Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Diarrhea, Acute
DIARRHEA, ACUTE
An increase in the frequency and fluid content of stools. It is usually self-limited in older children and adolescents but is potentially life-threatening in infants.
I. Etiology
A. Causes
1. Diet
2. Inflammation or irritation of the gastrointestinal mucosa
3. Gastrointestinal infection
a. Viral: Rotaviruses, adenoviruses
b. Bacterial: Shigella sp., Salmonella sp., Campylobacter sp.,
Yersinia sp., and Escherichia coli
c. Parasitic: Giardia sp.
4. Antibiotic-associated
5. Psychogenic disorders
6. Nongastrointestinal disease (“parenteral” diarrhea)
7. Mechanical or anatomic conditions
B. Pathophysiologic reactions
1. Disturbance of normal cell transport across the intestinal mucosa, as in sugar malabsorption
2. Increase in intestinal motility due to an excess of prostaglandins and serotonin
3. Decrease in intestinal motility causing an increase in bacterial colonization
4. Decrease in surface area available
5. Nonabsorbable molecules in the intestine
6. Excessive secretion of water and electrolytes because of increased intestinal permeability
II. Incidence
A. Common symptom throughout childhood
B. Diet is the most common cause of acute diarrhea in early infancy.
C. In older infants and children, infections of both the gastrointestinal tract and other systems are the most common causes.
D. Most viral diarrheas are spread by fecal–oral transmission with a 1to 3-day incubation period and a 3to 7-day duration of illness.
III. Subjective data
A. Temperature may be elevated.
B. Lethargy
C. Anorexia
D. Increase—sudden or gradual—in the number of stools
E. Decrease in the consistency of stools
F. Increase in the fluid content of stools (watery stools)
G. Crampy, abdominal pain
H. Pertinent subjective data to obtain
1. Usual pattern of elimination, description of stools
2. Last accurate weight
3. Type of onset (e.g., rapid, with explosive, watery stools)
4. Duration of diarrhea
5. Frequency of stools
6. Description of stools: Bloody, purulent, foul smelling, mucoid
7. Associated vomiting
8. Localized abdominal pain
9. Antibiotic therapy: Concurrent or recent course
10. Epidemiologic data: Exposure to others with gastrointestinal infection (e.g., home, day care, school)
11. Detailed dietary history to determine overfeeding, malnutrition, or foods that may cause diarrhea
12. Infant on formula: Type of formula
13. Breastfed infant: Check on mother’s diet and medication intake.
14. Introduction of new foods in diet
15. Previous history of allergic response to foods
16. Family history of atopy
17. Ingestion of suspected contaminated foods
18. History of travel
19. Use of laxatives, stool softeners
20. What treatments have been tried and how effective they have been.
21. Psychosocial factors creating stress in the child’s environment
22. Urinary output: Assess for symptoms of urinary tract infection; change in output.
IV. Objective data
A. Weight
B. Assess state of hydration (see Appendix H, p. 534)
C. Temperature: Elevation may be due to infection or related to the degree of dehydration.
D. Abdominal examination
1. Inspection: Abdominal distention
2. Auscultation: Hyperactive bowel sounds
3. Percussion: Increased tympany
4. Palpation: May be slight, generalized tenderness; no rebound tenderness, masses, or organomegaly
E. Ears, nose, throat, chest, glands: Examine for signs of associated infection.
F. Skin: Examine for rash.
V. Assessment
A. Diagnosis of acute diarrhea in children and infants generally can be made with a careful history.
1. It is usually a diagnosis of exclusion.
2. A stool culture or test for ova and parasites is not indicated unless the child is febrile, there is frank blood in the stool, or the history or clinical picture is indicative of a more complex problem.
3. A Hemoccult stool test can be readily done and should be negative for red blood cells.
4. Urine culture and electrolytes if either a UTI or significant dehydration is suspected.
B. Infectious diarrhea: Diagnosis made by history of exposure and positive stool culture
1. Viral (most common): Abrupt onset; vomiting is common; fever is rarely present; there is often an associated upper respiratory infection. Stools are loose with an unpleasant odor.
2. Salmonella: Onset 6 to 72 hours after ingestion of contaminated foods, such as milk, eggs, or poultry, or following contact with infected animals. Severe abdominal cramps and loose, slimy, sometimes bloody, green stools with a characteristic odor of rotten eggs are the diagnostic clinical features.
3. Shigella: Abrupt onset of fever, abdominal pain, and vomiting. Watery, yellow-green, relatively odorless stools, which may contain blood, occur shortly after onset. Transmitted by ingestion of infected foods or person-to-person contact.
