History
The history and physical examination serve two vital functions: (1) differentiating gastroenteritis from other causes of vomiting and diarrhea in children, and (2) estimating the degree of dehydration. In some cases, the history and physical examination can also aid in determining the type of pathogen responsible for the gastroenteritis, though only rarely will this affect management.
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Diarrhea: Duration of diarrhea, the frequency and amount of stools, the time since last episode of diarrhea, and the quality of stools. Frequent, watery stools are more consistent with viral gastroenteritis, whereas stools with blood or mucus are indicative of a bacterial pathogen, and "rice water" diarrhea is typically associated with cholera. Similarly, a long duration of diarrhea (>14 d) is more consistent with a parasitic or noninfectious cause of diarrhea. It is important to note that the WHO definition of diarrhea is 3 or more loose stools per day.
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Vomiting: Duration of vomiting, the amount and quality of vomitus (eg, food contents, blood, bile), and time since the last episode of vomiting. When symptoms of vomiting predominate, one should consider other diseases such as gastroesophageal reflux disease (GERD), diabetic ketoacidosis, pyloric stenosis, acute abdomen, or urinary tract infection.
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Urination: Increase or decrease in frequency of urination measured by number of wet diapers, time since last urination, color and concentration of urine, and presence of dysuria. Urine output may be difficult to determine with frequent watery stools.
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Abdominal pain: Location, quality, radiation, severity, and timing of pain, per report of parents and/or child. In general, pain that precedes vomiting and diarrhea is more likely to be due to abdominal pathology other than gastroenteritis.
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Signs of infection: Presence of fever, chills, myalgias, rash, rhinorrhea, sore throat, cough, known immunocompromised status. These may indicate evidence of systemic infection or sepsis.
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Appearance and behavior: Weight loss, quality of feeding, amount and frequency of feeding, level of thirst, level of alertness, increased malaise, lethargy, or irritability, quality of crying, and presence or absence of tears with crying.
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Antibiotics: History of recent antibiotic use increases the likelihood of Clostridium difficile.
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Travel: History of travel to endemic areas may make prompt consideration of organisms that are relatively rare in the United States, such as parasitic diseases or cholera.
Physical
See the list below:
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General: Weight, ill appearance, level of alertness, lethargy, irritability as depicted in the video below.
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Head, ears, eyes, nose, and throat (HEENT): Presence or absence of tears, dry or moist mucous membranes, and whether the eyes appear sunken as shown in the videos below.
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Cardiovascular: Heart rate and quality of pulses
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Respiratory: Rate and quality of respirations (The presence of deep, acidotic breathing suggests severe dehydration.). See the video below.
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Abdomen: Abdominal tenderness, guarding, and rebound, bowel sounds. Abdominal tenderness on examination, with or without guarding, should prompt consideration of diseases other than gastroenteritis.
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Back: Flank/costovertebral angle (CVA) tenderness increases the likelihood of pyelonephritis.
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Rectal: Quality and color of stool, presence of gross blood or mucus
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Extremities: Capillary refill time, warm or cool extremities
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Skin: Abdominal rash may indicate typhoid fever (infection with Salmonella typhi), whereas jaundice might make viral or toxic hepatitis more likely. The slow return of abdominal skin pinch suggests decreased skin turgor and dehydration (see the video below), while a doughy feel to the skin may indicate hypernatremia.
Causes
Identifying the specific etiologic agent responsible for the acute gastroenteritis rarely changes management. However, it may be helpful to differentiate between viral, bacterial, parasitic, and noninfectious causes of diarrhea.
By far, viruses remain the most common cause of acute gastroenteritis in children, both in high-resource and low-resource settings. In the United States, routine rotavirus vaccination has led to a 60-75% reduction in pediatric rotavirus hospitalization since 2006. [19] Rotavirus infection follows seasonal variation, with an increased incidence in winter and decreased incidence in summer months. A 2014 retrospective analysis reported that implementation of rotavirus vaccines has reduced diarrhea-related healthcare use in US children by as much as 94% in 2009–2010. [19, 20]
With the continued decline of rotavirus-associated gastroenteritis since the introduction of rotavirus vaccines, noroviruses (Norwalk-like viruses) have become the leading cause of medically attended acute gastroenteritis in children younger than 5 years in the United States, accounting for 14,000 hospitalizations, 281,000 emergency department visits, 627,000 outpatient visits, and more than $273 million in treatment costs each year. [21] Approximately half of the norovirus-related visits involved children aged 6-18 months according to a 2013 study from the US Centers for Disease Control and Prevention (CDC). [21, 22, 23] It has been estimated that globally norovirus resulted in a total of $4.2 billion in direct health system costs and $60.3 billion in societal costs per year. [16] Among this $60.3 billion, disease among children less than 5 years of age cost society $39.8 billion compared to $20.4 billion for all other age groups. Norovirus poses a considerable economic burden for both in high and low income countries and exceeds that of rotavirus. Rotavirus has been a target for vaccine because it kills more young children. Currently there is no approved vaccine against norovirus. [16]
Caliciviruses, astroviruses, and enteric adenoviruses make up the remainder of cases of viral gastroenteritis. Viral gastroenteritis typically presents with low-grade fever and vomiting followed by copious watery diarrhea (up to 10-20 bowel movements per day), with symptoms persisting for 3-8 days. [24] In high-resource settings, bacterial pathogens account for a small portion, perhaps 2-10%, of all cases of pediatric gastroenteritis. In the United States, the most important pathogens, in order of prevalence, are Campylobacter, Salmonella, Shigella, and enterohemorrhagic Escherichia coli (EHEC) species. [24] Relative to viral gastroenteritis, bacterial disease is more likely to be associated with high fevers, shaking chills, bloody bowel movements (dysentery), abdominal cramping, and fecal leukocytes.
In low-resource settings, a community-based cohort study enrolling patients from 8 sites in South America, Africa, and Asia found Norovirus, rotavirus, Campylobacter, astrovirus, and Cryptosporidium to be the most common causes of diarrhea overall in the first year of life, while Campylobacter, norovirus, rotavirus, astrovirus, and Shigella were the most common causes in the second year of life. [25] In this study, a causative agent was identified in less than one-third of cases, however. A recent case-control study conducted in 7 countries in Africa and South Asia specifically investigated causes of moderate-severe diarrhea in children under five. Using quantitative PCR analysis, they were able to identify causes for about 90% of cases, with the six most common being Shigella, rotavirus, adenovirus, ETEC, Cryptosporidium, and Campylobacter, though they found significant variation based on geography, seasonality, and severity of illness. [25] Of note, Shigella was by far the most common cause of bloody diarrhea in children, but also a common cause of watery diarrhea as well.
Clostridium difficile has emerged as an important cause of antibiotic-associated diarrhea in children. Any antibiotic can trigger infection with C difficile, though certain penicillins (e.g. co-amoxiclav) , cephalosporins, clindamycin and flouroquinolones are the most likely causes. [26] C. difficile testing in infants younger than 1 year of age is not recommended due to the high rates of colonization (37%). The rate of colonization decreases as age increases. [27]
Parasites remain yet another source of gastroenteritis in young children, with Giardia and Cryptosporidium the most common causes in the United States. Parasitic gastroenteritis generally present with watery stools but can be differentiated from viral gastroenteritis by a protracted course or history of travel to endemic areas. [28]
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Child with sunken eyes.
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Child with slow skin pinch (reduced skin turgor).
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Child with absent tears.
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Child with lethargy/poor general appearance.
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Child with hyperpnea (deep, acidotic breathing)
Tables
Symptom or Sign |
No or Minimal Dehydration |
Mild to Moderate Dehydration |
Severe Dehydration |
Mental status |
Alert |
Restless, irritable |
Lethargic, unconscious |
Thirst |
Drinks normally |
Drinks eagerly |
Drinks poorly |
Heart rate |
Normal |
Normal to increased |
Tachycardia |
Quality of pulses |
Normal |
Normal to decreased |
Weak or impalpable |
Breathing |
Normal |
Normal or fast |
Deep |
Eyes |
Normal |
Slightly sunken |
Deeply sunken |
Tears |
Present |
Decreased |
Absent |
Mouth and tongue |
Moist |
Dry |
Parched |
Skin fold |
Instant recoil |
Recoil < 2 seconds |
Recoil >2 seconds |
Capillary refill |
Normal |
Prolonged |
Prolonged or minimal |
Extremities |
Warm |
Cool |
Cold, mottled, cyanotic |
Urine output |
Normal |
Decreased |
Minimal |
*Adapted from King et al. MMWR Recomm Rep. 2003;52(RR-16):1-16. [6] |
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Severe Dehydration |
Two of the following signs: -Lethargic or unconscious -Sunken eyes -Not able to drink or drinking poorly -Skin pinch goes back very slowly |
Some Dehydration |
Two of the following signs: -Restless, irritable -Sunken eyes -Thirsty, drinks eagerly -Skin pinch goes back slowly |
No Dehydration |
Not enough of the above signs to classify as some or severe dehydration |
*Adapted from World Health Organization. [7] |
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| General Appearance | Normal | Thirsty, restless, or irritable | Lethargic or unconscious |
|---|---|---|---|
| Eyes | Normal | Slightly sunken | Very sunken |
| Mucous Membranes | Moist | Dry | Very dry |
| Tears | Tears present | Decreased tears | Absent tears |
| Clinical Sign | Finding | Points |
|---|---|---|
| General Appearance | Normal | 0 |
| Restless/irritable | 2 | |
| Lethargic/unconscious | 4 | |
| Tears | Normal | 0 |
| Decreased | 1 | |
| Absent | 2 | |
| Skin Pinch | Normal | 0 |
| Slow | 2 | |
| Very slow | 4 | |
| Respirations | Normal | 0 |
| Deep | 2 |
