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What is diarrhea?

Diarrhea is an illness in which someone develops more watery or more frequent stools than is typical for that person. Diarrhea can be caused by changes in diet, such as drinking an excessive amount of fruit juice, eating more than the usual amounts of certain foods, and the use of some medications. Diarrhea can also be the result of a problem with the intestines, such as inability to absorb nutrients or allergy to foods. Infections with some viruses, bacteria, parasites, and toxins produced by certain bacteria can cause diarrhea.

  • Viruses: Rotaviruses, enteric adenoviruses, astroviruses, caliciviruses, enteroviruses, and noroviruses

  • Bacteria: Shigella, Salmonella, Campylobacter, Shiga toxin-producing Escherichia coli, Clostridium difficile

  • Parasites: Giardia intestinalis, Cryptosporidium

What are the signs or symptoms?

  • Frequent loose or watery stools

  • Abdominal cramps and tenderness

  • Fever

  • Generally not feeling well

  • Blood in stool

Note: Individuals can be infected and infectious with minimal or no signs or symptoms.

What are the incubation and contagious periods?

See the Quick Reference Sheet for each specific disease.

How is it spread?

  • Fecal-oral route: Contact with feces of children who are infected. This generally involves an infected child contaminating his own fingers, and then touching an object that another child touches. The child who touched the contaminated surface then puts her fingers into her own mouth or another person’s mouth.

  • Water or food contaminated by human or animal feces (eg, swimming pools).

  • Contact with raw or undercooked poultry.

  • Contact with animals in the child’s environment (eg, puppies, reptiles, poultry) or during trips to sites with animals (eg, farms, pet stores, petting zoos).

What are some types of diarrhea?

  • Viruses cause most diarrheal illness in group care settings. Rotavirus is the most common virus associated with severe diarrhea in young children. Rotavirus vaccine was included in the routine immunizations of infants in 2006. Now, diarrhea caused by this virus is much less common. Rotavirus tends to cause illness in winter. Enteroviruses are more common in the summer than other times of the year. Noroviruses, now the most common viral cause of diarrhea in children, occur year-round. Noroviruses often cause outbreaks of diarrhea and vomiting. Other viral infections may include diarrhea as one symptom (see the Quick Reference Sheet for each specific disease for more information).

  • Diarrheal infections from bacteria are less common. They may cause bloody diarrhea. A health care provider should always evaluate anyone with bloody diarrhea. The evaluation should include one or more tests, usually including stool cultures to identify the type of bacteria involved.

  • Diarrhea from intestinal diseases, foods, juices, or medicines is not infectious and usually is not severe enough to cause dehydration.

How do you control it?

  • Ensure immunization of infants for rotavirus, following the most recent immunization recommendations.

  • Use good hand-hygiene technique at all the times listed in Chapter 2, especially after toilet use or handling soiled diapers and before anything to do with food preparation or eating.

  • Ensure proper surface disinfection that includes cleaning and rinsing surfaces that may have become contaminated with stool (feces) with detergent and water and application of a US Environmental Protection Agency– registered disinfectant according to the instructions on the product label.

  • Ensure proper cooking and storage of food.

  • Exclusion of infected staff members who handle food.

  • Exclusion for specific types of symptoms (see Exclude from group setting?).

What are the roles of the teacher/caregiver and the family?

  • Report the condition to the staff member designated by the early education/child care program or school for decision-making and action related to care of ill children and staff members. That person, in turn, alerts possibly exposed family and staff members to watch for symptoms.

  • Ensure staff members follow the control measures listed under How do you control it?

  • Report outbreaks of diarrhea (more than 2 children and/or staff members in the group) to the health consultant, who, in turn, may report the problem to the local health department.

  • Require a medical evaluation for any child or staff member with diarrhea and blood or mucus in the stool.

Exclude from group setting?

Yes, if

  • The local health department determines exclusion is needed to control an outbreak.

  • Stool is not contained in the diaper for diapered children.

  • Diarrhea is causing “accidents” for toilet-trained children.

  • Stool frequency exceeds 2 stools above normal during the time the child is in the program because this may cause too much work for teachers/caregivers and make it difficult for them to maintain sanitary conditions.

  • There is blood or mucus in the ill person’s stool.

  • The ill person’s stool is all black.

  • The child has a dry mouth, no tears, or no urine output in 8 hours (suggesting the child’s diarrhea may be causing dehydration).

  • The child is unable to participate and staff members determine they cannot care for the child without compromising their ability to care for the health and safety of the other children in the group.

  • The child meets other exclusion criteria.

Readmit to group setting?

Yes, when all the following criteria are met:

  • A health care provider must clear the child or staff member for readmission for all cases of diarrhea with blood or mucus. Readmit following the requirements of the local health department authorities, which may include testing for a diarrhea outbreak in which the stool culture result is positive for Shigella, Salmonella serotype Typhi and Paratyphi, or Shiga toxin-producing E coli. Children and staff members with Shigella should be excluded until diarrhea resolves and test results from at least 1 stool culture are negative (rules vary by state). Children and staff members with Shiga toxin-producing E coli should be excluded until test results from 2 stool cultures are negative at least 48 hours after antibiotic treatment is complete (if prescribed). Studies have not shown a benefit of antibiotics for this condition. Children and staff members with S Typhi and Paratyphi are excluded until test results from 3 stool cultures are negative. Stool should be collected at least 48 hours after antibiotics have stopped. State laws may govern exclusion for these conditions and should be followed by the health care provider who is clearing the child or staff member for readmission.

  • Once the frequency of bowel movements is no more than 2 stools above normal during the time the child is in the program, diapered children have their stool contained by the diaper (even if the stools remain loose), and toilet-trained children are not having toileting accidents. A child who has had diarrhea may establish a new normal pattern that may include more frequent stools for a period after the child has recovered from diarrhea and seems otherwise well.

  • When the child is able to participate and staff members determine they can care for the child without compromising their ability to care for the health and safety of the other children in the group.

Listing of resources does not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not responsible for the content of external resources. Information was current at the time of publication.

The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

Quick Reference Sheet from Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide.

© 2017 American Academy of Pediatrics. All rights reserved.

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