Approach to the diagnosis of chronic diarrhea in children in resource-rich countries
- Richard Kellermayer, MD, PhD
Richard Kellermayer, MD, PhD
- Associate Professor of Pediatrics
- Baylor College of Medicine
- Robert J Shulman, MD
Robert J Shulman, MD
- Professor of Pediatrics
- Baylor College of Medicine
In resource-rich ("developed") countries, a wide variety of disorders cause chronic diarrheas in children. The causes range from developmental and dietary factors (eg, excessive consumption of juice), to diseases causing malabsorption or maldigestion, disordered immune regulation, or enteric infections (particularly in immunocompromised patients) (table 1) [1,2].
In resource-limited countries, chronic diarrhea typically is associated with serial enteric infections and malnutrition [3,4]. This common pathophysiology calls for a distinct algorithmic approach to diagnosis and treatment, which is discussed separately. (See "Persistent diarrhea in children in resource-limited countries".)
The diagnostic approach to diarrheal diseases in resource-rich countries will be reviewed here. The causes of these diarrheal diseases are discussed separately. (See "Overview of the causes of chronic diarrhea in children in resource-rich countries".)
Diarrhea is defined as stool volume of more than 10 grams/kg/day in infants and toddlers, or more than 200 grams/day in older children . This typically translates to persistent loose or watery stools occurring at least three times a day, where the change in stool consistency is more important than stool frequency . To be considered chronic, the symptom must be present for four weeks [6,7]. Some have used two weeks to define chronicity in children .
Selection of the appropriate strategy to diagnose the cause of chronic diarrhea in a child depends on the presentation of the patient. In most cases, a thorough history and physical examination narrows the range of possibilities. Age at presentation and the population setting (eg, the genetic predisposition of the population) are also important factors to consider. For children presenting with chronic diarrhea in resource-rich countries, the most likely cause in young children (typically one to four years of age) is functional diarrhea. In this young age group, functional diarrhea is also known as chronic nonspecific diarrhea or "toddler's diarrhea." In older children and adolescents, functional diarrhea is associated with irritable bowel syndrome (IBS) as defined by the pediatric Rome IV criteria [7-10]. Celiac disease is also relatively common, and can be evaluated with a simple serologic screening test. Therefore, it is appropriate to consider these entities early in the evaluation before embarking on extensive laboratory testing. If these steps do not establish a diagnosis, then further laboratory testing can be selected based on history, physical examination, and the stool type. This stepwise strategy is outlined below (algorithm 1A-B).To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- HISTORY AND EXAMINATION
- LABORATORY EVALUATION
- Celiac serology
- Stool pH, electrolytes, and reducing substances
- Fecal calprotectin and occult blood
- Stool fat
- Other tests
- DIAGNOSTIC APPROACH
- Exclude celiac disease
- Consider functional diarrhea
- Selective testing according to stool type
- - Watery (osmotic versus secretory)
- - Inflammatory
- - Fatty
- Specific testing
- TREATMENT CONSIDERATIONS
- - Probiotics
- - Antidiarrheal drugs
- - Somatostatin
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS