********Mom replies,
"I've heard that bananas are good for a child with diarrhea. That's right, isn't it?"
Mom is referring to the BRAT diet: bananas, rice, applesauce and toast (no butter). This is a good diet for a child (or adult for that matter) with diarrhea, but don't forget to ask how long they have been on it - in this case, five days might be too long to eat only those few things.
Mom replies,
"No, no blood that I've seen."
It's always a good idea to ask about blood and melena specifically, even though you've already asked about the color of the stool. Don't forget to check for occult blood in the exam, since it could be microscopic. Bloody stool makes the differential more ominous, and would include intussusception as well as toxigenic E. Coli. Anal fissures can also bleed, but are not associated with diarrhea. With prolonged diarrhea, the area around the rectum can break down and lead to blood in the stool on that basis.
Mom replies,
"No, the pregnancy was fine. It took me six hours of labor to deliver him, but I was out of practice, since my then-youngest was 10 at the time."
Congenital anomalies in the GI tract should have declared themselves long before this, but don't forget to ask. Parents sometimes forget that you may not have been there or have access to all the patient's hospital records. Exposure to medications in utero could potentially lead to malformations, as well as maternal infections. Moms who are HIV positive and are not treated during pregnancy can pass the infection on to the newborn. Chronic diarrhea in such an infant would make me consider HIV as a possibility.
Mom replies,
"Not lately, but about two weeks ago everyone in the family had "colds". Nobody had 'stomach flu', if that's what you mean."
It is important to ask about sick contacts that were sick during the two or so weeks prior to the onset of symptoms in this child. Children under the age of two have a tendency to get diarrhea with a viral upper respiratory infection. One theory is that they swallow their post-nasal drainage, leading to an irritant diarrhea.
Mom replies,
"He wets about 8 diapers a day, but sometimes it's hard to tell with the diarrhea."
Boys are sometimes easier to tell with than with girls, due to where on the diaper the wetness occurs. But copious diarrhea may make it impossible. Thus this may not be a helpful way to determine hydration status.
Mom replies,
"The diarrhea is watery, with a few formed pieces, which are brown. It seems to have a different odor than usual."
Watery diarrhea with formed pieces is characteristic of a viral illness, but as usual this is not a hard and fast rule. Foul-smelling and greenish are terms that parents often use, and these may be consistent with a viral or bacterial etiology.
Mom replies,
"He's eating everything, just like normal. He eats baby food, soft table food, and still drinks two bottles of formula a day. No new foods, if that's what you mean."
Eating his usual foods in their usual amounts is a good sign that this child probably isn't very sick. If Mom hadn't told you about new foods, that would have been the next question to ask. Food allergies in children at this age usually show up as a rash, but you never know....
Mom replies,
"No, I don't think so. I have a thermometer, but I feel funny about putting something into his bottom. As soon as I do, it seems to trigger more diarrhea."
Not having or using a thermometer is a common problem, especially in infants. Parents don't like to use a rectal thermometer, so they often just feel the forehead. Problem is, if you ran around this building four times, you would feel hot, but wouldn't have a fever. So, skin temperature is not an accurate indicator. Children can be having a chill from a very high fever and feel cool to the touch. Another question to ask parents is when was the last dose of Tylenol?
Mom replies,
"He has had six episodes of diarrhea a day for the last week. His stool used to be brown and soft, but not watery like it is now."
Watery diarrhea with formed pieces is characteristic of a viral illness, but as usual this is not a hard and fast rule. Foul-smelling and greenish are terms that parents often use, and these may be consistent with a viral or bacterial etiology. Red or black stool, as in adults, signifies blood and is very worrisome.
Mom replies,
"He has six to eight episodes a day, usually right after eating."
The gastrocolic reflex (where eating triggers immediate stooling) is present during infancy normally, but is even worse during an episode of diarrhea. This question is important to ask, because some parents think that one runny stool (or for some, even a soft stool) constitutes diarrhea. The technical definition is 8 to 10 stools a day, but that is an average number.
Mom replies,
"I was giving him Tylenol when we started the antibiotic, and Dimetapp like I gave his brother and sister. I only gave him a tiny bit, and the last time was a week ago."