4. E. coli enterotoxigenic: Gradual onset of slimy, green, “pea soup” stools with a foul odor; fever and vomiting not predominant symptoms; major cause of traveler’s diarrhea, or “Montezuma’s revenge”
5. Giardiasis: Commonly waterborne, seen endemically and epidemically in day care centers and communities with inadequate water treatment facilities. Symptoms include anorexia, nausea, abdominal distention, and crampy abdominal pain. Stools are pale, greasy, bulky, and malodorous. Onset may be sudden or gradual. Cysts may not always be found in a stool specimen.
C. Parenteral diarrhea: Concurrent infection of another system (respiratory tract, urinary tract)
D. Diarrhea due to food or drug sensitivities: Indicated by history
E. Starvation diarrhea: Frequent scanty, green-brown stools; history of decreased food intake for 3 to 4 days
VI. Plan: Primary treatment of diarrhea is dictated by degree of dehydration.
A. No dehydration
1. Oral rehydration solution (ORS); Pedialyte, Ricelyte, Rehydralyte; 10 mL/kg for each stool; may not be required if regular diet is continued and increased fluids are encouraged
2. Diet
a. Nursing infants: Continue nursing.
b. Bottle-fed infants: Continue regular formula.
c. Foods: Age-appropriate diet of the following recommended foods
(1) Complex carbohydrates (rice, wheat, potatoes, bread, cereals)
(2) Lean meats
(3) Yogurt
(4) Fruits and vegetables
3. Increase fluid intake.
B. Mild dehydration: 3% to 5%
1. ORS
a. 50 mL/kg ORS
b. Replacement of losses from stool; 10 mL/kg for each stool
2. Reevaluate hydration at least every 2 hours. Once rehydrated, give age-appropriate diet as above. Unnecessary to dilute formula or milk.
C. Moderate dehydration: 6% to 9%
1. ORS 100 mL/kg plus replacement of continuing losses, 10 mL/kg for each stool during a 4-hour period
2. Assess rehydration each hour.
3. Once rehydrated, resume age-appropriate diet.
D. Severe dehydration
1. Refer
E. Salmonella
1. Antimicrobial treatment of mild illness does not shorten clinical course.
2. Consult and treat systemically if disease appears to be progressing systemically in infants, child is under 3 months of age, or if child is immunocompromised.
F. Shigella
1. If child has severe disease or is immunocompromised: Trimethoprimsulfamethoxazole: 8 mg/kg trimethoprim and 40 mg/kg sulfamethoxazole per day in 2 divided doses for 5 days for susceptible strains.
2. Bacteriologic cure will be achieved in 80% of children after 48 hours.
G. E. coli
1. Benefit of antibiotic therapy has not been proven.
H. Giardiasis
1. Metronidazole
a. Children: 15 to 20 mg/kg/d in 3 divided doses for 5–7 days (maximum 250 mg/dose).
b. Adolescents and adults: 250 mg tid
VII. Education
A. Oral rehydration therapy will rarely be refused by child who is dehydrated. Children who are not dehydrated may refuse it because of salty taste.
B. Acknowledge that administration of ORS is labor intensive.
C. Avoid antidiarrheal agents.
D. Too frequent feedings may exacerbate diarrhea by stimulating the gastrocolic reflex.
E. Use petroleum jelly or Desitin on perianal area to prevent excoriation.
F. Use careful handwashing technique to help prevent spread of infectious diarrhea. Keep child home from school to prevent spread.
G. Do not continue clear liquids any longer than 24 hours. If vomiting is not present, prolonged use of clear liquids and the exclusion of foods will prolong diarrhea.
H. Childhood diarrhea can be treated effectively by resting the gastrointestinal tract and then slowly resuming a normal diet, but the plan has to be followed carefully.
I. Call back immediately if child is not taking liquids, is vomiting, or has any signs of dehydration (see Appendix H, p. 534)
J. Sweetened juices and soda can increase the severity of diarrhea (hyperosmotic fluids draw more fluid into intestinal lumen).
K. Incubation period for viral diarrhea is 1 to 3 days (mean 2 days).
L. Duration of diarrhea is generally 3 to 7 days.
M. Transmission is via fecal–oral route.
N. Avoid
1. High fat foods
2. Foods high in simple sugars (tea, juices, soft drinks)
VIII. Follow-up
A. Telephone follow-up in 8 to 12 hours if child is not dehydrated and retains liquids. Have caretaker call back sooner if child refuses liquids or is vomiting.
B. Continue to maintain daily telephone contact until diarrhea has subsided, giving parent dietary instructions at each stage.
C. With infants, check weight daily. Continue follow-up until pre-illness weight is reestablished.
IX. Complications: With simple diarrhea, dehydration is the major complication.
X. Consultation/referral
A. Any child with signs of dehydration
B. Bloody diarrhea
C. Diarrhea in a child who is taking antibiotics (e.g., ampicillin, erythromycin) or iron
D. Infant under 3 months of age
E. Diarrhea persisting longer than 3 to 4 days
F. Abdominal pain
G. Toxic appearance