Below is a concise but complete paediatric reference on Diarrheal Disorders in Children covering Acute Diarrhea, Persistent Diarrhea, and Celiac Disease (without images).
Diarrheal Disorders in Children (Paediatrics)
Diarrheal diseases are one of the most common causes of morbidity and mortality in children, especially under 5 years of age.
Definition of Diarrhea
Passage of ≥3 loose or watery stools per day or increased stool frequency compared to normal pattern.
Types in Children
- Acute diarrhea – lasts <14 days
- Persistent diarrhea – lasts ≥14 days
- Chronic diarrhea – usually >4 weeks
- Malabsorption disorders (example: Celiac disease)
1. Acute Diarrhea in Children
Definition
Sudden onset diarrhea lasting less than 14 days, most commonly due to infection.
Pathophysiology
Mechanisms include:
- Secretory diarrhea
* Intestinal secretion of electrolytes and water
* Example: cholera
- Osmotic diarrhea
* Poor absorption leads to osmotic retention of water
* Example: lactose intolerance
- Inflammatory diarrhea
* Mucosal damage with blood and pus
* Example: Shigella
- Motility-related diarrhea
Causes
Viral (most common)
- Rotavirus
- Norovirus
- Adenovirus
- Astrovirus
Bacterial
- Escherichia coli (ETEC, EPEC)
- Shigella
- Salmonella
- Campylobacter
- Vibrio cholerae
Parasitic
- Giardia lamblia
- Entamoeba histolytica
- Cryptosporidium
Non-infectious
- Food allergy
- Antibiotic associated diarrhea
- Lactose intolerance
Clinical Features
Mild illness
- Loose watery stools
- Vomiting
- Mild fever
- Reduced appetite
Moderate to severe illness
- Dehydration
- Sunken eyes
- Dry mouth
- Reduced urine
- Lethargy
- Abdominal pain
Dysentery
- Blood and mucus in stool
- Fever
- Tenesmus
Assessment of Dehydration
No dehydration
- Alert
- Normal thirst
- Normal skin turgor
Some dehydration
- Restlessness
- Sunken eyes
- Drinks eagerly
- Skin pinch returns slowly
Severe dehydration
- Lethargy
- Unable to drink
- Very sunken eyes
- Skin pinch very slow
Investigations
Usually not required in mild cases.
Possible tests:
- Stool microscopy
- Stool culture
- Stool antigen test
- Electrolytes
- Blood glucose
- CBC
Indications:
- Bloody diarrhea
- Severe dehydration
- Immunocompromised child
- Persistent diarrhea
Management
1. Rehydration Therapy (Most Important)
Oral Rehydration Solution (ORS)
WHO low-osmolar ORS:
Composition (per liter)
- Sodium 75 mEq
- Glucose 75 mmol
- Potassium 20 mEq
- Citrate 10 mmol
ORS dosing
No dehydration
Extra ORS after each stool
- <2 years → 50–100 ml
- 2–10 years → 100–200 ml
- > 10 years → as desired
Some dehydration
75 ml/kg over 4 hours
Severe dehydration
Immediate IV fluids
2. Intravenous Fluids
Preferred fluid: Ringer Lactate
Regimen (WHO Plan C)
First 30 ml/kg
- Infants: 1 hour
- Older children: 30 minutes
Next 70 ml/kg
- Infants: 5 hours
- Older children: 2.5 hours
3. Zinc Supplementation
Drug: Zinc sulfate
Mechanism
- Enhances intestinal epithelial regeneration
- Improves immunity
- Reduces duration of diarrhea
Dose
- <6 months → 10 mg daily for 14 days
- ≥6 months → 20 mg daily for 14 days
Adverse effects
- Vomiting
- Metallic taste
4. Antibiotics (Only in Specific Cases)
Indications
- Cholera
- Dysentery (Shigella)
- Severe bacterial infection
Examples
Drug: Azithromycin
Mechanism
- Inhibits bacterial protein synthesis (50S ribosomal subunit)
Dose
- 10 mg/kg/day for 3 days
Adverse effects
- Nausea
- Diarrhea
- QT prolongation
Drug interactions
- Antacids reduce absorption
Monitoring
- Clinical response
5. Feeding
Continue feeding
Breastfeeding should never be stopped.
