis or food allergy
• Non-gastrointestinal (GI) infections
• Parasites.

Continued information gathering

You find that the child has been to the toilet at least five times over the last 24 hours. She normally goes once or twice a day. She has also vomited at least twice over the same period.

Before trying to work out what might be the cause, you ask the customer how his daughter is, apart from these symptoms. He says she seems well in herself and still wants to play and do normal activities. This suggests she is not systemically unwell and not moderately or severely dehydrated (see red flags).

To try to ascertain the cause of the symptoms, you ask if the child has started any new medicines. The father says she isn’t taking anything from the doctor, and he and his wife haven’t given her anything either. Medicines can therefore be ruled out as the cause.

Parasitic infections are normally associated with drinking contaminated water, usually while abroad or from visiting a farm or petting zoo.

The incubation period can be around two weeks (up to four weeks in exceptional cases), so you ask if they have been abroad or to a petting zoo in the last month. They have not, which appears to rule out giardiasis. At this point, infection seems likely, but a food allergy cannot be discounted.

Problem refinement

You ask about any other symptoms he has noticed in his daughter both prior to, and during, the diarrhoea and vomiting. He cannot think of anything in particular, apart from the fact that she has complained of tummy ache. You ask about skin rashes (allergy), high temperature, coughs or ear problems (non-GI origin infection). Again, he says he has not noticed these symptoms.

The lack of other symptoms now points strongly to a GI infection. Bacterial causes tend to be associated with food sources, but investigation into her diet reveals no unusual or different foods. 

His daughter seems to be suffering from a bout of viral gastroenteritis.

Red flags

In children suffering from diarrhoea, the key consideration is to make sure that they do not dehydrate. Mild dehydration (<10 per cent) manifests with symptoms such as thirst, dry mouth and headache.

However, in young children, this may also present as appearing unwell, irritability or lethargy, cold extremities or decreased urine output. This child does not seem to have any clinical signs of dehydration.

Management

• Self-care options

To minimise any chances of her passing the infection on to others, you should recommend good hygiene measures that include handwashing before any meals and after each visit to the toilet.

• Prescribing options

As the child is not showing signs of clinical dehydration, you can tell the father to encourage her to keep drinking but not to have fruit juices or carbonated drinks.

You could offer an oral rehydration solution as the child is potentially at risk of dehydration due to the number of times she has had diarrhoea and vomited. Once made up, the solution is best sipped every 5 to 10 minutes rather than drunk in large quantities less frequently.

Safety netting

You tell the father you believe the diarrhoea is probably being caused by a viral infection – although it is difficult to know precisely – and that his daughter’s symptoms should begin to ease off in the next 24 hours but could last for another two or three days.

You explain to him that if his daughter still has symptoms after this time, she needs to be reassessed. In addition, you tell him to look out for signs of dehydration, such as being visibly more poorly, lethargic or irritable.