and schistocytes The urinalysis shows hematuria (dipstick detection of free hemoglobin) and proteinuria In patients with suspected pseudomembranous colitis, stool toxin analysis provides the mainstay of diagnosis Polymerase chain reaction (PCR) has been shown to have higher sensitivities for toxin A and B than enzyme immunoassay (EIA) Testing for fecal leukocytes is neither sensitive nor specific for inflammatory diarrhea; fecal lactoferrin is a more sensitive marker but not specific for detection of particular pathogens When selected bacterial or parasitic pathogens are strongly suspected, appropriate microbiologic studies should be collected If a multiplex polymerase chain reaction assay, is collected, the results should be interpreted in the context the clinical picture as these panels detect DNA and not viable organism FIGURE 23.1 Diagnostic approach to the immunocompetent child with diarrhea FIGURE 23.2 Dehydration scales A: WHO dehydration scale (From Jauregui J, Nelson D, Choo E, et al External validation and comparison of three pediatric clinical dehydration scales PloS One 2014;9(5):e95739 Copyright © 2014 Jauregui et al https://creativecommons.org/licenses/by/4.0/ ) B: Gorelick scale (From Pringle K, Shah SP, Umulisa I, et al Comparing the accuracy of the three popular clinical dehydration scales in children with diarrhea Int J Emerg Med 2011;4:58 Copyright © 2011 Pringle et al; licensee Springer http://creativecommons.org/licenses/by/2.0 ) C: CDS dehydration scale (From Jauregui J, Nelson D, Choo E, et al External validation and comparison of three pediatric clinical dehydration scales PloS One 2014;9(5):e95739 Copyright © 2014 Jauregui et al https://creativecommons.org/licenses/by/4.0/ ) TREATMENT The treatments for the different causes of diarrhea are covered in the medical and surgical sections of this book; however, the therapy for viral gastroenteritis or parenteral diarrhea merits a summary All children with circulatory compromise and many children with moderate to severe dehydration need intravenous rehydration with isotonic (normal saline or lactated Ringer’s) fluids, given rapidly in increments of 20 mL/kg boluses Infants and children who are symptomatically hypoglycemic should receive IV glucose However, most pediatric patients with acute gastroenteritis can be managed with oral solutions Most children will tolerate small feedings given frequently Fluids may also be delivered via a nasogastric tube if needed Optimal oral rehydration therapy emphasizes the use of appropriate glucose and electrolyte solutions, as well as the early reintroduction of feeding Ideal oral rehydration solutions, based on formulas carefully tested by the WHO, have a carbohydrate:sodium ratio that approaches 1:1 Although some recommend, particularly for young infants, initial oral rehydration with a solution that contains 75 to 90 mEq/L of sodium (i.e., WHO 2003 oral rehydration salts solution) and subsequent maintenance with a more hypotonic formulation (i.e., Pedialyte), most clinicians use a single preparation during the course of routine, brief illnesses Older children with mild gastroenteritis tolerate juices and other commercial products, even though the carbohydrate:sodium ratio deviates from the WHO standard Feeding with age-appropriate diet, including breast-feeding for infants, is recommended as soon as rehydration is complete Doing so appears to reduce stool output and duration of the diarrheal disease Foods with complex carbohydrates, lean meats, fruits, and vegetables are better tolerated than those that contain fat and simple sugars The commonly recommended restriction to clear liquid and BRAT (bananas, rice, applesauce, toast) diets provide suboptimal nutrition and are no longer recommended Probiotics (Lactobacillus rhamnosus GG strain most commonly used) has previously been recommended to reduce duration and frequency of diarrheal stools in children with presumed infectious diarrhea However, a recent multicenter, prospective, randomized, double-blind trial of children months to years of age with infectious diarrhea failed to show a difference in outcomes of patients receiving probiotics (5-day course of L rhamnosus ) versus placebo No differences in frequency and duration of moderate to severe diarrhea, rate of household transmission, and duration of absenteeism from work or daycare were seen between the two study groups Antibiotics are not routinely recommended for patients with diarrhea, even for those with bloody diarrhea, because acute diarrheal illnesses are usually self-limited Antibiotics should only be used when diagnostic tests reveal a treatable bacterial or parasitic etiology In general, antidiarrheal agents are ineffective, have potentially serious side effects, and therefore have no role in the treatment of infectious gastroenteritis Antimotility ... dehydration scale (From Jauregui J, Nelson D, Choo E, et al External validation and comparison of three pediatric clinical dehydration scales PloS One 2014;9(5):e95739 Copyright © 2014 Jauregui et al... dehydration scale (From Jauregui J, Nelson D, Choo E, et al External validation and comparison of three pediatric clinical dehydration scales PloS One 2014;9(5):e95739 Copyright © 2014 Jauregui et al... Infants and children who are symptomatically hypoglycemic should receive IV glucose However, most pediatric patients with acute gastroenteritis can be managed with oral solutions Most children will