Remember that many over the counter medications now come with instructions for infants, so parents are much more likely to use them without first consulting a physician. For some parents that means that the medicine is not important enough to report, so they may need encouragement to tell you everything they have been using.
Mom replies,
"Besides the bananas, we tried half-strength formula, and Kaopectate. But I was a bit worried about the Kaopectate, so I only tried a little bit one time."
Kaopectate is basically chalk, and it works by absorbing the liquid in the stool. It is find to use in a child this age, but remember that it only gives the illusion of normalcy. The frequency of stools is often the same, and now they look funny as well. Infants less than six months are given Pedialyte for a day, then half-strength formula for the next day, then back to full-strength formula. There is quite a bit of debate as to whether or not this really helps. If the child is clinically dehydrated, I would certainly rehydrate them orally if possible. But if we are only trying to control the symptoms, and the child is otherwise fine, formula already is mostly water, so I'd stick to full strength for now.
Mom replies,
"No, since everyone has been sick recently, we've been pretty much staying home."
Outdoor parties can sometimes leave food out, allowing the growth of bacteria, so food poisoning rises on the differential list when this occurs. Swimming in a river or lake can expose folks to pathogens like Giardia, which is more common than you might think.
Mom replies,
"Yes, he's taking the bubble gum medicine for his ear infection...I think it's called Amoxicillin."
Don't forget to ask about OTC (over the counter) preparations, as most patients don't seem to count those as medications. Also ask about herbs or other "natural" medicines - patients often don't volunteer these either. Sometimes they borrow medicines from a neighbor, and I've even heard of moms buying a syringe of penicillin (!) and administering it to the child.
Mom replies,
"No, we haven't ever given him shellfish to eat."
Hepatitis A can be found in contaminated shellfish. It has a URI-like prodrome, before the liver gets really involved. However, diarrhea is not a prominent symptom, as far as I know. This would not be in my first round of questions.
Mom replies,
"Yes, we were behind for a while, but he got his last shots a month ago, and your nurse told me that he won't need any more until he's a year old."
Reactions to vaccines are most commonly fever, so that wouldn't be a likely explanation. Diphtheria, however, could account for diarrhea, which is something to keep in mind. Fortunately, this child is caught up on his shots.
Mom replies,
"Yes, he was treated at an urgent care clinic near our house for an infection in his right ear a little over a week ago. He started pulling on it about three days after we all caught the cold that his older brother brought home from camp."
Ah, the plot thickens. And what did Mom do for the cold? Turns out that the entire family was on Dimetapp for a while there, to try to dry up all the runny noses in the house.
Mom replies,
"Well, he is still pulling on his ear like he was a week ago, but he's less cranky than he was, and he's sleeping better."
Even though it's only been a week, the presumed otitis should be getting better. Remember that ear pulling is the child's response to the pain or pressure in the ear most likely secondary to Eustachian tube dysfunction. This does not necessarily mean that there is still an infection. If the patient is still pulling on his ears, retain an otitis as part of the differential diagnosis.
Mom replies,
"Well, I think so, he's acting the way he does when he's teething. But I don't see any new teeth yet."
Teething is the movement of primary teeth toward the surface of the gingiva. Some practitioners feel that this causes a mild foreign body type reaction which distracts the immune system from it's otherwise strict surveillance, allowing viruses to gain a foothold and cause an upper respiratory infection. Other practitioners disagree, but most will admit that a mild fever can be seen with teething. The teeth can take a long time to break the surface, accompanied by the characteristic drooling and irritability. This can sometimes be difficult to distinguish from a mild URI (as above). Perhaps it could also be associated with a mild "stomach flu" but I've yet to see a case of gastroenteritis that could only be attributed to teething.
Mom replies,
"Yes, we went to Canada on vacation two weeks ago to visit relatives."
Actually, Canada isn't considered a foreign country in this instance. What we look for is travel to another country that might have endemic parasites that could cause diarrhea. Depending on the parasite, we might then consider ordering a stool test for ova and parasites. Although not all parasites are found this way, the ones that can cause diarrhea can often be identified in a stool specimen.
Mom replies,
"Yes, we have our own well, but it was tested last month and the water is fine."
Don't forget that well water can be contaminated with pathogens - bacteria and/or parasites.