From the Guidelines
For a 20-month-old with diarrhea lasting 2 weeks, a comprehensive workup is needed, starting with a detailed history and physical examination, followed by initial testing including stool studies, complete blood count, comprehensive metabolic panel, and inflammatory markers. The workup should prioritize assessing the child's hydration status, growth parameters, and abdominal findings.
- Initial testing should include:
- Stool studies (culture, ova and parasites, Giardia/Cryptosporidium antigen, C. difficile if antibiotics were recently used)
- Complete blood count
- Comprehensive metabolic panel
- Inflammatory markers like CRP
- Consider celiac screening if there's poor weight gain, as suggested by 1. Empiric treatment depends on the clinical picture but may include oral rehydration therapy with solutions like Pedialyte while maintaining nutrition, as recommended by 1 and 1.
- Avoid anti-diarrheal medications in this age group as they can be harmful.
- Probiotics like Lactobacillus GG or Saccharomyces boulardii may help reduce duration, although the evidence is not as strong. Persistent diarrhea in toddlers can indicate infectious causes, post-infectious enteropathy, early inflammatory bowel disease, celiac disease, or toddler's diarrhea (functional diarrhea), as discussed in 1. If symptoms persist despite initial management, referral to pediatric gastroenterology is warranted for possible endoscopy and additional testing, considering the guidelines from 1 and 1.
From the Research
Diagnostic Approach
The workup for a 20-month-old with diarrhea lasting 2 weeks involves a comprehensive approach to determine the underlying cause of the chronic diarrhea.
- The definition of chronic diarrhea is passing watery stools that lasts for more than 2 weeks 2.
- The etiology of chronic diarrhea is varied, and it is essential to consider the child's age and clinical manifestations with alarm signals for an application of proper treatments to children with chronic diarrhea 2.
- Oral rehydration can be used to treat and prevent dehydration, the major sequela of diarrhea in children 3.
- The impact of diarrhea on nutrition may also be reduced through the rapid restoration of a normal, age-appropriate diet 3.
Potential Causes
Several potential causes of chronic diarrhea in children include:
- Infectious enteritis
- Cow milk protein intolerance
- Malnutrition
- Anatomic abnormalities
- Congenital enteropathies 4
- Congenital diarrhea and enteropathies (CoDEs) condition, a rare cause of chronic diarrhea in infants 5
Diagnostic Tests
An extensive workup may be significant for:
- Hypernatremic metabolic acidosis
- Positive stool-reducing substances
- Trials of protein-hydrolysate and elemental amino acid-based formulas
- Carbohydrate-free, hydrolyzed protein-based formula (3232A)
- Diagnostic test for specific carbohydrate malabsorption, such as glucose supplementation followed by fructose supplementation 5
Management
Management of chronic diarrhea in children involves: