A Child Presenting With Diarrhea- Important Questions In History

Diarrhea is a common presenting complaint in pediatric practice and following questions are important to be asked from the parent as these help in determining the condition of the child and the cause of diarrhea.

Immediate Questions

1. How old is patient?
In a young infant the intestinal mucosa tends to be more permeable to water than in an older child or adult. This can result in greater net fluid and electrolyte losses. Diarrhea in the first few months of life requires more immediate attention.

2.What are the vital signs?
Tachycardia suggests volume depletion. Hypotension suggests hypovolemic or septic shock. fever implies an infectious etiology. Diarrhea with associated tachycardia, hypotension or fever should be evaluated immediately.

3. Is diarrhea grossly bloody?
Bloody diarrhea is caused by invasive bacterial infections, ischemic bowel or infarction, allergic phenomenon or inflammatory bowel disease. It requires more active and immediate intervention.

4. Is this acute or chronic problem?
Acute diarrhea: Usually a self limited disease, which can often be treated symptomatically. The most common cause is infection. Other common causes include drugs e.g antibiotics as well as excessive intake of high carbohydrate fluids or non absorbable fillers (e.g sorbitol).

Chronic diarrhea: defined as diarrhea that lasts longer than 4 weeks. Common causes include chronic non specific diarrhea (toddler’s diarrhea), lactose intolerance, milk-protein allergy, encopresis, irritable bowel syndrome, various infections, drugs and IBD. It can also present as an acute exacerbation.

5. Are there risk factors that suggest a specific cause?
Risk factors include day care, winter season, ill contacts, drugs, travel, animal exposure, constipation, excessive juice intake, poorly perpared or stored poultry or salads, untreated water sources, prior abdominal surgery, immunodeficiency and prematurity.

6. Is there associated vomiting?
Sometimes diarrhea is associated with vomiting which increases the risk of significant dehydration.

7. Associated abdominal pain?
Absence of pain makes inflammatory causes such as ulcerative colitis less likely. Malabsorption presents with diarrhea, abdominal pain, flatulence and greasy stools without concurrent fever.

8. What is the volume of stool?
Small bowel conditions tend to produce large volume watery stools that are relatively infrequent. Conversely large bowel involvement usually due to a bacterial induced inflammatory process tends to produce frequent less watery stools.

9. Has the patient participated in any recreational water activities? Infectious causes has been associated with recreation water activities e.g swimming pools, water parks, lakes, rivers, hot tubs and the organisms invoved are shigella sonnie and cryptosporidium pavum.

10. Is there a reason to suspect laxative abuse?Although not common in young children but can be suspected in an adolescent girl with a history of bulimia. Stool can be tested for laxative without going through other extensive laboratory workup.