Diarrhea Follow-up

Updated: Jun 23, 2017
  • Author: Stefano Guandalini, MD; Chief Editor: Carmen Cuffari, MD  more...
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Follow-up

Further Outpatient Care

Follow-up care depends on the severity of diarrhea and the child's age. Uncomplicated diarrhea in a school-aged child may not require follow-up care if the caregiver is reliable and has quick access to a physician. Closely monitor young children to ensure that complications do not occur. Closely monitor children who require labor-intensive ORT. Neonates require strict follow-up care within a few days of illness to ensure that malabsorption and dehydration do not occur.

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Further Inpatient Care

Admit neonates or young infants with moderate dehydration, suspected infection with enterohemorrhagic E coli, or bloody diarrhea.

Oral rehydration therapy (ORT) is the universally recommended form of treatment, proven to be successful even in children who vomit or have mild-to-moderate dehydration. Admit a child with severe dehydration. Also, ORT requires vigilance. If the caregiver cannot comply with protocol, consider admission.

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Deterrence/Prevention

Vaccines are indicated for persons with high risk of exposure to some pathogens.

  • In February 2006, the United States Food and Drug Administration (FDA) approved an oral vaccine for rotavirus (RotaTeq). Soon thereafter, the AAP and the Advisory Committee on Immunization Practices (ACIP) recommended RotaTeq to be part of regularly scheduled childhood immunizations. RotaTeq is administered in a 3-dose series starting between age 6-12 weeks and completing before 32 weeks. An older rotavirus vaccine (RotaShield) was associated with an increased incidence of intussusception and is no longer on the market, but RotaTeq did not show an increased risk compared with placebo in clinical trials.

  • In April 2008, the FDA approved Rotarix, another oral vaccine, for prevention of rotavirus gastroenteritis. The current recommendation is to administer 2 separate doses of Rotarix to patients aged 6-24 weeks. Rotarix was efficacious in a large study, which reported that Rotarix protected patients with severe rotavirus gastroenteritis and decreased the rate of severe diarrhea or gastroenteritis of any cause. [15]

  • A study that involved over 63,000 patients who received Rotarix or placebo at age 2 months and at age 4 months reported a decreased risk of intussusception in patients who received Rotarix. [15] The intussusception data was determined over a 31-day observation period (inpatient or outpatient) after each dose of the Rotarix vaccine; this also included a 100-day surveillance period for all serious adverse events. Although more patients who received Rotarix were observed to have seizures or pneumonia-related deaths, this link has not been directly established to Rotarix. However, on March 22, 2010, the FDA recommended the temporary discontinuation of its use, pending further studies on the reported presence of an apparently benign pig virus in the Rotarix vaccine.

  • A Cochrane Database review evaluated the results of 43 trials with 190,551 participants comparing rotavirus vaccines, both the monovalent and pentavalent types (RV1 and RV5), with placebo. Both vaccines were found to be effective in preventing rotavirus diarrhea. [16]

  • The Salmonella typhi vaccine is recommended for travelers to countries with a high risk of this infection, persons with intimate exposure to a documented typhoid fever carrier, and workers with frequent exposure to this bacteria. Live-attenuated, killed whole-cell, and capsular polysaccharide vaccines are available.

  • The Vibrio species vaccine is available but only protects 50% of immunized persons for 3-6 months. It is not indicated for use.

  • A study documented a diverse range of pathogens associated with community diarrhea in children in low-income and middle-income countries to make an estimate of pathogen-specific diarrhea burdens in the community. The study concluded that there was substantial heterogeneity in pathogen-specific burdens of diarrhea, with important determinants including age, geography, season, rotavirus vaccine usage, and symptoms. The authors also added that these findings suggest that although single-pathogen strategies have an important role in the reduction of the burden of severe diarrheal disease, the effect of such interventions on total diarrheal incidence at the community level might be limited. [17]

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Complications

Common complications include the following:

  • Aeromonas caviae - Intussusception, gram-negative sepsis, hemolytic-uremic syndrome (HUS)

  • Campylobacter species -Bacteremia, meningitis, cholecystitis, urinary tract infection, pancreatitis, Reiter syndrome (RS)

  • C difficile - Chronic diarrhea

  • C perfringens serotype C - Enteritis necroticans

  • Enterohemorrhagic E coli - Hemorrhagic colitis

  • Enterohemorrhagic E coli O157:H7 - HUS

  • Plesiomonas species - Septicemia

  • Salmonella species - Seizures, HUS, perforation, RS

  • Vibrio species - Rapid dehydration

  • Y enterocolitica - Appendicitis, perforation, intussusception, peritonitis, toxic megacolon, cholangitis, bacteremia, RS

  • Rotavirus - Isotonic dehydration, carbohydrate intolerance

  • Giardia species - Chronic fat malabsorption

  • Cryptosporidium species - Chronic diarrhea

  • Entamoeba species - Colonic perforation, liver abscess

Enteric fever is caused by S typhi. This syndrome has an insidious onset of malaise, fever, abdominal pain, and bradycardia. Diarrhea and rash (rose spots) appear after 1 week of symptoms. Bacteria may have disseminated at that time, and treatment is required to prevent systemic complications such as hepatitis, myocarditis, cholecystitis, or GI bleeding.

HUS is caused by damage to vascular endothelial cells by verotoxin (released by enterohemorrhagic E coli and by Shigella organisms). Thrombocytopenia, microangiopathic hemolytic anemia, and acute renal failure characterize HUS. Symptoms usually develop one week after onset of diarrhea, when the organism may be absent.

RS can complicate acute infections and is characterized by arthritis, urethritis, conjunctivitis, and mucocutaneous lesions. Individuals with RS usually do not demonstrate all features.

Carrier states are observed after some bacterial infections.

  • After diarrhea caused by Salmonella organisms, 1-4% of individuals with nontyphoid and enteric fever infections become carriers. The carrier stage for Salmonella organisms is more likely for females, infants, and individuals with biliary tract disease.

  • Asymptomatic C difficile carriage may be observed in as many as 20% of hospitalized patients receiving antibiotics and in 50% of infants.

  • Rotavirus is excreted asymptomatically in feces of children who were previously infected, typically for as long as 1-2 weeks.

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Prognosis

In developed countries, with proper management, prognosis is very good. However, data show an increase in diarrhea-associated deaths among US children from the mid-1980s through 2006. During 2005-2007, 1087 diarrhea-associated infant deaths were reported with 86% of deaths occurring among low birthweight (< 2500g) infants. Risk factors for these infants included male sex, black race, and low 5-minute Apgar score (< 7). [7]

Death is caused predominantly by dehydration and secondary malnutrition from a protracted course. Severe dehydration must be managed with parenteral fluids. Once malnutrition from secondary malabsorption begins, prognosis turns grim unless the patient is hospitalized and supplemental parenteral nutrition is started. Neonates and young infants are at particular risk of dehydration, malnutrition, and malabsorption syndromes.

Even though the mortality rate is low in developed countries, children can die from complications; however, prognosis for children in countries without modern medical care and children with comorbid conditions is more guarded.

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Patient Education

Education is most important for prevention and treatment. Proper ORT prevents dehydration, and early refeeding speeds recovery of intestinal mucosa. With caregiver, emphasize proper hygiene and food preparation practices to prevent future infections and spread.

For patient education resources, see the Esophagus, Stomach, and Intestine Center, as well as Irritable Bowel Syndrome, Inflammatory Bowel Disease, and Diarrhea.

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