Recommended foods
- Rice
- Banana
- Yogurt
- Khichdi
- Potato
Avoid
- Sugary drinks
- Soft drinks
- High fat foods
Complications
- Severe dehydration
- Electrolyte imbalance
- Hypoglycemia
- Acute kidney injury
- Sepsis
- Malnutrition
2. Persistent Diarrhea
Definition
Diarrhea lasting ≥14 days.
Common in malnourished children.
Causes
Post-infectious
- Rotavirus
- Bacterial infection
Malabsorption
- Lactose intolerance
- Celiac disease
Chronic infections
- Giardia
- Cryptosporidium
Other causes
- Immunodeficiency
- Inflammatory bowel disease
Pathophysiology
- Intestinal mucosal damage
- Villous atrophy
- Reduced enzyme activity
- Malabsorption of nutrients
Clinical Features
- Chronic watery diarrhea
- Weight loss
- Failure to thrive
- Abdominal distension
- Nutritional deficiencies
Investigations
- Stool microscopy
- Stool fat test
- Stool culture
- Celiac serology
- CBC
- Electrolytes
- Endoscopy (selected cases)
Management
Rehydration
ORS
Nutritional therapy
Recommended diet
- Low lactose diet
- High energy foods
- Protein rich diet
Micronutrients
- Zinc
- Vitamin A
- Folate
Treat underlying cause
Examples
- Antiparasitic drugs
- Gluten free diet (celiac)
3. Celiac Disease in Children
Definition
Celiac disease is an autoimmune disorder triggered by gluten ingestion leading to immune mediated damage of small intestinal mucosa.
Occurs in genetically susceptible individuals.
Etiology
Triggered by gluten proteins
Found in:
- Wheat
- Barley
- Rye
Genetic predisposition
- HLA-DQ2
- HLA-DQ8
Pathophysiology
Gluten → gliadin peptides
Gliadin triggers immune response:
- Tissue transglutaminase modifies gliadin
- T-cell activation
- Autoimmune inflammation
- Villous atrophy
Results in malabsorption.
Clinical Features
Classical symptoms
- Chronic diarrhea
- Steatorrhea
- Abdominal distension
- Failure to thrive
- Weight loss
Extraintestinal features
- Iron deficiency anemia
- Short stature
- Delayed puberty
- Osteopenia
- Dermatitis herpetiformis
Investigations
Serology
Best screening test
- Anti-tTG IgA
Other tests
- Anti-endomysial antibody
- Total IgA
Confirmatory test
Duodenal biopsy
Findings
- Villous atrophy
- Crypt hyperplasia
- Increased intraepithelial lymphocytes
Management
Lifelong Gluten Free Diet
Avoid
- Wheat
- Barley
- Rye
Allowed foods
- Rice
- Corn
- Millet
- Fruits
- Vegetables
- Meat
- Eggs
Nutritional supplementation
- Iron
- Folate
- Vitamin B12
- Calcium
- Vitamin D
Prognosis
With strict gluten-free diet:
- Intestinal mucosa heals
- Growth improves
- Symptoms resolve
Untreated disease can lead to:
- Severe malnutrition
- Osteoporosis
- Intestinal lymphoma
Key Differences
| Feature | Acute Diarrhea | Persistent Diarrhea | Celiac Disease |
| -------------- | -------------- | ------------------------------- | ---------------- |
| Duration | <14 days | ≥14 days | Chronic |
| Cause | Infection | Post-infection or malabsorption | Autoimmune |
| Stool type | Watery | Chronic watery | Steatorrhea |
| Main treatment | ORS + zinc | Nutritional therapy | Gluten-free diet |
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