Diarrhoea in Children
This is a very common ‘day duty’ presentation and is usually caused by gastroenteritis or some other acute infection. Less common is the subacute or prolonged case, where the differential is wider and where a more detailed analysis is required.
Differential diagnosis
Common Diagnoses
- Gastroenteritis
- Other Systemic Infection (e.g. UTI, Otitis Media, Pneumonia)
- Toddler’S Diarrhoea
- Medication Side Effects (Usually Antibiotics)
- Cow’s Milk Protein Intolerance (CMPI)
Occasional Diagnoses
- Lactose Intolerance (Typically Following a Bout of Gastroenteritis in Babies)
- Faecal Impaction (Causing Overflow Diarrhoea)
- Irritable Bowel Syndrome
- Coeliac Disease
- Other Gastrointestinal Infections, e.g. Giardia
Rare Diagnoses
- Inflammatory Bowel Disease (IBD)
- Appendicitis (Relatively Common but Rarely Presents with Diarrhoea)
- Intussusception
- Cystic Fibrosis
Ready reckoner
Key distinguishing features of the most common diagnoses
| Gastroenteritis | Other Systemic Infection | Toddler’s Diarrhoea | Medication Side Effects | CMPI | |
|---|---|---|---|---|---|
| Blood in Diarrhoea | Possible | No | No | No | Possible |
| Recent or Current Antibiotics | No | Possible | No | Yes | No |
| Fever | Possible | Possible | No | Possible | No |
| Lasts More than 2 Weeks | Possible | No | Yes | Possible | Yes |
| Other Localising Symptoms (e.g. Respiratory, Urinary or Ear) | No | Yes | No | Possible | No |
Possible investigations
Likely: None.
Possible: Stool culture, urinalysis, MSU, FBC, CRP, ESR, anti-endomysial and anti-gliadin antibodies, faecal calprotectin.
Small Print: Hospital-based tests (e.g. for cystic fibrosis, IBD and to confirm coeliac disease).
- Stool culture: For microbiological examination if the diarrhoea persists more than a week, is bloody or there is relevant recent foreign travel; send three specimens for ova, cysts and parasites if giardia suspected.
- Urinalysis: May help if a UTI is suspected as the underlying cause.
- MSU: For confirmation of a suspected UTI.
- FBC, ESR, CRP: Hb may be reduced, and CRP/ESR raised in IBD.
- Anti-endomysial and anti-gliadin antibodies: If coeliac is a possibility.
- Faecal calprotectin: To help rule out IBD if diarrhoea is prolonged.
- Hospital-based tests: These might include endoscopy and biopsy in suspected IBD or coeliac disease, and tests for possible cystic fibrosis.
Top Tips
- It is not unusual for the diarrhoea in gastroenteritis to take a couple of weeks to settle; consider a stool specimen if it is not starting to improve after a week.
- Don’t overlook faecal impaction as a cause of overflow diarrhoea in children, the clues being soiling and a preceding history of constipation.
- Lactose intolerance tends to be over-diagnosed and often confused with CMPI. The former is less common, typically follows gastroenteritis and is usually short lived.
- Undigested food (‘peas and carrots syndrome’) in the persistent loose stool of an otherwise well and thriving child is virtually pathognomic of the harmless toddler’s diarrhoea.
Red Flags
- In the acute case – particularly in younger children with severe diarrhoea and associated vomiting – assess for dehydration as a priority. If the child is significantly dehydrated, then admission will be needed regardless of cause.
- Bloody diarrhoea raises the stakes somewhat. In the acute situation, this could be one of the more severe forms of gastroenteritis or, especially in those under 1 year of age, intussusception. In more prolonged cases, it might indicate CMPI or IBD.
- Very minor, transient weight loss is common during a bout of gastroenteritis. More prolonged weight loss with persistent diarrhoea should, on the other hand, prompt urgent referral.
- Remember that appendicitis can cause diarrhoea. In such cases, the abdominal pain is usually more marked and constant than in a typical gastroenteritis, where it is typically mild (and therefore not the presenting complaint) and intermittent.