Acute Viral Gastroenteritis in Children in Resource-Abundant Countries - Clinical Features and Diagnosis - UpToDate

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Acute viral gastroenteritis in children in resource-abundant

countries: Clinical features and diagnosis
AUTHOR: Miguel G O'Ryan, MD
SECTION EDITORS: Morven S Edwards, MD, B UK Li, MD
DEPUTY EDITOR: Diane Blake, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2024.

This topic last updated: Sep 27, 2022.
INTRODUCTION
The epidemiology, clinical features, and diagnosis of acute viral gastroenteritis in children in
resource-abundant countries will be discussed here. The prevention and treatment of acute viral
gastroenteritis in children in resource-abundant countries, acute diarrhea in children in resource-
limited countries, and chronic diarrhea in children are discussed separately.
● (See "Acute viral gastroenteritis in children in resource-abundant countries: Management and

prevention".)
● (See "Approach to the child with acute diarrhea in resource-limited settings".)
● (See "Overview of the causes of chronic diarrhea in children in resource-abundant settings" and
"Approach to chronic diarrhea in children >6 months in resource-abundant settings" and
"Persistent diarrhea in children in resource-limited settings".)
DEFINITIONS
● Acute gastroenteritis – A clinical syndrome often defined by increased stool frequency with
loose consistency with or without vomiting, fever, or abdominal pain [1-5]; examples of
increased stool frequency include:
• ≥3 loose or watery stools in 24 hours
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• Number of loose/watery bowel movements that exceeds the child's usual number of daily
bowel movements by two or more
Acute gastroenteritis usually lasts less than one week and not longer than two weeks. Most
cases of acute gastroenteritis are caused by viruses, bacteria, and parasites, although
noninfectious conditions can cause similar manifestations. (See 'Etiology' below.)
● Acute viral gastroenteritis – Acute gastroenteritis caused by a viral pathogen
● Persistent or chronic diarrhea – Diarrhea that lasts >14 days
● Recurrent diarrhea – Diarrhea that recurs after seven days without diarrhea
PATHOGENESIS
The major clinical manifestations of viral gastroenteritis are caused by intestinal infection and
destruction of enterocytes, which results in transudation of fluid into the intestinal lumen and net
loss of fluid and salt in the stool [6-10]. Intestinal injury also decreases the ability to digest food,
particularly complex carbohydrates, and to absorb digested food across the intestinal mucosa. The
pathogenesis of acute diarrhea is discussed in detail separately. (See "Pathogenesis of acute diarrhea
in children" and "Clinical manifestations and diagnosis of rotavirus infection", section on
'Pathogenesis and histopathology'.)
Factors associated with severe or prolonged clinical manifestations include [11-16]:
● First infection with a particular pathogen

● Malnutrition
● Lack of maternally acquired immunity (eg, antibody acquired transplacentally or via human
milk)
● Immune compromise
● Large inoculum of virus
EPIDEMIOLOGY
Acute viral gastroenteritis occurs throughout the year, with a fall and winter predominance in most
temperate climates ( table 1) [17-20]. During the first two years of the coronavirus disease 2019
(COVID-19) pandemic, there was a global decrease of acute childhood gastrointestinal infections,
most likely related to the seclusion of children in households.
Acute viral gastroenteritis can be transmitted by asymptomatic carriers as well as by symptomatic

patients before the onset of symptoms [4,21,22]. It is generally transmitted by the fecal-oral route.
The possibility of airborne transmission of rotavirus and norovirus has been suggested in some
outbreaks [23-25].
ETIOLOGY
The most common causes of acute viral gastroenteritis in children are described below ( table 1).
In active surveillance in the United States during 2011 to 2016, a pathogen was detected in 51.2
percent of 660 children age 14 days to 11 years who were hospitalized with acute gastroenteritis and
in 20.6 percent of 624 age-matched healthy controls [26]. The most commonly detected viruses were
norovirus (18.5 percent of cases, 6.6 percent of controls), rotavirus (16.1 percent of cases, 9.8 percent
of controls), and adenovirus (7.7 percent of cases, 1.4 percent of controls).
● Rotavirus – Rotavirus gastroenteritis usually occurs in children between six months and two
years of age [27,28]. It occurs in the fall and winter in middle- to high-income countries with
temperate climates and throughout the year in low and middle-low income countries and
countries with tropical climates ( table 1). (See "Clinical manifestations and diagnosis of
rotavirus infection".)
Rotavirus has historically been the most common cause of medically attended viral
gastroenteritis in children. In countries that routinely immunize infants against rotavirus,
rotavirus gastroenteritis has decreased substantially, although some older children and adults
develop symptomatic rotavirus disease [29-31]. (See "Rotavirus vaccines for infants", section on
'Efficacy/effectiveness'.)
In the United States, laboratory surveillance during the prevaccine (2000 to 2006) and
postvaccine (2007 to 2018) periods demonstrates decreases in rotavirus-positive laboratory
tests (from 26 to 6 percent) and rotavirus-positive laboratory tests during the characteristic
autumn-winter peak (from 43 to 14 percent) and in the duration of the "rotavirus season" (from
26 to 9 weeks), as well as the emergence of a biennial pattern with alternating years of low and
high rotavirus activity ( figure 1) [32]. In the United States, state-specific annual rotavirus
season activity appears to be related to accumulation of susceptible children (ie, high birth rate
and low rotavirus vaccination coverage) [33].
● Norovirus – Norovirus gastroenteritis occurs in people of all ages. It occurs year-round [34].
Norovirus is highly contagious and the leading cause of outbreaks of gastroenteritis [22,35,36].
Older children and adolescents with severe acute gastroenteritis, especially as part of a
common source outbreak (food, water source, or fomite), are more likely to have norovirus than
other causes of acute gastroenteritis [22,37,38]. Norovirus also causes sporadic gastroenteritis,
which occurs primarily in young children [39,40]. (See "Norovirus".)
Norovirus is, or is becoming, the leading cause of medically attended gastroenteritis in children
in countries that immunize infants against rotavirus gastroenteritis [30,41-44]. In active
surveillance in the United States during 2011 to 2016, norovirus was detected in 18.5 percent of
children (age 14 days to 11 years) hospitalized with acute gastroenteritis compared with 6.6
percent of healthy controls [26].
● Sapovirus – Sapovirus gastroenteritis mainly affects infants and toddlers [35,45,46]. It occurs
year-round. The clinical illness is milder than that of rotavirus.
In laboratory surveillance from three counties in the United States during 2008 to 2009,
sapovirus was isolated from 5.4 percent of 1281 children younger than five years with medically
attended acute gastroenteritis [17]. It was detected throughout the year, with the highest
proportion from March through July. In active surveillance in the United States during 2012,
sapovirus was detected in 7 percent of children <2 years of age who were hospitalized or seen
in the emergency department for acute diarrhea compared with 3 percent of healthy controls
[47].
● Astrovirus – Astrovirus occurs in people of all ages. It may cause outbreaks in closed
populations [35]. Sporadic astrovirus gastroenteritis occurs primarily in children younger than
four years. Astrovirus gastroenteritis usually occurs in the winter months.
Astrovirus is less frequently isolated from hospitalized children than rotavirus and norovirus. In
laboratory surveillance from three counties in the United States during 2008 to 2009, astrovirus
was isolated from 4.9 percent of 1281 children younger than five years with medically attended
acute gastroenteritis [17]. Astrovirus was predominantly detected from November through May.
In active surveillance in the United States during 2012, astrovirus was detected in 3 percent of
children <2 years of age who were hospitalized or seen in the emergency department for acute
diarrhea compared with 0.3 percent of healthy controls [47].
● Enteric adenovirus – Adenovirus gastroenteritis predominantly affects children younger than

four years [10,35]. It occurs throughout the year, with a peak in the summer [17,18,35]. (See
"Pathogenesis, epidemiology, and clinical manifestations of adenovirus infection", section on
'Gastrointestinal system'.)
In laboratory surveillance from three counties in the United States during 2008-2009, enteric
adenovirus was isolated from 11.8 percent of 1281 children younger than five years with
medically attended acute gastroenteritis [17]. Enteric adenovirus was detected throughout the
year, with the highest proportion in June. In active surveillance in the United States during 2012,
adenovirus was detected in 23 percent of children <2 years of age who were hospitalized or
seen in the emergency department for acute diarrhea compared with 16 percent of healthy
controls [47].
● Other viruses – Viruses that typically have extraintestinal manifestations (eg, coxsackievirus,
echovirus, poliovirus, severe acute respiratory syndrome coronavirus 1 or 2, influenza virus type
B) also may cause mild gastroenteritis.
● Mixed viral infections – Mixed viral infections are common, but the clinical significance of
coinfection with multiple viruses is unclear. In a 2014 literature review of studies using
polymerase chain reaction to detect viral gastroenteritis pathogens, the prevalence of mixed
infections in children with symptoms of gastroenteritis ranged from 5.7 to 17 percent [48].
Detection of more than one virus did not appear to influence clinical presentation or severity.
CLINICAL PRESENTATION
Although most viral enteric infections are asymptomatic, virtually every child has more than one
symptomatic episode of acute gastroenteritis before two years of age [4,21].
Among symptomatic children, illness generally begins 12 hours to 10 days after exposure and lasts
for 3 to 9 days ( table 1) [6,8,9]. The typical presentation is diarrhea, vomiting, or both; additional
manifestations may include fever, abdominal pain or cramps [49], anorexia, headache, and myalgia.
The constellation of findings varies by age (young infants have less specific signs), from day to day,
and from person to person. Children may have only diarrhea or vomiting at first but with progression
can become sufficiently ill to require hospitalization. Other symptoms may develop as the disease
evolves; approximately 10 percent of children hospitalized for rotavirus infection have only fever
and/or vomiting at the time of admission [50]. In children, vomiting is a prominent feature in both
rotavirus and norovirus gastroenteritis [51,52].
Vomiting usually lasts for one to two days and diarrhea for five to seven days [2,18,53]. Stools are
typically loose or watery; however, they may be normal in color or relatively pale colored. They may
be odorless or have a characteristic odor [54]. Visible blood or mucus in the stool are uncommon in
viral gastroenteritis and should prompt consideration of a nonviral etiology. (See 'Bacterial or
parasitic gastroenteritis' below.)
The clinical features of medically attended viral gastroenteritis in immune-competent children were
described in a review of 135 cases of polymerase chain reaction-confirmed gastroenteritis from a
tertiary care children's hospital between 2006 and 2009 (during which there was an outbreak of
norovirus) [18]:
● Diarrhea was present in 90 percent; the median duration of diarrhea was six days (interquartile
range 3 to 14); the median maximum number of stools per day was six (interquartile range 4 to
10)
● Vomiting was present in 56 percent; the median duration of vomiting was four days
(interquartile range two to six); the median maximum number of episodes of emesis per day
was three (interquartile range two to five)
● Fever (>38.3°C [101°F]) was present in 42 percent
● Abdominal cramping was reported in 12 percent; abdominal distension in 16 percent; and

abdominal tenderness in 16 percent
COMPLICATIONS
Complications of acute viral gastroenteritis include [27]:
● Hypovolemia/dehydration – Severe dehydration that is not promptly addressed with

rehydration may lead to shock, multiorgan dysfunction, and death, particularly in
immunocompromised patients. (See "Clinical assessment of hypovolemia (dehydration) in
children" and "Hypovolemic shock in children in resource-abundant settings: Initial evaluation
and management", section on 'Etiology'.)
Acute viral gastroenteritis that requires medical attention for dehydration occurs predominantly
in young children, particularly those younger than two years. Young children are more
susceptible to dehydration than older children because they have a higher body surface-to-
volume ratio, a higher metabolic rate, lower fluid reserves, and depend upon others to provide
fluids [3].
● Electrolyte abnormalities – Acute viral gastroenteritis may be associated with electrolyte

abnormalities and acid base disturbance (hypernatremia, hyponatremia, hypokalemia,
metabolic acidosis). Hypokalemia may cause ileus, which can worsen emesis and impair fluid
and electrolyte absorption. (See "Acid-base and electrolyte abnormalities with diarrhea" and
"Hypokalemia in children", section on 'Muscular weakness'.)
● Carbohydrate intolerance – Carbohydrate intolerance, particularly lactose intolerance (due to

damage to and loss of mature enterocytes containing lactase) is uncommon. In one series of
107 children with acute gastroenteritis, lactose intolerance was demonstrated in 11 percent and
lasted for ≤5 days [55]. The diagnosis of lactose intolerance is supported by reducing
substances in the stool and/or stool pH <5.5. Lactose intolerance can be recognized at disease
onset and when patients develop an exacerbation of diarrhea after introduction of lactose-
containing foods and beverages (including infant formulas). (See "Lactose intolerance and
malabsorption: Clinical manifestations, diagnosis, and management", section on 'Secondary
lactose malabsorption'.)
● Irritant diaper dermatitis – (See "Diaper dermatitis", section on 'Risk factors'.)

EVALUATION
Setting of evaluation — The evaluation of children with acute gastroenteritis may begin with a
telephone call to assess whether the child needs to be seen in the office or the emergency
department. The child's fluid status and the possibility of severe illness or condition other than acute
gastroenteritis that requires specific therapy are the focus of this conversation. (See "Acute viral
gastroenteritis in children in resource-abundant countries: Management and prevention", section on
'Severity assessment' and "Clinical assessment of hypovolemia (dehydration) in children" and
"Hypovolemic shock in children in resource-abundant settings: Initial evaluation and management".)
Indications for a medical visit include [1-3,56]:
● Age <6 months or weight <8 kg (17 pounds 10 ounces)
● Temperature ≥38°C (100.4°F) for infants <3 months or ≥39°C (102.2°F) for children 3 to 36
months
● Visible blood in stool or melena
● Frequent vomiting over a period of several hours
● Frequent and substantial volumes of diarrhea
● Diarrhea for >7 days or persistent vomiting
● Caregiver's report of symptoms of moderate to severe dehydration ( table 2)
● Multisystem compromise, cardiovascular instability (these children should be referred directly

to the emergency department)
● Inability of the caregiver to administer or failure of the child to tolerate or respond to oral
rehydration therapy at home
● Underlying immunodeficiency or condition complicating the treatment or course of illness (eg,

malnutrition, diabetes mellitus or other metabolic disease)
● Social circumstances that make telephone assessment unreliable
History and examination — The history ( table 3) and examination ( table 4) of children with
symptoms and signs of gastroenteritis focus upon:
● Determining the severity of illness; gastroenteritis severity is reflected by the degree of

dehydration ( table 2) [1,3,57]. The best individual signs of hypovolemia include (see "Clinical
assessment of hypovolemia (dehydration) in children", section on 'Clinical assessment'):
• Weight loss
• Dry mucous membranes
• Prolonged capillary refill time
• Loss of skin turgor
• Increased and deep respiratory pattern
Other important signs include elevated pulse, diminished systolic and/or diastolic blood
pressure, and sunken fontanelle (in children whose fontanelle remains open) ( table 2).
Tachycardia may be the first sign of hypovolemic shock among infants.
● Evaluating other causes of diarrhea and/or vomiting that require definitive therapy and can be
confused with acute gastroenteritis in the first day or two of symptoms (eg, meningitis, acute
abdominal processes, diabetic ketoacidosis, toxic ingestions, pneumonia, streptococcal
pharyngitis) [2,3,27,57-59]. (See 'Differential diagnosis' below and "Diagnostic approach to
diarrhea in children in resource-abundant settings" and "Approach to the infant or child with
nausea and vomiting".)
Laboratory evaluation
● Well-appearing immunocompetent children with typical presentation – Most immune-

competent children older than one year of age with typical findings of acute gastroenteritis do
not require laboratory evaluation. The results of laboratory tests are unlikely to change
management, which focuses on fluid repletion and maintenance (even for bacterial and
parasitic gastroenteritis).
● Ill-appearing children and children with hypovolemia, atypical presentation, or uncertain

diagnosis – For children who are ill appearing and/or who have hypovolemia, an atypical
presentation ( table 5), or uncertain diagnosis, laboratory evaluation may be helpful. The
laboratory evaluation is guided by the clinical scenario and diagnostic considerations.
As examples:
• During the COVID-19 pandemic, we suggest testing for severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) in children with diarrhea and exposure to a person with SARS-
CoV-2 infection. (See "COVID-19: Clinical manifestations and diagnosis in children", section
on 'Criteria for COVID-19 testing'.)
• For children with moderate to severe volume depletion, who may require intravenous
therapy ( table 2), we suggest measurement of serum electrolytes. The serum sodium
concentration guides fluid management. (See "Clinical assessment of hypovolemia
(dehydration) in children", section on 'Laboratory testing' and "Treatment of hypovolemia
(dehydration) in children in resource-abundant settings", section on 'Intravenous

rehydration therapy'.)
Electrolyte abnormalities and acid-base disorders in patients with diarrhea are discussed
separately. (See "Acid-base and electrolyte abnormalities with diarrhea".)
In children with volume depletion, a complete blood count (CBC) may show signs of
hemoconcentration (eg, increased hemoglobin or hematocrit) but is not necessary for
diagnosis or management.
• For children with suspected bacterial gastroenteritis (eg, known outbreak; exposure to
potentially contaminated food such as undercooked meats, eggs, or shellfish, unpasteurized
milk ( table 6); visible blood or mucus in stool; elevated band count [if CBC is obtained]),
microscopic examination of a fecal smear stained with Wright stain or methylene blue for
fecal leukocytes and/or stool cultures may be warranted. (See "Causes of acute infectious
diarrhea and other foodborne illnesses in resource-abundant settings", section on 'Clinical
clues to the microbial cause'.)
Fecal leukocytes indicate inflammation in the bowel wall, which is more characteristic of
bacterial than viral gastroenteritis, but do not distinguish between infectious and
noninfectious inflammatory processes. Most bacteria cause a polymorphonuclear
inflammation, although Salmonella typhi may cause a mononuclear reaction.
For children with suspected bacterial gastroenteritis, we do not obtain markers of

inflammation in the serum (C-reactive protein, procalcitonin) or stool (fecal lactoferrin, fecal
calprotectin) because even if elevated they are unlikely to change the management of young
children with acute gastroenteritis [1,57,60]. Stool lactoferrin may be falsely positive in
breastfed infants.
• For children with suspected parasitic gastroenteritis (eg, persistent diarrhea,

immunocompromised host, travel to areas with inadequate handling of sewage, peripheral
eosinophilia [if CBC is obtained], or eosinophils on Wright-stained fecal smear, uncertain
diagnosis), we suggest obtaining stool studies for ova and parasites [61,62].
• For children with suspected inflammatory bowel disease (eg, persistent or recurrent
episodes of diarrhea, visible blood or mucus in the stool, poor growth, extraintestinal
manifestations), microscopic examination of a fecal smear stained with Wright stain or
methylene blue for fecal leukocytes may be warranted [63-65]. Fecal leukocytes indicate
inflammation in the bowel wall but do not distinguish between infectious and noninfectious
inflammatory processes. Eosinophils may suggest ulcerative colitis [66,67]. (See "Clinical
presentation and diagnosis of inflammatory bowel disease in children", section on 'Clinical
manifestations'.)
• For children with suspected C. difficile ( table 7), we obtain stool studies for C. difficile. (See
"Clostridioides difficile infection in children: Clinical features and diagnosis", section on
'Testing for C. difficile'.)
• Suspected urinary tract infection (eg, suprapubic or flank tenderness, dysuria, urgency,
frequency or history of previous urinary tract infection) – Urinalysis and urine culture. (See
"Urinary tract infections in infants and children older than one month: Clinical features and
diagnosis", section on 'Clinical presentation'.)
DIAGNOSIS
Clinical diagnosis — The diagnosis of acute viral gastroenteritis is made clinically; laboratory studies
are not routinely necessary. Clinical features suggestive of viral gastroenteritis include:
● Diarrhea (eg, ≥3 loose or watery stools in 24 hours or a number of loose/watery bowel

movements that exceeds the child's usual number of daily bowel movements by two or more),
with or without vomiting, fever, or abdominal pain
● Absence of visible blood and mucus in the stool
● Absence of atypical features: findings more characteristic of bacterial or parasitic

gastroenteritis, extraintestinal infections, or noninfectious conditions associated with diarrhea
and vomiting ( table 5) (see 'Differential diagnosis' below)
In children with atypical features, other causes of acute gastroenteritis, extraintestinal infections, and
noninfectious causes of diarrhea and/or vomiting must be considered and may require exclusion (by
history, examination, or targeted laboratory or imaging studies) before making the diagnosis of
acute viral gastroenteritis. (See 'Differential diagnosis' below and "Diagnostic approach to diarrhea in
children in resource-abundant settings" and "Approach to the infant or child with nausea and
vomiting".)
Etiologic diagnosis — Microbiologic testing usually is not necessary in immunocompetent hosts with
routine gastroenteritis; however, microbiologic testing, including virologic assays, bacterial stool
cultures, testing for C. difficile toxins, and/or stool examination for ova and parasites, may be
indicated in the following circumstances or patients [1,2,58]:
● Children with a known in-person exposure to a laboratory-confirmed case of COVID-19 within

the previous 14 days (see "COVID-19: Clinical manifestations and diagnosis in children", section
on 'Criteria for COVID-19 testing')
● During outbreaks of gastroenteritis, particularly in an institution with a closed population

(hospital, childcare center, school)
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● For cohorting and isolation of hospitalized patients (see "Acute viral gastroenteritis in children in
resource-abundant countries: Management and prevention", section on 'Prevention')
● Patients with underlying conditions (eg, immune compromise, cancer, inflammatory bowel
disease [IBD])
● Patients with prolonged diarrhea (ie, >7 days)
● Uncertain diagnosis (eg, acute viral gastroenteritis versus IBD)
Clinical features and the pattern of illness may suggest a particular virus ( table 1), but
confirmation requires microbiologic testing because no feature is pathognomonic [18]. Viral
gastroenteritis pathogens are excreted in the stool. They can be detected one to two days before
symptom onset through a week or two after symptom resolution. Diagnosis of most of the common
causes of acute viral gastroenteritis in children is discussed separately:
● Norovirus (see "Norovirus", section on 'Diagnosis')
● Rotavirus (see "Clinical manifestations and diagnosis of rotavirus infection", section on

'Diagnosis')
● Adenoviruses 40 and 41 (see "Diagnosis, treatment, and prevention of adenovirus infection",

section on 'Diarrhea in young children')
Molecular methods such as multiplex real-time polymerase chain reaction (RT-PCR) are commercially
available for the detection of fecal viral pathogens, including astrovirus, and are replacing traditional
tests [48]. The major advantages of molecular diagnostic methods are increased sensitivity for
common viruses, such as rotavirus and adenovirus, and the ability to detect uncultivable viruses such
as norovirus, sapovirus, and astrovirus [68,69]. Interpretation of assay results may be complicated by
the frequent detection of viruses in fecal samples from asymptomatic children and the detection of
multiple viruses in a single sample [69-71]. When multiple pathogens are detected, the clinician
should recognize that disease outbreaks in closed settings and individual cases in regions with poor
water and sewage handling may be caused by multiple pathogens, with a clinical presentation of
features of each pathogen, such as profuse and watery diarrhea, with blood apparent, in a patient
simultaneously ill from rotavirus and hemorrhagic Escherichia coli infection.
DIFFERENTIAL DIAGNOSIS
Bacterial or parasitic gastroenteritis — Nonvirus enteritis pathogens (eg, bacteria and parasites)
account for approximately 30 percent of cases of acute gastroenteritis in children; the proportion is
lower in resource-abundant countries and higher in resource-limited countries [27]. Clinical features
that favor bacterial or parasitic gastroenteritis over viral gastroenteritis include:
● Age >2 years – Bacterial and parasitic agents generally cause gastroenteritis in children at an
older age (eg, two to four years), whereas viral pathogens more frequently cause serious
gastroenteritis in those younger than two years.
● Visible blood or mucus in the stool – Visible blood or mucus in the stool is more suggestive of
bacterial than viral gastroenteritis but may occasionally occur in viral gastroenteritis [18]; occult
blood (detected only by stool guaiac test) does not help to distinguish viral from bacterial
gastroenteritis.
● High fever (ie, >40°C [104°F]), tenesmus, central nervous system symptoms (eg, seizures),
severe abdominal pain, and smaller volume stools are more characteristic of bacterial
pathogens [1,27,58,60], but high fever and seizures have been reported in rotavirus and
norovirus gastroenteritis [72,73].
● Exposures (eg, international travel, exposure to poultry or other farm animals, consumption of
processed meat, consumption of unfiltered/untreated water, swimming in natural bodies of
water).
● An elevated band count (if complete blood count is performed) is suggestive of bacterial
gastroenteritis.
Bacterial causes of acute gastroenteritis in children include:
● Diarrheagenic E. coli (see "Shiga toxin-producing Escherichia coli: Microbiology, pathogenesis,

epidemiology, and prevention" and "Shiga toxin-producing Escherichia coli: Clinical
manifestations, diagnosis, and treatment" and "Clinical manifestations and diagnosis of Shiga
toxin-producing Escherichia coli (STEC) hemolytic uremic syndrome in children")
● Salmonella (see "Nontyphoidal Salmonella: Microbiology and epidemiology" and "Enteric

(typhoid and paratyphoid) fever: Epidemiology, clinical manifestations, and diagnosis" and
"Nontyphoidal Salmonella: Gastrointestinal infection and asymptomatic carriage")
● Shigella (see "Shigella infection: Epidemiology, clinical manifestations, and diagnosis")
● C. difficile (see "Clostridioides difficile infection in children: Microbiology, pathogenesis, and

epidemiology" and "Clostridioides difficile infection in children: Clinical features and diagnosis")
● Campylobacter jejuni (see "Campylobacter infection: Microbiology, pathogenesis, and

epidemiology" and "Campylobacter infection: Clinical manifestations, diagnosis, and
treatment")
● Campylobacter upsaliensis (see "Campylobacter: Infection with less common species and related
bacteria", section on 'Campylobacter upsaliensis')
● Mycobacteria, such as Mycobacterium avium complex, particularly in immunocompromised

patients (see "Disseminated nontuberculous mycobacterial (NTM) infections and NTM
bacteremia in children", section on 'Clinical features')
Parasitic causes of acute gastroenteritis in children include:
● Giardia (see "Giardiasis: Epidemiology, clinical manifestations, and diagnosis")
● Cryptosporidium (see "Cryptosporidiosis: Epidemiology, clinical manifestations, and diagnosis")
● C. belli (formerly known as I. belli) (see "Epidemiology, clinical manifestations, and diagnosis of
Cystoisospora (Isospora) infections")
● Microsporidia and Cyclospora (see "Microsporidiosis" and "Cyclospora infection")
Extraintestinal infections — Extraintestinal infections that may present with diarrhea and/or
vomiting are listed below [27,59]. These infections can usually be differentiated from acute
gastroenteritis by their extraintestinal manifestations and/or specific laboratory tests (eg, chemistry,
cell count, and culture of cerebrospinal fluid; urinalysis and urine culture).
● Meningitis – Characteristic features of meningitis include fever, altered level of consciousness,

and meningeal signs. (See "Bacterial meningitis in children older than one month: Clinical
features and diagnosis", section on 'Clinical features' and "Viral meningitis in children: Clinical
features and diagnosis".)
● Bacterial sepsis – Clinical features of sepsis include alterations in vital signs and white blood cell
count indicating a systemic inflammatory response syndrome (SIRS) in the presence of clinical
or laboratory findings of infection. (See "Sepsis in children: Definitions, epidemiology, clinical
manifestations, and diagnosis".)
● Pneumonia – Clinical features of pneumonia include fever and symptoms or signs of respiratory
distress (eg, tachypnea, nasal flaring, grunting, retractions, crackles, decreased breath sounds).
(See "Community-acquired pneumonia in children: Clinical features and diagnosis", section on
'Clinical presentation'.)
● Urinary tract infection (UTI) – Clinical features of UTI include suprapubic or flank tenderness,
dysuria, urgency, and frequency. (See "Urinary tract infections in infants and children older than
one month: Clinical features and diagnosis", section on 'Clinical presentation'.)
● Streptococcal tonsillopharyngitis – Clinical features of streptococcal tonsillopharyngitis include

enlarged erythematous tonsils with exudate and palatal petechiae. (See "Group A streptococcal
tonsillopharyngitis in children and adolescents: Clinical features and diagnosis", section on
'Clinical features'.)
● Otitis media – Symptoms and signs of otitis media include ear pain, bulging of the tympanic
membrane, and hearing loss. (See "Acute otitis media in children: Clinical manifestations and
diagnosis", section on 'Clinical presentation' and "Acute otitis media in children: Clinical
manifestations and diagnosis", section on 'Clinical diagnosis'.)
Noninfectious conditions — A number of noninfectious conditions can present with symptoms that
mimic those of infectious gastroenteritis ( table 8). The approach to distinguishing these conditions
from acute viral gastroenteritis is discussed separately. (See "Diagnostic approach to diarrhea in
children in resource-abundant settings" and "Approach to the infant or child with nausea and
vomiting".)
INDICATIONS FOR REFERRAL
Urgent referral for diagnostic evaluation and therapy may be warranted in children with:
● Severe dehydration ( table 2) associated with cardiovascular instability and/or

electrolyte/acid-basic imbalance (eg, hypernatremia, hypokalemia, metabolic acidosis) (see
"Hypernatremia in children" and "Hypokalemia in children" and "Approach to the child with
metabolic acidosis")
● Clinical features suggesting extraintestinal involvement or another etiology (see 'Differential

diagnosis' above)
● Immune compromise
● Diarrhea lasting more than seven days (see "Overview of the causes of chronic diarrhea in
children in resource-abundant settings" and "Approach to chronic diarrhea in children >6
months in resource-abundant settings" and "Approach to chronic diarrhea in neonates and
young infants (<6 months)")
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around
the world are provided separately. (See "Society guideline links: Acute diarrhea in children".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The
Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level,
and they answer the four or five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer short, easy-to-read
materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for patients
who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or
email these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on "patient education" and the keyword[s] of interest.)
● Basics topics (see "Patient education: Viral gastroenteritis in adults (The Basics)" and "Patient
education: Diarrhea in children (The Basics)" and "Patient education: Rotavirus infection (The
Basics)")
● Beyond the Basics topic (see "Patient education: Acute diarrhea in children (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
● Definitions – Acute gastroenteritis is a clinical syndrome often defined by increased stool

frequency (eg, ≥3 loose or watery stools in 24 hours or a number of loose/watery bowel
movements that exceeds the child's usual number of daily bowel movements by two or more),
with or without vomiting, fever, or abdominal pain. Acute viral gastroenteritis is caused by a
viral pathogen. (See 'Definitions' above.)
● Epidemiology – Acute viral gastroenteritis occurs throughout the year with a fall and winter
predominance in most temperate climates ( table 1). It can be transmitted by asymptomatic
carriers as well as by symptomatic patients before the onset of symptoms. It is generally
transmitted by the fecal-oral route. (See 'Epidemiology' above.)
● Etiology – The most common causes of acute viral gastroenteritis in children include rotavirus,
norovirus, sapovirus, astrovirus, and enteric adenoviruses ( table 1). Mixed viral infections are
common, but the clinical significance of coinfection with multiple viruses is unclear. (See
'Etiology' above.)
● Clinical presentation – Among symptomatic patients, the clinical manifestations include

diarrhea, vomiting, fever, abdominal cramps, anorexia, headache, and myalgia. The
constellation of symptoms varies from day to day and from person to person. (See 'Clinical
presentation' above.)
● Complications – Acute viral gastroenteritis may be complicated by dehydration, electrolyte and

acid-base disturbances, and carbohydrate intolerance. Acute viral gastroenteritis that requires
medical attention for dehydration occurs predominantly in young children, particularly those
younger than two years. (See 'Complications' above.)
● Evaluation
• The history ( table 3) and examination ( table 4) of children with symptoms and signs of
gastroenteritis focus upon determining the severity of illness, mainly dehydration
( table 2) and evaluating other causes of diarrhea and/or vomiting that may be confused
with viral gastroenteritis and require definitive therapy (eg, meningitis, acute abdominal
processes, diabetic ketoacidosis, pneumonia, streptococcal pharyngitis, toxic ingestions,).
(See 'History and examination' above.)
• Most immune-competent children older than one year of age with typical findings of acute
gastroenteritis do not require laboratory evaluation. For children who are ill appearing
and/or who have hypovolemia, an atypical presentation ( table 5), or uncertain diagnosis,
laboratory evaluation may be helpful. The laboratory evaluation is guided by the clinical
scenario and diagnostic considerations. (See 'Laboratory evaluation' above.)
● Diagnosis – The diagnosis of acute viral gastroenteritis is made by the characteristic clinical
features, including (see 'Diagnosis' above):
• Diarrhea with or without vomiting, fever, or abdominal pain

• Absence of visible blood or mucus
• Absence of atypical findings ( table 5)
● Differential diagnosis – The differential diagnosis of acute viral gastroenteritis includes

bacterial and parasitic gastroenteritis, extraintestinal infections, and noninfectious conditions.
These conditions generally are associated with features that are atypical for acute viral
gastroenteritis ( table 5). (See 'Differential diagnosis' above.)
ACKNOWLEDGMENT
The editorial staff at UpToDate acknowledge David O Matson, MD, PhD, who contributed to an earlier
version of this topic review.
Use of UpToDate is subject to the Terms of Use.
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Topic 5984 Version 43.0
GRAPHICS
Epidemiologic and clinical features of common causes of acute viral gastroenteritis

in children*
Common
Possibility
modes of
Predominant Incubation of transient
Virus transmission Age Duration
season period lactose
in order of
intolerance ¶
frequency
Rotavirus Fall/winter in 1 to 3 days Fecal-oral 6 to 24 5 to 7 days Yes

middle- to Respiratory? months
high-income
countries
with
temperate
climates
Throughout
the year in
low- and
middle-low-
income
countries
with tropical
climates
Norovirus All year 12 to 48 Fecal-oral All ages 1 to 4 days No

(winter) hours Water
Shellfish
Other foods
Respiratory?
Sapovirus All year 1 to 2 days Fecal-oral Infants 3 to 4 days

and
toddlers
Astrovirus Winter 4 to 5 days Fecal-oral All ages 5 to 6 days Yes

Water
Enteric Summer 3 to 10 days Fecal-oral Children 6 to 9 days Yes

adenovirus
(types 40
and 41)
SARS-CoV-1: severe acute respiratory syndrome coronavirus 1; SARS-CoV-2: severe acute respiratory syndrome
virus 2.
* Viruses that typically have extraintestinal manifestations (eg, coxsackievirus, echovirus, poliovirus, SARS-CoV-
1, SARS-CoV-2, influenza virus type B) also may cause gastroenteritis.
¶ It is not necessary to switch to lactose-free formula.
Data from:
1. Dennehy PH. Viral gastroenteritis in children. Pediatr Infect Dis J 2011; 30:63.
2. Lee RM, Lessler J, Lee RA, et al. Incubation periods of viral gastroenteritis: A systematic review. BMC Infect Dis 2013; 13:446.
3. Public Health Agency of Canada. Adenovirus (serotypes 40 & 41). Available at: www.phac-aspc.gc.ca/lab-bio/res/psds-
ftss/adenovirus-eng.php (Accessed on August 5, 2015).
Graphic 80471 Version 8.0
Percent positivity of rotavirus tests among the 23 continuously reporting National

Respiratory and Enteric Virus Surveillance System (NREVSS) laboratories*
* Data were aggregated by week and are presented using a 3-week moving average for the total number of
rotavirus tests performed and the number of positive test results.
Reproduced from: Hallowell BD, Parashar UD, Curns A, et al. Trends in the laboratory detection of rotavirus before and after
implementation of routine rotavirus vaccination — United States, 2000–2018. MMWR Morb Mortal Wkly Rep 2019; 68:539.
Physical findings of volume depletion in infants and children
Mild Moderate Severe

Finding
(3 to 5%) (6 to 9%) (≥10%)
Pulse Full, normal rate Rapid* Rapid* and weak or

absent
Systolic pressure Normal Normal to low Low
Respirations Normal Deep, rate may be Deep, tachypnea or

increased decreased to absent
Buccal mucosa Tacky or slightly dry Dry Parched
Anterior fontanelle Normal Sunken Markedly sunken
Eyes Normal Sunken Markedly sunken
Tears (in infants) Present Decreased Absent
Skin turgor Normal Reduced Tenting
Skin temperature and Normal Cool Cool, mottled,

appearance acrocyanosis
Urine output Normal or mildly reduced Markedly reduced Anuria
Systemic signs Increased thirst Listlessness, irritability Grunting, lethargy, coma
* Tachycardia may be the first sign of hypovolemic shock in infants.
Important aspects of the history for a child with acute gastroenteritis
Historical feature Potential significance
Duration of illness Symptoms >7 days may indicate underlying

gastrointestinal or metabolic disease, or systemic
disease (eg, IBD, celiac disease, immunodeficiency)
Frequency, volume, and character of stools (eg, blood Frequent, watery, large volume without blood or
mucus) mucus favors viral gastroenteritis
Small volume, gross blood, or mucus favors
bacterial gastroenteritis
Blood or mucus also may occur with
intussusception, appendicitis, toxic megacolon
Frequency, volume, and character of emesis (eg, blood, Prolonged vomiting increases risk of dehydration
bile, projectile) and concern for underlying systemic or metabolic
disorder
Bilious or projectile vomiting may indicate intestina
obstruction (eg, intussusception, pyloric stenosis)
Hematemesis may suggest esophageal injury or
varices (with underlying liver disease)
Weight before illness Used to assess degree of dehydration and response

to fluid repletion
Urine output Decreased: Suggests dehydration

Increased: May indicate diabetes ketoacidosis
Associated symptoms: fever, headache, localized May suggest alternate etiology (eg, urinary tract
abdominal pain, urinary complaints, and others infection, appendicitis, and others)
Recent intake of food and fluids Used to assess degree of dehydration and other
causes of diarrhea (eg, starvation stools, food
poisoning, food allergy/intolerance, overfeeding
[particularly with hyperosmolar fluids])
Underlying medical problems May increase risk of complications
Recent medications (particularly antibiotics) and May be associated with vomiting or diarrhea
medications in the home Clinical manifestations of certain ingestions may
mimic findings of acute gastroenteritis (eg,
tachypnea and acidosis in salicylate ingestion)
Immunization history (particularly rotavirus) Rotavirus immunization decreases likelihood of

rotavirus gastroenteritis (even after one dose)
Incomplete pneumococcal or Haemophilus
influenzae type b immunization may increase
likelihood of extraintestinal infection with these
organisms (eg, otitis media, pneumonia,

meningitis)
Contacts with acute diarrhea or vomiting Supports infectious gastroenteritis, may suggest a
common source outbreak
Symptoms may suggest etiology (eg, prominence o
vomiting suggests norovirus)
Exposures: Increases risk of bacterial or parasitic

Known source of enteric infection (eg, gastroenteritis
contaminated food or water)
Unsafe foods (eg, raw/undercooked meats, eggs,
shellfish, unpasteurized milk or juice)
Swimming in or drinking untreated fresh surface
water
Farm, petting zoo, reptiles, pets with diarrhea
International travel
IBD: inflammatory bowel disease.
Important aspects of the examination of a child with acute gastroenteritis
Clinical finding Potential significance
Growth parameters
Body weight Used to determine degree of dehydration and

response to fluid repletion
Growth retardation Chronic underlying condition (eg, gastrointestinal

disease, immune deficiency)
Vital signs
Fever: Temperature elevation tends to be higher in

≥38°C (100.4°F) in patient <3 months extraintestinal infection or bacterial gastroenteritis
≥39°C (102.2°F) in patient ≥3 months (particularly if >40°C [104°F])
Rapid, weak, or absent pulse Dehydration
Decreased blood pressure Dehydration, shock, sepsis
Hypotension disproportionate to apparent illness Adrenal crisis
HEENT
Sunken anterior fontanelle, sunken eyes Moderate to severe dehydration
Bulging anterior fontanelle Increased intracranial pressure
Scleral icterus HUS, viral hepatitis
Bulging tympanic membrane Acute otitis media
Tacky, dry, or parched mucous membranes Dehydration
Fruity/ketotic breath Diabetic ketoacidosis
Exudative tonsillitis/palatal petechiae Streptococcal pharyngitis
Neck
Neck stiffness, nuchal rigidity, other meningeal Meningitis

signs
Chest
Deep respirations Moderate to severe dehydration, acidosis
Tachypnea, crackles, decreased breath sounds Pneumonia
Abdomen
Severe, localized pain, rebound tenderness, marked Acute abdomen (eg, appendicitis, bowel
abdominal distension
obstruction, toxic megacolon)
Hypoactive/absent bowel sounds Hypokalemia
Flank pain or suprapubic tenderness UTI
Abdominal mass "Olive" at lateral edge of rectus abdominus in RUQ:

pyloric stenosis
"Sausage-shaped" right-sided mass:
intussusception
Skin
Cool, mottled, poor capillary refill, decreased turgor Moderate to severe dehydration, sepsis
Nonblanching lesions (petechiae, purpura, bruises) HUS, trauma (intracranial, intra-abdominal)
Jaundice HUS, viral hepatitis
Neurologic
Altered consciousness or focal neurologic Toxic ingestion, diabetic ketoacidosis, CNS mass, or
abnormalities inborn error of metabolism
HEENT: head, eyes, ears, nose, throat; HUS: hemolytic uremic syndrome; UTI: urinary tract infections; RUQ:
right upper quadrant; CNS: central nervous system.
Clinical features atypical for acute viral gastroenteritis in children
Clinical feature Potential significance
Historical features
Fever: Extraintestinal infection (eg, UTI, otitis media,

≥38°C (100.4°F) in infants <3 months pneumonia, etc) or bacterial gastroenteritis
≥39°C (102.2°F) in infants and children ≥3 (particularly if >40°C [104°F])
months
Gross blood or mucus in stool Bacterial gastroenteritis, IBD
Bilious vomiting Intestinal obstruction
Projectile vomiting Pyloric stenosis, intestinal obstruction
Persistent diarrhea (>7 days) Underlying gastrointestinal, metabolic, or CNS

disease
Persistent, recurrent, or isolated vomiting CNS disease, metabolic disease
Increased urine output Diabetic ketoacidosis
Altered consciousness, seizures, focal neurologic Increased ICP (CNS mass, hydrocephalus, idiopathic
abnormalities intracranial hypertension)
History of trauma Intracranial or intra-abdominal injury (eg, duodena

hematoma)
Weight loss and multisystem involvement Parasitic gastroenteritis; underlying gastrointestina

or metabolic disorder
Recent antibiotic exposure Antibiotic-associated diarrhea, including

Clostridioides difficile colitis
International travel Bacterial or parasitic gastroenteritis, measles
Exposures: unsafe foods (eg, raw/undercooked Bacterial or parasitic gastroenteritis

meats, eggs, shellfish, unpasteurized milk or juice),
farm animals, petting zoo, reptiles, pets with
diarrhea, untreated surface water
Examination
Moderate to severe dehydration in a child >2 years May indicate underlying condition predisposing to
dehydration
Bulging fontanelle Hydrocephalus, meningitis
Bulging tympanic membrane Acute otitis media
Hypotension disproportionate to apparent illness Adrenal crisis

and/or hyponatremia with hyperkalemia
Tachypnea, retractions, crackles, decreased breath Pneumonia or other respiratory tract infection
sounds
Marked abdominal distention, peritoneal signs, Acute abdomen (eg, appendicitis, intestinal
absent bowel sounds or increased high-pitched obstruction)
bowel sounds ("borborygmi")
Focal abdominal tenderness RLQ: appendicitis, Crohn disease

RUQ: gallbladder disease, pancreatitis
Suprapubic or flank: UTI
Epigastric: pancreatitis, peptic ulcer
disease/gastritis
Abdominal mass "Olive" at lateral edge of rectus abdominus in RUQ:

pyloric stenosis
"Sausage-shaped" right-sided mass:
intussusception
Petechiae, purpura, bruising Hemolytic uremic syndrome, trauma, extraintestina

infection (eg, RMSF, meningococcemia)
Jaundice Viral hepatitis, HUS
Signs of trauma Intracranial or intra-abdominal injury (eg, duodena

hematoma)
Increased muscle tone, hyperreflexia Hyperkalemia
Laboratory findings (if performed)
Abnormal CBC Anemia, thrombocytopenia, hemolysis: HUS

Elevated band count: bacterial gastroenteritis
Elevated eosinophil count: parasitic gastroenteritis
Elevated serum C-reactive protein, procalcitonin Bacterial gastroenteritis, IBD
Fecal leukocytes, fecal lactoferrin, fecal calprotectin Bacterial gastroenteritis, IBD
Eosinophils on fecal smear Amoeba or other intestinal parasite
Persistent watery diarrhea Microsporidia, Cyclospora, and other intestinal

parasites
UTI: urinary tract infection; IBD: inflammatory bowel disease; CNS: central nervous system; ICP: intracranial
pressure; RLQ: right lower quadrant; RUQ: right upper quadrant; RMSF: Rocky Mountain spotted fever; HUS:
hemolytic uremic syndrome; CBC: complete blood count.
Differential diagnosis of foodborne disease by item consumed
Item Commonly associated microbes*
Raw seafood Norwalk-like virus, Vibrio spp, hepatitis A
Raw eggs Salmonella spp
Undercooked meat or poultry Salmonella spp, Campylobacter spp, STEC, Clostridium perfringens
Unpasteurized milk or juice Salmonella spp, Campylobacter spp, STEC, Yersinia enterocolitica
Unpasteurized soft cheeses Salmonella spp, Campylobacter spp, STEC, Y. enterocolitica, Listeria monocytogenes
Homemade canned goods Clostridium botulinum
Raw hot dogs, deli meat L. monocytogenes
STEC: shiga toxin-producing Escherichia coli.
* This association lists the commonly associated organisms and is not fully comprehensive.
Features suggestive of Clostridioides difficile infection in children
Clinical features
Severe diarrhea (volume, frequency [>6 stools/day], abdominal pain)
Fever (≥102°F [38.9°C])
Leukocytosis (≥15,000 white blood cells/microL)
Fecal leukocytes or occult blood
Hypoalbuminemia
Acute abdomen with no passage of stool due to ileus
Radiographic evidence of colitis:
a. Plain film: Bowel wall thickening, dilatation, thumbprinting, ascites
b. Ultrasound: Bowel wall thickening, ascites
c. CT: Bowel wall thickening, dilatation, accordion sign, mural enhancement, fat stranding, ascites
Pseudomembranous colitis (noted at endoscopy)
Risk factors and predisposing conditions

Antibiotic exposure in the past 10 weeks
Recent hospitalization
Acid suppressant exposure (proton pump inhibitors or histamine-2 receptor antagonists)
Gastrointestinal feeding tubes
Inflammatory bowel disease
Immunodeficiency (malignancy, solid organ or hematopoietic transplantation)
Cystic fibrosis
Hirschsprung enterocolitis
Structural or postoperative intestinal disorders
CT: computed tomography.
Etiology of diarrhea in children by age
Older children and

Cause Infants and young children
adolescents
Gastrointestinal infections Viruses* Viruses*
Bacteria* Bacteria*
Parasites Parasites
Nongastrointestinal infections Otitis media* Systemic infections

(parenteral diarrhea)
Urinary tract infections* Staphylococcal toxic shock
syndrome ¶
Other systemic infections
Dietary disturbances Functional diarrhea (eg, excess Starvation stools*

fructose and/or sorbitol intake
[fruit juices])/overfeeding*
Food allergy*
Starvation stools*
Anatomic abnormalities Intussusception ¶ Appendicitis ¶
Hirschsprung-associated Partial obstruction ¶

enterocolitis (±toxic megacolon ¶ )
Blind loop syndrome
Partial bowel obstruction ¶
Blind loop syndrome (also in

patients with dysmotility)
Intestinal lymphangiectasis
Short gut syndrome
Inflammatory bowel disease Early onset inflammatory bowel Ulcerative colitis (±toxic
disease (rare, monogenic) megacolon ¶ )
Crohn disease (±toxic megacolon ¶ )
Malabsorption or increased Cystic fibrosis Celiac disease

secretion
Celiac disease Disaccharidase deficiency (primary
or secondary)*
Disaccharidase deficiency (eg,
lactase deficiency due to infectious Acrodermatitis enteropathica
diarrhea)*
Neuroendocrine secretory tumors
Acrodermatitis enteropathica
Congenital secretory diarrhea
Immunodeficiency Severe combined HIV infection

immunodeficiencies and other
genetic disorders
HIV infection
Endocrinopathy Congenital adrenal hyperplasia Hyperthyroidism
Hypoparathyroidism
Miscellaneous Antibiotic-associated diarrhea* Antibiotic-associated diarrhea*
Clostridioides difficile C. difficile colitis

colitis (±pseudomembranous (±pseudomembranous colitis ¶ )
colitis ¶ )
Toxins Δ
Toxins Δ
Irritable bowel syndrome*
Hemolytic uremic syndrome ¶
Psychogenic disturbances*
Neonatal drug withdrawal
HIV: human immunodeficiency virus.
* Common cause.
¶ Life-threatening cause.
Δ Potential toxins include foodborne toxin disease, poisonous plants or mushrooms, and organophosphates or
carbamates.
Courtesy of Gary R Fleisher, MD.
Contributor Disclosures
Miguel G O'Ryan, MD Grant/Research/Clinical Trial Support: Bharat Institute [Rotavirus vaccine]; Janssen [SARS-
CoV-2 vaccine]; Pfizer [Streptococcus pneumoniae]. All of the relevant financial relationships listed have been
mitigated. Morven S Edwards, MD No relevant financial relationship(s) with ineligible companies to disclose. B
UK Li, MD Consultant/Advisory Boards: GLG Consulting [Antiemetics]; Takeda [Antiemetics]. All of the relevant
financial relationships listed have been mitigated. Diane Blake, MD No relevant financial relationship(s) with
ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.
Conflict of interest policy

Acute Viral Gastroenteritis in Children in Resource-Abundant Countries - Clinical Features and Diagnosis - UpToDate

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9/4/24, 18:56 Acute viral gastroenteritis in children in resource-abundant countries: Clinical features and diagnosis - UpToDate

Official reprint from UpToDate®

Acute viral gastroenteritis in children in resource-abundant

Literature review current through: Mar 2024.

● (See "Acute viral gastroenteritis in children in resource-abundant countries: Management and

● (See "Approach to the child with acute diarrhea in resource-limited settings".)

• ≥3 loose or watery stools in 24 hours

● Acute viral gastroenteritis – Acute gastroenteritis caused by a viral pathogen

● Persistent or chronic diarrhea – Diarrhea that lasts >14 days

Factors associated with severe or prolonged clinical manifestations include [11-16]:

● First infection with a particular pathogen

Acute viral gastroenteritis can be transmitted by asymptomatic carriers as well as by symptomatic

● Enteric adenovirus – Adenovirus gastroenteritis predominantly affects children younger than

● Fever (>38.3°C [101°F]) was present in 42 percent

● Abdominal cramping was reported in 12 percent; abdominal distension in 16 percent; and

Complications of acute viral gastroenteritis include [27]:

● Hypovolemia/dehydration – Severe dehydration that is not promptly addressed with

● Electrolyte abnormalities – Acute viral gastroenteritis may be associated with electrolyte

● Carbohydrate intolerance – Carbohydrate intolerance, particularly lactose intolerance (due to

● Irritant diaper dermatitis – (See "Diaper dermatitis", section on 'Risk factors'.)

Indications for a medical visit include [1-3,56]:

● Age <6 months or weight <8 kg (17 pounds 10 ounces)

● Visible blood in stool or melena

● Frequent vomiting over a period of several hours

● Frequent and substantial volumes of diarrhea

● Diarrhea for >7 days or persistent vomiting

● Caregiver's report of symptoms of moderate to severe dehydration ( table 2)

● Multisystem compromise, cardiovascular instability (these children should be referred directly

● Underlying immunodeficiency or condition complicating the treatment or course of illness (eg,

● Social circumstances that make telephone assessment unreliable

● Determining the severity of illness; gastroenteritis severity is reflected by the degree of

● Well-appearing immunocompetent children with typical presentation – Most immune-

● Ill-appearing children and children with hypovolemia, atypical presentation, or uncertain

(dehydration) in children in resource-abundant settings", section on 'Intravenous

For children with suspected bacterial gastroenteritis, we do not obtain markers of

• For children with suspected parasitic gastroenteritis (eg, persistent diarrhea,

● Diarrhea (eg, ≥3 loose or watery stools in 24 hours or a number of loose/watery bowel

● Absence of visible blood and mucus in the stool

● Absence of atypical features: findings more characteristic of bacterial or parasitic

● Children with a known in-person exposure to a laboratory-confirmed case of COVID-19 within

● During outbreaks of gastroenteritis, particularly in an institution with a closed population

● Patients with prolonged diarrhea (ie, >7 days)

● Uncertain diagnosis (eg, acute viral gastroenteritis versus IBD)

● Norovirus (see "Norovirus", section on 'Diagnosis')

● Rotavirus (see "Clinical manifestations and diagnosis of rotavirus infection", section on

● Adenoviruses 40 and 41 (see "Diagnosis, treatment, and prevention of adenovirus infection",

Bacterial causes of acute gastroenteritis in children include:

● Diarrheagenic E. coli (see "Shiga toxin-producing Escherichia coli: Microbiology, pathogenesis,

● Salmonella (see "Nontyphoidal Salmonella: Microbiology and epidemiology" and "Enteric

● Shigella (see "Shigella infection: Epidemiology, clinical manifestations, and diagnosis")

● C. difficile (see "Clostridioides difficile infection in children: Microbiology, pathogenesis, and

● Campylobacter jejuni (see "Campylobacter infection: Microbiology, pathogenesis, and

● Mycobacteria, such as Mycobacterium avium complex, particularly in immunocompromised

Parasitic causes of acute gastroenteritis in children include:

● Giardia (see "Giardiasis: Epidemiology, clinical manifestations, and diagnosis")

● Cryptosporidium (see "Cryptosporidiosis: Epidemiology, clinical manifestations, and diagnosis")

● Microsporidia and Cyclospora (see "Microsporidiosis" and "Cyclospora infection")

● Meningitis – Characteristic features of meningitis include fever, altered level of consciousness,

● Streptococcal tonsillopharyngitis – Clinical features of streptococcal tonsillopharyngitis include

INDICATIONS FOR REFERRAL

● Severe dehydration ( table 2) associated with cardiovascular instability and/or

● Clinical features suggesting extraintestinal involvement or another etiology (see 'Differential

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